Long-term impacts of different posterior operations on curvature, neurological recovery and axial symptoms for multilevel cervical degenerative myelopathy

Comparison of Postoperative Pain and Surgical Outcomes Between Three Types of Modified Muscle-Sparing Laminoplasty and Conventional Laminoplasty for Multilevel Degenerative Cervical Myelopathy

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

This study aimed to compare postoperative pain and surgical outcomes of open-door laminoplasty (LP) and three types of muscle-sparing laminoplasties, namely unilateral muscle-preservation laminoplasty (UL), spinous process splitting double-door laminoplasty (DL) and intermuscular "raising roof" laminoplasty (RL) for multilevel degenerative cervical myelopathy (MDCM).

METHODS

Consecutive MDCM patients underwent LP or modified laminoplasties (UL, DL, RL) in 2022 were enrolled. Patients' preoperative baseline data and surgical characteristics were collected. Postoperative transient pain (TP), the axial pain and Japanese Orthopedic Association (JOA) score and neck disability index (NDI) at 6-month and 12-month follow-up were documented.

RESULTS

A total of 154 MDCM patients were included and a 12-month follow-up was completed for 148 patients (LP: 36, UL:39, DL: 37, RL:36). No significant difference was observed in the baseline data. Four groups presented favorable and comparable surgical outcome. The RL group reported significantly the least severe TP on the first three days following surgery. However, no significant difference was found in the axial pain and axial symptoms at both follow-ups. After regression analysis, RL group exhibited significantly better efficacy in alleviating Day-1 TP (P = 0.047) and 6-month axial pain (P = 0.040). However, this superiority was not observed at 12-month follow-up.

CONCLUSION

All the three muscle-sparing laminoplasty procedures showed similar short-term surgical outcomes compared to LP. The RL procedure demonstrated superiority in alleviating TP and 6-month axial pain compared to LP. The RL and DL groups showed less C5 palsy compared to LP.

Correlation of imaging characteristics of degenerative cervical myelopathy and the surgical approach with improvement for postoperative neck pain and neural function: a retrospective cohort study

Background

Complex degenerative cervical spondylotic myelopathy (DCM) is characterized by a variety of complex imaging features. The surgical method for DCM remains controversial. This study aimed to examine the correlation between the imaging characteristics of DCM with varying degrees of complexity and the surgical approach and clinical outcome.

Methods

A retrospective cohort study involving retrospective data collection was performed. A total of 139 patients with DCM who underwent surgery between January 2015 and January 2018 in the Orthopedics Department of Shanxi Bethune Hospital were divided into 3 groups according to the complexity of imaging features: 18 patients in the mild group, 66 patients in the moderate group, and 55 patients in the severe group. The Visual Analog Scale (VAS) and Japanese Orthopaedic Association (JOA) scores were used to compare the effects of neck pain and neural function prior to surgery according to the rate of improvement as of the last follow-up. Routine X-ray films were obtained at the follow-up of 3-6 months. The necessity of computed tomography (CT) and magnetic resonance imaging (MRI) examinations was determined based on clinical findings and X-ray images. Analysis of variance (ANOVA) was used to compare groups, the least significant difference (LSD) test was used for multiple comparisons, and the Chi-square test was used to compare classification indicators (imaging manifestations, gender), with P<0.05 being statistically significant. Binary logistic regression analysis was performed to determine the primary influencing factors of the JOA recovery rate.

Results

In all three groups, JOA and VAS scores at the final follow-up were significantly higher than those before surgery (P<0.001). There were significant differences in the preoperative VAS and JOA scores between any two groups, as well as in the VAS and JOA scores and improvement rates at the last follow-up between the mild group and the moderate group and between the mild group and the severe group (P<0.001). Age, preoperative JOA scores, MRI intramedullary hyperintensity signal, and the degree of spinal cord compression were primarily related to the nervous system recovery rate (P<0.001).

Conclusions

Age, MRI intramedullary hyperintensity signal, degree of spinal cord compression, and other variables were associated with the improvement of neural function in patients with DCM. Therefore, in addition to the JOA improvement rate or VAS score, additional factors, such as the patient's condition, the improvement in quality of life, and the patient's financial capacity, should be considered in evaluating the improvement of postoperative neck pain and neural function.

Comparative Analysis of Postoperative Sagittal Balance in Expansive Open-Door Laminoplasty versus Laminectomy with Fusion for Multilevel Ossification of Posterior Longitudinal Ligament: A Retrospective Study

BACKGROUND This single-center study included 80 patients with multilevel cervical ossification of the posterior longitudinal ligament (OPLL) and aimed to compare postoperative sagittal balance following treatment with expansive open-door laminoplasty (LP) vs total laminectomy with fusion (LF). MATERIAL AND METHODS Data of 80 patients with multilevel OPLL treated with LP vs LF between January 2017 and January 2022 were retrospectively analyzed. The basic data, cervical sagittal parameters, and clinical outcomes of the patients were counted in the preoperative and postoperative periods, and complications were recorded. Forty patients underwent LP and 40 underwent LF. Cervical sagittal parameters were compared between and within the 2 groups. Clinical outcomes and complications were compared between the 2 groups. RESULTS At last follow-up, the postoperative C2-C7 Cobb angel, T1 slope (T1S), and C7 slope (C7S) were significantly higher in the LF group than in the LP group (P<0.001). C2-C7 SVA (cSVA) was slightly higher in the LF group (P>0.05) and significantly higher in the LP group (P<0.05). The incidence of postoperative complications in the LP group was significantly lower than in the LF group (P=0.02). The postoperative scores on the Visual Analog Scale (VAS), Neck Disability Index (NDI), and Japanese Orthopedic Association (JOA) were significantly improved in both groups (P<0.001). CONCLUSIONS Both procedures had good outcomes in neurological improvement. After posterior surgery, the cervical vertebrae all showed a tilting forward. Compared to LP, LF may change cervical balance in Cobb angel, T1S. LF has better efficacy in improving cervical lordosis compared with LP. Patients with high T1 slope after surgery may has more axial pain.

The value of Clinical signs in the diagnosis of Degenerative Cervical Myelopathy - A Systematic review and Meta-analysis

STUDY DESIGN

Delayed diagnosis of degenerative cervical myelopathy (DCM) is likely due to a combination of its subtle symptoms, incomplete neurological assessments by clinicians and a lack of public and professional awareness. Diagnostic criteria for DCM will likely facilitate earlier referral for definitive management.

OBJECTIVES

This systematic review aims to determine (i) the diagnostic accuracy of various clinical signs and (ii) the association between clinical signs and disease severity in DCM?

METHODS

A search was performed to identify studies on adult patients that evaluated the diagnostic accuracy of a clinical sign used for diagnosing DCM. Studies were also included if they assessed the association between the presence of a clinical sign and disease severity. The QUADAS-2 tool was used to evaluate the risk of bias of individual studies.

RESULTS

This review identified eleven studies that used a control group to evaluate the diagnostic accuracy of various signs. An additional 61 articles reported on the frequency of clinical signs in a cohort of DCM patients. The most sensitive clinical tests for diagnosing DCM were the Tromner and hyperreflexia, whereas the most specific tests were the Babinski, Tromner, clonus and inverted supinator sign. Five studies evaluated the association between the presence of various clinical signs and disease severity. There was no definite association between Hoffmann sign, Babinski sign or hyperreflexia and disease severity.

CONCLUSION

The presence of clinical signs suggesting spinal cord compression should encourage health care professionals to pursue further investigation, such as neuroimaging to either confirm or refute a diagnosis of DCM.

The Frequency of Symptoms in Patients With a Diagnosis of Degenerative Cervical Myelopathy: Results of a Scoping Review

STUDY DESIGN

Delayed diagnosis of degenerative cervical myelopathy (DCM) is associated with reduced quality of life and greater disability. Developing diagnostic criteria for DCM has been identified as a top research priority.

OBJECTIVES

This scoping review aims to address the following questions: What is the diagnostic accuracy and frequency of clinical symptoms in patients with DCM?

METHODS

A scoping review was conducted using a database of all primary DCM studies published between 2005 and 2020. Studies were included if they (i) assessed the diagnostic accuracy of a symptom using an appropriate control group or (ii) reported the frequency of a symptom in a cohort of DCM patients.

RESULTS

This review identified three studies that discussed the diagnostic accuracy of various symptoms and included a control group. An additional 58 reported on the frequency of symptoms in a cohort of patients with DCM. The most frequent and sensitive symptoms in DCM include unspecified paresthesias (86%), hand numbness (82%) and hand paresthesias (79%). Neck and/or shoulder pain was present in 51% of patients with DCM, whereas a minority had back (19%) or lower extremity pain (10%). Bladder dysfunction was uncommon (38%) although more frequent than bowel (23%) and sexual impairment (4%). Gait impairment is also commonly seen in patients with DCM (72%).

CONCLUSION

Patients with DCM present with many different symptoms, most commonly sensorimotor impairment of the upper extremities, pain, bladder dysfunction and gait disturbance. If patients present with a combination of these symptoms, further neuroimaging is indicated to confirm the diagnosis of DCM.

What is the Preferable Method for the C3 and C7 Segments in Unilateral Open-Door Laminoplasty for Patients Diagnosed with Cervical Spondylotic Myelopathy?

BACKGROUND

Traditional C3-C7 unilateral open-door laminoplasty (UOLP) often leads to various postoperative complications as a result of damage of cervical posterior muscles and nuchal ligaments. We aimed to thoroughly evaluate postoperative outcomes after our modified UOLP versus traditional UOLP in treating multilevel cervical spondylotic myelopathy (MCSM).

METHODS

Seventy-six patients with MCSM who underwent the modified UOLP with C3 laminectomy and C7 upper hemilaminectomy (40 patients) or traditional C3-C7 UOLP (36 patients) were included. Preoperative and postoperative cervical radiologic parameters, as well as clinical and surgical outcomes, were evaluated.

RESULTS

Postoperatively, Japanese Orthopaedic Association scores improved significantly more in the modified UOLP group than in the traditional UOLP group (P = 0.028), whereas visual analog scale scores and Neck Disability Index improved similarly in both groups. Follow-up scores for Japanese Orthopaedic Association, Neck Disability Index, and visual analog scale were not significantly different between the 2 groups. At the final follow-up, the C2-C7 sagittal vertical axis and T1 slope increased in the traditional UOLP group and did not change in the modified UOLP group and were unchanged in the modified UOLP group. The C2-C7 Cobb angle decreased significantly in the traditional UOLP group and did not change in the modified UOLP group. The modified UOLP group lost less cervical posterior muscle area compared with the traditional UOLP group (3.72% ± 3.54% vs. 6.67% ± 2.81%; P < 0.001). The range of motion in the modified UOLP group was significantly greater than in the traditional UOLP group at the final follow-up (P < 0.001). Also, the modified UOLP group experienced a notable reduction in operative time, blood loss volume, and postoperative hospital stay.

CONCLUSIONS

We recommend performing our modified UOLP with C3 laminectomy and C7 upper hemilaminectomy instead of traditional C3-C7 UOLP.

Surgical treating lumbar intraspinal tumor through a para-split laminotomy

BACKGROUND

to explore the feasibility and effectiveness of para-split laminotomy in the treatment of lumbar intraspinal tumors.

METHODS

We retrospectively review the clinical data of 15 patients suffering lumbar intraspinal tumors, who underwent tumor resection using the para-split laminotomy, from October 2016 to May 2018. Observation indicators were as follows: (1) surgical and postoperative recovery situations; (2) the neurological function of the spinal cord and the follow-up situations.

RESULTS

Mean blood loss was 95.3 ± 58.2 ml, and the mean duration of the surgical procedure was 176.7 ± 35.2 min. All lumbar intraspinal tumors were resected completely. There were no operative complications. The postoperative CT scans showed no pedicle or vertebral fractures. During the follow-up period of 6-18 months (average 10.8 ± 3.9 months), no tumor recurrence or spinal deformation was found according to the imaging examination. CT 3D reconstructions showed that the split laminae tended to heal. The average preoperative JOA score was 15.5 ± 4.9 and the average postoperative JOA score improved to 24.0 ± 3.5 (average improvement rate 65.9 ± 19.6%).

CONCLUSION

The para-split laminotomy could reduce the damage to the posterior spinal tension band and help to protect the stability of the spine. It is feasible and effective to apply the para-split laminotomy to the operation of a lumbar intraspinal tumor, and this technique may be a promising option when considering surgical methods for some multilevel well-circumscribed intraspinal tumors.

The clinical efficacy of laminectomy fusion fixation and posterior single open-door laminoplasty in the treatment of multilevel cervical ossification of the posterior longitudinal ligament (OPLL): a retrospective study

BACKGROUND

To compared the clinical efficacy of two surgical methods, posterior laminectomy fusion fixation, and posterior single open-door laminoplasty, in treating multilevel cervical ossification of the posterior longitudinal ligament (OPLL).

METHODS

The study retrospectively included 102 patients treated between December 2016 and December 2020. The patients were included into an observation group (56 cases) treated with total laminectomy and lateral screw fixation, and a control group (46 cases) treated with single open-door laminoplasty.

RESULTS

After 24 months, both groups showed significant improvement in Japanese Orthopaedic Association (JOA) scores and Visual Analogue Scale (VAS) scores, indicating better clinical symptoms and functional recovery. There was no significant difference in preoperative JOA and VAS scores between the two groups (P > 0.05). At 24 months after surgery, there was no significant difference in JOA and VAS scores between the two groups (P > 0.05). However, the observation group had a significantly higher cervical curvature index (CCI) and lower range of motion (ROM) of the cervical spine compared to the control group (P < 0.05). The CCI in control group was lower than before surgery, while the CCI in observation group was higher than before surgery, and CCI in the control group was considerably lower than that in the observation group (P < 0.05). The complication rate was lower in the control group, with fewer cases of axial symptoms, fifth cervical nerve root palsy, and overall complications. The overall complication rate was 25.0% (14/56) in the observation group and 10.8% (5/46) in the control group (P < 0.05).

CONCLUSIONS

Both posterior laminectomy fusion fixation and posterior single open-door laminoplasty yield positive outcomes in improving clinical neurological function, cervical curvature, range of motion of the cervical spine, and cervical sagittal balance. Although open-door laminoplasty is less effective than total laminectomy in maintaining CCI and sagittal balance, it excels in preserving cervical range of motion, less surgical trauma and complications. Thus, open-door laminoplasty may be a suitable first-choice treatment for multi-segmental cervical OPLL, especially for patients with lordotic cervical spine physiological curvature.

Clinical outcomes of modified versus traditional expansive open-door laminoplasty for cervical spondylotic myelopathy: A single-institution experience

PURPOSE

To compare the surgical outcomes of modified expansive open-door laminoplasty (EOL) (C4-C6) and traditional EOL (C3-C7) in patients with cervical spondylotic myelopathy (CSM).

METHODS

One hundred and two CSM patients were retrospectively recruited from Fujian Medical University Union Hospital between March 2012 and December 2019. Seventy-one patients with CSM underwent modified EOL, and 31 patients underwent traditional EOL. The primary endpoint was axial symptoms.

RESULTS

Patients who underwent modified EOL had a significantly lower incidence of axial symptoms (odds ratio: 0.273; 95% confidence interval: 0.184-0.691; p = .002). The length of hospital stay (p = .263), and intraoperative blood loss (p = .402) were not significantly different between the groups. Significantly more postoperative drainage was observed in patients who underwent modified EOL (p < .001), while the cost of hospitalization in patients treated with traditional EOL was higher (p = .011). There were significant differences between modified and traditional EOL for the changes in range of motion (p < .001), modified Japanese Orthopaedic Association score (p = .001), and the Nurick grade (p = .014), while the changes of visual analogue scale (p = .250), and the neck disability index (p = .134) were not significantly different between the groups.

CONCLUSION

This study found modified EOL may decrease the incidence of axial symptoms in patients with CSM compared to traditional EOL.

Posterior hybrid surgery for atlantoaxial dislocation coexisting with multilevel cervical spondylotic myelopathy

Background

To introduce a hybrid surgery of posterior craniovertebral fusion plus subaxial laminoplasty for atlantoaxial dislocation (AAD) coexisting with multilevel cervical spondylotic myelopathy (CSM).

Methods

A retrospective study was performed by reviewing data from 23 patients with the coexistence of AAD and CSM who underwent the hybrid technique (n = 23). Clinical outcomes, including visual analogue scale (VAS), Japanese Orthopaedic Association (JOA), and neck disability index (NDI) score, and radiological cervical alignment parameters including C0-2 and C2-7 Cobb angle and range of motion (ROM) were analyzed. The operation time, blood loss, surgical levels, and complications were recorded.

Results

The included patients were followed up with an average of 20.91 months (range, 12-36 months). Clinical outcomes including JOA, NDI, and VAS scores were significantly improved at different postoperative follow-up points. C0-2 Cobb angle, C2-7 Cobb angle, and ROM showed a stable tendency after 1-year follow-up. No major perioperative complications occurred.

Conclusion

This study underlined the importance of pathologic condition of AAD coexisting with CSM and presented a novel hybrid approach of posterior craniovertebral fusion plus subaxial laminoplasty. This hybrid surgery was effective in achieving the desired clinical outcomes and better maintaining cervical alignment, proving its value and safety as an alternative technique.

Concepts and Techniques to Prevent Cervical Spine Deformity After Spine Surgery: A Narrative Review

Adult cervical spine deformity is associated with decreased health-related quality of life, disability, and myelopathy. A number of radiographic parameters help to characterize cervical deformity and aid in the diagnosis and treatment. There are several etiologies for cervical spine deformity, the most common being iatrogenic. Additionally, spine surgery can accelerate adjacent segment degeneration which may lead to deformity. It is therefore important for all spine surgeons to be aware of the potential to cause iatrogenic cervical deformity. The aim of this review is to highlight concepts and techniques to prevent cervical deformity after spine surgery.

Cervical alignment and clinical outcome of open-door laminoplasty vs. laminectomy and instrumentation in kyphotic multilevel cervical degenerative myelopathy

INTRODUCTION

The aim of this study was to determine whether the sagittal lordotic alignment, clinical outcomes and axial symptoms (AS) could be improved by kyphotic correction through the posterior approach for the treatment of multilevel cervical degenerative myelopathy (CDM) and to further analyze the changes of cervical spinal alignment parameters after correction of kyphosis. The hypothesis was that correction of kyphosis can improve the severity of AS and neurological recovery.

MATERIALS AND METHODS

We retrospectively reviewed 109 patients who suffered from multilevel CDM combined with kyphosis. The patients had undergone open-door laminoplasty (Group LP, 53 patients) and laminectomy with instrumentation (Group LI, 56 patients) between January 2014 and December 2018. Cervical spinal alignment parameters, including curvature index (CI), T1 slope, C2-7 Cobb angle, C2-7 SVA, were measured on the pre- and postoperative lateral radiographs. The recovery rate was calculated based on the Japanese Orthopedic Association (JOA) score. AS severity was quantified using Neck Disability Index (NDI). A P value less than 0.05 was considered to be significant.

RESULTS

Analyses of postoperative follow-up data showed significant differences (P < 0.001) in CI, correction of CI, C2-7 Cobb angle, T1 slope, C2-7 SVA and NDI between Group LP and LI, but no significant differences in JOA score (P = 0.23) and recovery rate (P = 0.13). There were significant differences (P < 0.001) in CI, T1 slope, C2-7 Cobb angle, C2-7 SVA, JOA score, and NDI between pre- and postoperative follow-up in both groups. Correction of CI showed negative correlation with AS severity (r = -0.51, P < 0.001), and no association with recovery rate (r = 0.14, P = 0.15).

CONCLUSIONS

Satisfied neurological improvement was achieved by LP and LI for multilevel CDM combined with kyphosis. Cervical kyphotic correction produced significant improvement of AS and increase of T1 slope and C2-7 SVA. However, the kyphotic correction may not be associated with better neurological recovery in the short-term postoperative period.

Impact of cervical and global spine sagittal alignment on cervical curvature changes after posterior cervical laminoplasty

OBJECTIVE

To analyze the correlation between the changes in cervical curvature and the sagittal parameters of spino-pelvic and clinical efficacy after posterior laminoplasty (LP).

METHODS

The patients with cervical spondylosis treated with LP from June 2018 to December 2020 were reviewed. The preoperative and follow-up spine full-length films were measured. The measured data included C2-C7 Cobb angle, C2-7 sagittal vertical axis (SVA), T1 slope (T1S), pelvic incidence, sacral slope (SS), pelvic tilt (PT), lumbar lordosis (LL), thoracic kyphosis (TK), and C7-SVA. Japanese Orthopaedic Association (JOA) score and neck disability index (NDI) score were recorded before surgery and follow-up.

RESULTS

There were 56 patients in this study. There were no significant differences in spino-pelvic sagittal parameters before and after surgery; however, the JOA score significantly improved. The changes in postoperative cervical lordosis correlated with SS, PT, LL, T1S, and C7-SVA (P < 0.05). Regression analysis showed that T1S and C7-SVA were associated with reducing cervical lordosis (P = 0.021 and P = 0.001, respectively). Patients with larger T1S combined with larger C7-SVA had more cervical lordosis loss, poor JOA improvement, and high postoperative NDI scores (P < 0.001, P = 0.018, and P < 0.001, respectively).

CONCLUSION

Patients should be examined with full-length spine film before surgery to evaluate the cervical and spino-pelvic sagittal balance. T1S and C7-SVA correlated with changes in cervical sagittal alignment after LP.

LEVEL OF EVIDENCE

III.

Long-Term Follow-Up After Cervical Laminectomy without Fusion for Cervical Spondylotic Myelopathy

OBJECTIVE

The objectives were to study the effect of cervical laminectomy without fusion on the incidence of further cervical surgeries, the risk for cervical misalignment, and current functional status.

METHODS

We retrospectively analyzed the clinical data of 340 patients who had undergone simple laminectomy for cervical spondylotic myelopathy (CSM) at Helsinki University Hospital between 2000 and 2011.

RESULTS

Forty-one patients (12.1%) had later undergone another cervical surgery during the follow-up of a mean of 8.5 years (maximum, 17.5 years). The most common indication for further surgery was residual stenosis at adjacent or other cervical levels (34%). Five patients (1%) required further surgery for correction of a sagittal balance problem. The mean Neck Disability Index was 28% at a median of 9.0 years after laminectomy. The mean EQ-5D (EuroQol 5 Dimension 3 Level) index score was 58.8 for patients and 77.2 for age-matched and gender-matched general population controls (P = 0.000), indicating patients' reduced health-related quality of life. Worse preoperative condition in the Nurick score was related to a lower (i.e., worse) EQ-5D score. In an additional arm of the study with radiographic imaging (40 patients), the mean change in sagittal alignment was 4.0° toward lordotic, and a newly developed kyphosis was found in 7.5% of patients.

CONCLUSIONS

Because CSM is a serious degenerative progressive condition resulting in decreased health-related quality of life even after surgical treatment, the low rate of corrective surgery needed for alignment issues per se indicates that simple laminectomy can be a viable treatment option in treating multilevel CSM.

Laminoplasty and simultaneous C2 semi-laminectomy with internal fixation in treating ossification of the posterior longitudinal ligament in cervical discs at C2 segment

OBJECTIVE

To explore the effect of open-door laminoplasty and simultaneous C2 semi-laminectomy with lateral mass screw fixation (LSLF) in treating ossification of the posterior longitudinal ligament (OPLL) in cervical discs at C2 segment.

METHODS

In this retrospective study, 76 patients diagnosed with OPLL in cervical discs at C2 segment from November 2016 to May 2019 were included. These patients were assigned into a LSLF group (n=41, LSLF surgery) and LF group (n=35, laminectomy and lateral mass screw fixation) according to the treatment they received. The surgery time and intraoperative blood loss were recorded. Improvements in neurological function (JOA score), cervical curvature index (CCI), spinal cord drift distance, cross-sectional area (CSA) of the posterior muscles from cervical spine, occurrence of C5 palsy, and severity of axial symptoms were evaluated between LSLF group and LF group.

RESULTS

Compared with LF group, the operative time was longer and blood loss volume was higher in LSLF group (P<0.05). No statistical difference was found in decompression width between LSLF group and LF group, while the drift distance of spinal cord in LSLF group was larger than that in LF group (P<0.05). No obvious differences were observed in anteroposterior dural sac diameter after the surgery between LSLF group and LF group. CSA in LF group decreased more than that in LSLF group (P<0.05). No remarkable difference was obtained in CCI at the final follow-up between LSLF group and LF group. The NDI score after surgery in the LSLF group was significantly decreased compared to LF group (P<0.05), while no differences were observed in JOA scores or the neurological recovery rate between LSLF group and LF group. The occurrence of C5 palsy in the LSLF group was 4.9%, which was less than that of LF group (20.0%). In contrast to LF group, postoperative axial symptoms in LSLF group were decreased (P<0.05).

CONCLUSION

Compared to LF, LSLF could better improve neck functions, and reduce the severity of axial symptoms and the occurrence of C5 palsy for patients with OPLL at C2 segment.

Clinical and Radiological Outcomes of Two Modified Open-door Laminoplasties Based on a Novel Paraspinal Approach for Treatment of Multilevel Cervical Spondylotic Myelopathy

STUDY DESIGN

A case-control study.

OBJECTIVES

The aim of this study was to evaluate the outcomes of two modified laminoplasties (LPs) based on a novel paraspinal approach for treating multilevel cervical spondylotic myelopathy.

SUMMARY OF BACKGROUND DATA

No laminoplasty through a natural intermuscular plane mimicking Wiltse approach to minimize intraoperative injury to extensor muscles has ever been developed and studied.

METHODS

Ninety-two patients were enrolled, including patients treated with either modified LP and patients treated with concurrent conventional LP. Operation time, blood loss, and complications were recorded. Clinical outcomes were evaluated by VAS, JOA scores, and recovery rate. Cervical sagittal alignment was measured on cervical radiographs. Spinal canal expansion was assessed on CT scans. Cross-sectional area (CSA) and atrophy rate (AR) of cervical deep extensors were evaluated on MRI.

RESULTS

The average follow-up duration was 33.05, 31.55, 33.02, and 32.52 months, respectively in each group. Compared to concurrent conventional procedure, unilateral muscle-preserving procedure displayed similar, whereas bilateral muscle-preserving procedure showed significantly increased operation time and blood loss; each modified procedure resulted in comparable and satisfied perioperative clinical scores, spinal canal expansion while achieving significantly lower axial pain incidence, better cervical lordosis maintenance, and better deep extensor preservation. AR of deep extensors on the open side was significantly lower than that on the hinge side. Bilateral paraspinal approach demonstrated significantly better muscle-preservation on the open side and increased operation duration, with similar clinical scores, axial pain incidence, cervical lordosis maintenance, and spinal canal expansion compared to unilateral paraspinal approach. Loss of cervical lordosis was strongly correlated with AR of deep extensors.

CONCLUSION

Paraspinal approach is a good manner to protect deep extensor muscles; the two modified LPs have similar effects on clinical outcomes.Level of Evidence: 3.

Comparative Effectiveness and Safety of Open-Door Laminoplasty, French-Door Laminoplasty, Laminectomy and Fusion, and Laminectomy Alone for Multilevel Degenerative Cervical Myelopathy: A Bayesian Network Analysis

OBJECTIVES

To evaluate the comparative effectiveness and safety of open-door laminoplasty (OLP), French-door laminoplasty (FLP), laminectomy and fusion (LF), and laminectomy alone (LA) in treating multilevel degenerative cervical myelopathy (MDCM).

METHODS

Embase, PubMed, and Cochrane library were searched from their inception date to 7 January 2021. Randomized controlled trials and cohort studies comparing OLP, FLP, LF, and LA were identified to perform a network meta-analysis (NMA).

RESULTS

A total of 30 studies with 2671 patients were included. Our NMA results showed no significant difference between LF and OLP, but both are superior to LA and FLP in the comparison of JOA (Japanese Orthopaedic Association) score improvement. LF showed a most unsatisfactory outcome in postoperative range of motion (ROM) compared with LA or OLP or with FLP. For the complication outcome, no significant differences were found. The surface under the cumulative ranking curves (SUCRA) for JOA improvement was as follows: LF, OPL, LA, and FLP. For ROM reduction it was LA, OPL, FPL, and LF. For complications it was LF, LA, OLP, and FLP.

CONCLUSIONS

Considering all the evaluated criteria, none of the procedures showed the best outcome with least complications and optimal efficacy. However, OLP can be most recommended because of its second-ranking spectra in both of JOA improvement and ROM reduction, also with an acceptable incidence of complications, with the third least.

Is there any correlation between the recovery rate of JOA and the increasing of cervical spinal cord area after single-door cervical laminoplasty?

OBJECTIVES

The aim of the study is to investigate the clinical and radiologic factors represented by the increasing of spinal cord area associated with the prognosis of the patients at long-term follow-up by multivariate analysis after single-door cervical laminoplasty (SDCL).

METHODS

A total of 115 patients who underwent cervical laminoplasty with miniplate fixation were included from November 2008 to June 2018. The average postoperative follow-up period was 17.3 months (range, 12-105 months). The prognosis of the patients following cervical laminoplasty was evaluated by the recovery rate of Japanese Orthopedic Association (JOA) at the final follow-up. The recovery rate of JOA ≤ 50% were classified as poor prognosis group (PP group) whose prognosis is relatively poor, and those> 50% were classified as good prognosis group (GP group) whose have a better prognosis. The clinical factors including gender, age, duration of symptoms, diagnosis type, blood loss, operative time, pre- and post-JOA score, etc. were recorded. The radiologic factors including sagittal canal diameter (SCD), the cervical curvature index (CCI), the range of motion (ROM), the spinal canal area and the increasing of cervical spinal cord area, etc. were collected before and after operation and measured by X-ray plain and computed tomography (CT) scan images. The univariate analysis and multivariate logistic regression analysis were performed.

RESULTS

There were 62 patients in PP group and 53 patients in GP group. The multivariate analysis showed that the preoperative (OR=6.875, P = 0.001) and postoperative JOA scores (OR=24.000, P = 0.001), preoperative spinal canal area (OR=2.464, P = 0.023) and the increasing of cervical spinal cord area (OR=5.438, P = 0.001) maybe related factors to the recovery rate of JOA at the final follow-up.

CONCLUSIONS

The preoperative spinal canal area, the increasing of cervical spinal cord area, preoperative and postoperative JOA scores play important roles in long-term prognosis after SDCL.

Multivariate analysis of factors associated with spinal cord area in single-door cervical laminoplasty with miniplate fixation

Objectives

To explore the factors associated with the increased spinal cord area in single-door cervical laminoplasty (SDCL) with miniplate fixation.

Methods

A retrospective study enrolled 83 patients underwent SDCL with miniplate fixation and the patient characteristics such as age, gender, tobacco use, alcohol use, diabetes mellitus, hypertension, diagnosis, operative level, etc., were obtained. The opening angle, door shaft position and spinal canal area of the patients were measured after surgery. The sagittal canal diameter (SCD), the C2–7 Cobb angle, the cervical curvature index (CCI), the range of motion (ROM) and the spinal canal area were measured before and after operation. The increased cervical spinal cord area was also measured before and after surgery, and the correlation between the above indicators and the increased cervical spinal cord area was studied through Pearson’s correlation analysis and multivariate logistic regression analysis.

Results

There were 34 patients in small spinal cord area increment group (SAI group), 29 patients in middle spinal cord area increment group (MAI group) and 20 patients in large spinal cord area increment group (LAI group). The preoperative diagnosis(P = 0.001), door shaft position (P = 0.008), preoperative spinal canal area (P = 0.004) and postoperative spinal canal area (P = 0.015) were significant different among the 3 groups. The multivariate analysis showed that the preoperative diagnosis (OR = 2.076, P = 0.035), door shaft position (OR = 3.425, P = 0.020) and preoperative spinal canal area (OR = 10.217, P = 0.009) were related to increased spinal cord area.

Conclusions

The preoperative diagnosis, door shaft position and preoperative spinal canal area might be associated with increased spinal cord area after cervical laminoplasty with miniplate fixation. Preoperative symptoms are mostly caused by compression of the spinal cord, so spinal cord area enlargement can bring a better recovery in patients alongside long-term. Spine surgeons should pay more attention to the accuracy of the preoperative diagnosis, the preoperative measurement of spinal canal area and the door shaft position during the operation.

Relationship of Change in Cervical Curvature after Laminectomy with Lateral Mass Screw Fixation to Spinal Cord Shift and Clinical Efficacy

BACKGROUND AND STUDY AIMS

 Although laminectomy with lateral mass screw fixation (LCSF) is an effective surgical treatment for cervical spondylotic myelopathy (CSM), loss of cervical curvature may result. This study aimed to investigate the effect of cervical curvature on spinal cord drift distance and clinical efficacy.

PATIENTS AND METHODS

 We retrospectively analyzed 78 consecutive CSM patients with normal cervical curvature who underwent LCSF. Cervical curvature was measured according to Borden's method 6 months after surgery. Study patients were divided into two groups: group A, reduced cervical curvature (cervical lordosis depth 0-7mm; n = 42); and group B, normal cervical curvature (cervical lordosis depth 7-17mm; n = 36). Spinal cord drift distance, laminectomy width, neurologic functional recovery, axial symptom (AS) severity, and incidence of C5 palsy were measured and compared.

RESULTS

 Cervical lordosis depth was 5.1 ± 1.2 mm in group A and 12.3 ± 2.4 mm in group B (p < 0.05). Laminectomy width was 21.5 ± 2.6 mm in group A and 21.9 ± 2.8 mm in group B (p > 0.05). Spinal cord drift distance was significantly shorter in group A (1.9 ± 0.4 vs. 2.6 ± 0.7 mm; p < 0.05). The Japanese Orthopaedic Association (JOA) score significantly increased after surgery in both groups (p < 0.05). Neurologic recovery rate did not differ between the two groups (61.5 vs. 62.7%; p > 0.05). AS severity was significantly higher in group A (p < 0.05). C5 palsy occurred in three group A patients (7.1%) and four group B patients (11.1%), but the difference was not significant (p > 0.05).

CONCLUSION

 After LCSF, 53.8% of the patients developed loss of cervical curvature. A smaller cervical curvature resulted in a shorter spinal cord drift distance. Loss of cervical curvature was related to AS severity but not improvement of neurologic function or incidence of C5 palsy.

Relationship between cervical curvature and spinal cord drift distance after laminectomy via lateral mass screw fixation and its effect on clinical efficacy

BACKGROUND

Laminectomy with lateral mass screw fixation (LCS) is considered an effective surgical procedure for cervical spondylotic myelopathy. However, varying degrees of loss of the cervical curvature were noted in some patients postoperatively. The aim of this study was to observe the relationship between cervical curvature and spinal drift distance after LCS and to determine its effect on neurological function, axial symptoms, and C5 palsy.

METHODS

A total of 117 consecutive cervical spondylotic myelopathy patients with normal cervical curvature underwent LCS from April 2015 to May 2017 in our institution. Of these patients, 90 patients who accepted to undergo an integrated follow-up were enrolled in this study. The patients were divided into 3 groups based on their postoperative cervical curvature. In group A (28 patients), the cervical curvature became straight postoperatively (0°≤cervical spine angle≤5°); in group B (36 patients), the cervical curvature decreased (5°<cervical spine angle≤16.5°); and in group C (26 patients), the cervical curvature remained normal (cervical spine angle>16.5°). Spinal drift distance, neurological recovery, axial symptoms, and C5 palsy in the patients were recorded and analyzed.

RESULTS

Postoperative measurements showed that there was no significant difference in laminectomy width between the groups (P > .05). The cervical spine angle was 2.7° ± 0.5° in group A, 11.2° ± 2.6° in group B, and 20.8° ± 4.1° in group C (P < .05), while the spinal drift distance was 1.2 ± 0.2 mm, 1.8 ± 0.4 mm, and 3.0 ± 0.5 mm, respectively (P < .05). The postoperative Japanese Orthopedic Association score was significantly increased in all groups (P < .05), and there was no significant difference between the groups at different time points (P > .05). However, significant differences were noted between the groups in axial symptoms (P < .05), which were analyzed via the visual analog scale score. The occurrence of C5 palsy in groups A, B, and C was 7.1% (2/28), 8.3% (3/36), and 11.5% (3/26), respectively (P > .05).

CONCLUSION

In LCS, the cervical curvature should be maintained at the normal angle to obtain a good spinal cord drift distance and a lower incidence of axial symptoms.

The Relative Merits of Posterior Surgical Treatments for Multi-Level Degenerative Cervical Myelopathy Remain Uncertain: Findings from a Systematic Review

Objectives: To assess the reporting of study design and characteristics in multi-level degenerative cervical myelopathy (DCM) treated by posterior surgical approaches, and perform a comparison of clinical and radiographic outcomes between different approaches. Methods: A literature search was performed in Embase and MEDLINE between 1995–2019 using a sensitive search string combination. Studies were selected by predefined selection criteria: Full text articles in English, with >10 patients (prospective) or >50 patients (retrospective), reporting outcomes of multi-level DCM treated by posterior surgical approach. Results: A total of 75 studies involving 19,510 patients, conducted worldwide, were identified. Laminoplasty was described in 56 studies (75%), followed by laminectomy with (36%) and without fusion (16%). The majority of studies were conducted in Asia (84%), in the period of 2016–2019 (51%), of which laminoplasty was studied predominantly. Twelve (16%) prospective studies and 63 (84%) retrospective studies were identified. The vast majority of studies were conducted in a single centre (95%) with clear inclusion/exclusion criteria and explicit cause of DCM. Eleven studies (15%) included patients with ossification of the posterior longitudinal ligament exclusively with cohorts of 57 to 252. The clinical and radiographic outcomes were reported with heterogeneity when comparing laminoplasty, laminectomy with and without fusion. Conclusions: Heterogeneity in the reporting of study and sample characteristics exists, as well as in clinical and radiographic outcomes, with a paucity of studies with a higher level of evidence. Future studies are needed to elucidate the clinical effectiveness of posterior surgical treatments.

Risk Factors for Axial Symptoms After Anterior Surgery Treating for Multilevel Cervical Disorder with kyphosis

STUDY DESIGN

A retrospective study.

OBJECTIVE

The aim of this study was to investigate the risk factors associated with axial symptoms (AS) after anterior surgery in treatment of multilevel cervical disorder with kyphosis based on subgroup of follow-up time.

SUMMARY OF BACKGROUND DATA

Although many scholars reported on AS after cervical surgery, the risk factors associated with AS are controversial. Few studies have investigated the risk factors of AS after anterior cervical surgery treating multilevel cervical disorder with kyphosis.

METHODS

Totally, 103 patients who suffered from multilevel cervical disorder with kyphosis receiving anterior surgery from July 2015 to June 2017 were reviewed for clinical and radiological outcomes. These data were collected at the time of before surgery, 1 week, 3 months, 6 months, 1 year, and 2 years after surgery. Data were performed to compare between the patients with and without AS.

RESULTS

In our study, the occurrence of AS was 46.6%, 34.0%, 20.4%, 12.6%, and 10.7% at the time of 1 week, 3 months, 6 months,1 year, and 2 years after surgery, respectively. Our findings showed that patients with smoking, disease duration, preoperative Modic changes (Mcs), post-operative Cobb angle of C2-7, cervical range of motion (ROM) and T1 slope, and change of Cobb angle of C2-7, cervical ROM and T1 slope were associated with AS within 1 year after surgery. However, patients with smoking and preoperative Mcs were found to be risk factors associated with AS at at any follow-up.

CONCLUSION

In the present study, many factors were related to AS during 1-year after surgery. What's more, patients with smoking and preoperative Mcs were associated with AS at any follow-up. We hope this article can provide a reference for spinal surgeons to predict which patients were susceptible to suffer from AS after anterior surgery in treatment of multilevel cervical disorder with kyphosis.Level of Evidence: 3.

Laminoplasty versus laminectomy with fusion for treatment of multilevel cervical compressive myelopathy: an updated meta-analysis

BACKGROUND

Multilevel cervical spondylotic myelopathy (CSM) and ossification of the posterior longitudinal ligament (OPLL) are debilitating degenerative diseases. If conservative treatment is ineffective, surgical options for multilevel CSM and OPLL include laminoplasty (LP) and laminectomy with fusion (LF). In this updated meta-analysis, we aimed to compare the clinical outcomes and complications of both approaches.

METHODS

We searched PubMed, the Cochrane Library and Embase datasets from their inception to 31 March 2020, to identify all eligible studies comparing LP versus LF for multilevel CSM and OPLL. Data were extracted according to predefined endpoints. We summarised data by the random-effects or fixed-effect models, as necessary.

RESULTS

Of 533 eligible studies, 16 were identified, which included 638 patients who underwent LP and 671 patients who underwent LF. No significant differences were observed between preoperative and postoperative scores of the Japanese Orthopaedic Association (p=1.0 and 0.20, respectively); Visual Analogue Scale (p=0.24 and 0.89, respectively); sagittal vertical axis ((p=0.16 and 0.87, respectively); Nurick Scale (p=0.59 and 0.17, respectively); and range of motion (p=0.67 and 0.63, respectively). However, total complications were higher for LF compared with LP (p=0.006). A significantly higher incidence of C5 palsy was observed in the LF group (p=0.004). The postoperative Neck Disability Index (NDI) was also higher in the LF group (p<0.001).

CONCLUSIONS

Although LP and LF shared similar clinical improvement, LP had fewer complications, a lower incidence of C5 palsy, and better NDI scores and recovery outcomes than LF. Randomised studies are warranted to validate these findings.

Laminoplasty with selective fusion at unstable segment versus laminectomy with fusion for multilevel cervical myelopathy: a case-control study

Background

Segmental cervical instability is a risk factor for the progression of osteophytic bone spurs and development of myelopathy, and is treated as a relative contraindication of cervical laminoplasty. The aim of this study was to compare laminoplasty with selective fixation (LPSF) versus laminectomy with fusion (LCF) in patients with multilevel cervical myelopathy accompanied by segmental instability.

Methods

A case-control study was conducted by reviewing data from 63 patients who underwent LPSF (n = 30) or LCF (n = 33). Cervical alignment, range of motion (ROM), neurologic status and axial symptom severity pre-operation, 3-days after operation, and at the final follow-up (minimum 24 months) were measured and compared between groups.

Results

Postoperation, patients in the LPSF group lost 31.1 ± 17.3 % of cervical lordosis and 43.2 ± 10.9 % cervical ROM while patients in the LCF group lost 5.7 ± 8.2 % and 67.9 ± 15.5 %, respectively. Both LPSF and LCF groups significantly improved neurologic status and axial symptom severity at the final follow-up with similar between-group results(P > 0.05). Blood loss, operation time, hospital stay, and medical cost in the LPSF group were significantly less than in the LCF group(P < 0.05).

Conclusions

In 2 years of clinical observation, LPSF was effective in maintaining the stability of the cervical spine with less sacrifice of mobility and surgical trauma for multilevel myelopathy with segmental instability compared to LCF.

Current surgical practice for multi-level degenerative cervical myelopathy: Findings from an international survey of spinal surgeons

Degenerative cervical myelopathy (DCM) results from compression of the cervical spine cord as a result of age related changes in the cervical spine, and affects up to 2% of adults, leading to progressive disability. Surgical decompression is the mainstay of treatment, but there remains significant variation in surgical approaches used. This survey was conducted in order to define current practice amongst spine surgeons worldwide, as a possible prelude to further studies comparing surgical approaches.

METHODS

An electronic survey was developed and piloted by the investigators using SurveyMonkey. Collected data was categorical and is presented using summary statistics. Where applicable, statistical comparisons were made using a Chi-Squared test. The level of significance for all statistical analyses was defined as p < 0.05. All analysis, including graphs was performed using R (R Studio).

RESULTS

127 surgeons, from 30 countries completed the survey; principally UK (66, 52%) and North America (15, 12%). Respondents were predominantly Neurosurgeons by training (108, 85%) of whom 84 (75%) reported Spinal Surgery as the principal part of their practice. The majority indicated they selected their surgical procedure for multi-level DCM on a case by case basis (62, 49%). Overall, a posterior approach was more popular for multi-level DCM (74, 58%). Region, speciality or annual multi-level case load did not influence this significantly. However, there was a trend for North American surgeons to be more likely to favour a posterior approach.

CONCLUSIONS

A posterior approach was favoured and more commonly used to treat multi-level DCM, in an international cohort of surgeons. Posterior techniques including laminectomy, laminectomy and fusion or laminoplasty appeared to be equally popular.

Analysis of Cervical Spine Alignment Change after Modified Kurokawa Cervical Laminoplasty in the Patients with Cervical Myelopathy and Straight Cervical Spine

Laminoplasty is widely used to decompress the spinal cord in patients with multilevel cervical lesions. Straight cervical alignment may not be a good candidate for laminoplasty because of postoperation progression of kyphosis and loss of cervical spine range of motion (ROM). However, clinical outcomes of laminoplasty did not show a strong and consistent effect based on cervical sagittal alignment. Moreover, the kyphosis progression and ROM change after operation for the patients with preoperative strange cervical alignment are still unclear. This study is to evaluate the change of cervical alignment and ROM in patients with straight cervical alignment after modified Kurokawa cervical laminoplasty. Thirty patients with multiple-level cervical spondylosis (CSM) and straight cervical alignment were included. All patients underwent laminoplasty with the reconstruction of the spinous process-ligament-muscular complex (SPLMC). The modified JOA score was analyzed for clinical assessment. The change of cervical alignment, ROM, T1 slope, and intervertebral disc space Cobb angle were analyzed for radiological assessment. The average JOA score at preoperative and 2 years follow-up were 7.8 ± 1.4 and 13.6 ± 2.1, respectively. The recovery ratio was 63%. At the 2 years follow-up, there were 18 patients who acquired lordotic cervical alignment. 10 patients remained as straight cervical curve, and 2 patients' cervical alignment developed mild kyphosis. 28 out of 30 patients showed improvement of cervical alignment. The cervical alignment was improved from 1.29 ± 10.04° preoperative to 9.58 ± 8.65° postoperative. However, the ROM decreased from 36.8 ± 18.92 preoperative to 25.08 ± 12.10° postoperative. A positive correlation was found between the C2/4 angle change and cervical alignment change, T1 slope and cervical alignment, cervical alignment, and neutral position flexion reserved ROM. A negative correlation was found between the C1/2 angle change and cervical alignment change. Laminoplasty with a reconstruction of SPLMC followed by appropriate postoperative muscle exercises may be an encouraging way to maintain or improve physiological alignment and prevent postoperation kyphosis deformity at 2 years follow-up.

A modified cutting line in the single-door cervical laminoplasty via a computed tomography-based morphological study of the subaxial cervical spine

OBJECTIVE

To modify the conventional methods of grooving and direction during the single-door cervical laminoplasty (SDCL) in the subaxial cervical spine.

METHODS

The distance between the left and the right lamina-lateral mass junction at the upper, middle, and lower levels of each segment (DLL-U, DLL-M, DLL-L), angle between the posterior edge of the vertebral body and the lamina (AVL) and thickness of lamina (TL) were measured in the transverse plane. The parameters of preoperative computed tomography scans of 200 patients who had undergone SDCL were measured. The patients were divided into male and female groups and developmental canal stenosis (DCS) and non-DCS (NDCS) groups.

RESULTS

DLL-M gradually increased from the cranial to the caudal except for C7, and DLL-L > DLL-M > DLL-U in each vertebra. AVL increased from C3 to C7, TL decreased from C3 to C5 and increased from C5 to C7, with both parameters showing no significant differences between the left and right sides. AVL of the DCS group was less than that of the NDCS group (P < 0.01).

CONCLUSIONS

In the SDCL, the ideal surgical trough should be several discontinuous lines sloping from top to bottom, rather than a straight line. The abduction angle during drilling should gradually increase from C3 to C7 in the SDCL averaging 40 degrees. This method mentioned above improves the efficiency of the operation with less blood loss as an extended cut into the lateral mass is avoided.

The ratio of C2-C7 Cobb angle to T1 slope is an effective parameter for the selection of posterior surgical approach for patients with multisegmental cervical spondylotic myelopathy

BACKGROUND

To our knowledge, laminectomy with fusion (LCF) and laminoplasty alone (LP) are both effective posterior surgical approaches for decompression of cervical spondylotic myelopathy (CSM). However, which one is suitable for patients has no standard answer. This study estimated whether the ratio of C2-C7 Cobb angle to T1 slope (CL/T1S) could be an indication of posterior surgical approach.

METHODS

We retrospectively reviewed 128 patients with at least 6 months of follow-up who underwent LCF or LP. Radiological measurements, including C2-C7 Cobb angle, decompressed Cobb angle, T1 slope, cervical sagittal vertical axis, and curvature index (CI), and clinical outcomes, including Japanese Orthopedic Association score and visual analogue scale were evaluated. ROC curve analysis was used to identify discriminative power of CL/T1S ratio to predict kyphotic deformity and severe lordosis loss. The t-test and Mann-Whitney U-test were used to evaluate the difference between LCF and LP. Kruskal-Wallis H - test and ANOVA were used to evaluate the difference among different ratio CL/T1S groups.

RESULTS

The cervical lordosis decreased after LCF or LP (p < 0.001, p < 0.001, respectively). Based on ROC curve analysis, CL/T1S ratio had a good discriminative power to predict kyphotic deformity and severe lordosis loss (AUC = 0.70, AUC = 0.88, respectively). According to CI value changes, cervical lordosis losses in group LP were larger than that in group LCF (p = 0.006). However, there was no significant difference in CI changes of fair-ratio CL/T1S group between LCF and LP. For patients with low CL/T1S ratio or high CL/T1S ratio, CI changes in group LP were greater than that in group LCF (p = 0.037, p = 0.042, respectively).

CONCLUSIONS

CL/T1S ratio could be an indication of posterior surgical approach. Compared with LP, LCF reduces postoperative cervical lordosis losses in low-ratio and high-ratio CL/T1S groups.

C3 laminectomy combined with modified unilateral laminoplasty and in situ reconstruction of the midline structures maintained cervical sagittal balance: a retrospective matched-pair case-control study

BACKGROUND CONTEXT

Open-door laminoplasty often results in postoperative complications such as loss of cervical lordosis, limitations of cervical motion, and axial symptoms. However, current modified laminoplasty techniques such as muscle-sparing type or spinous process splitting technique are not as effective as expected.

PURPOSE

To evaluate the radiological and clinical outcomes of C3 laminectomy combined with modified unilateral laminoplasty (preservation of posterior muscle-ligament complex and reconstruction of the midline structures) versus traditional open door laminoplasty in treating cervical spondylotic myelopathy or ossification of the posterior longitudinal ligament.

STUDY DESIGN

Retrospective case-control study.

PATIENT SAMPLE

One hundred and eleven patients with multilevel cord compression and myelopathic symptoms.

OUTCOME MEASURES

The outcome parameters were operation time, blood loss volume, complications, osseous fusion status, C0-C2 and C2-C7 Cobb angles, T1 slope, cervical sagittal vertical axis (cSVA), cervical curvature index (CCI), range of motion (ROM), cross-sectional area (CSA) of the semispinalis cervicis, axial symptoms, visual analog scale (VAS) score, Japanese Orthopedic Association (JOA) score, and neck disability index (NDI).

METHODS

We matched 37 patients who underwent modified laminoplasty with 74 patients treated by traditional open door laminoplasty (ratio, 1:2) according to age, sex, body mass index, compromised level, and radiographic characteristics. Preoperative and postoperative cervical parameters, namely, the C2-C7 Cobb angle, ROM, and CCI were measured on X-ray films. The CSA of the semispinalis cervicis was assessed on magnetic resonance images, and osseous fusion status of the hinge side and the osteotomy site was evaluated by computed tomography. We used the JOA and VAS scores, and the NDI to evaluate clinical outcomes.

RESULTS

The average follow-up period in the modified group was 24.1 months (range, 18-37 months) compared with 24.7 months (range, 18-38 months) in the control group. At the final follow-up, C0-C2 Cobb angle, T1 slope, and cSVA increased in the control group and were unchanged in the modified group. The C2-C7 Cobb angle decreased significantly in the control group and did not change in the modified group. ROM and CCI loss rate did not change in the modified group but decreased significantly in the control group. The CSA loss in the semispinalis cervicis was 222.90±79.56 mm² in the control group and 49.11±75.93 mm² in the modified group, with a significant difference (p<.001). The final CSA of the semispinalis cervicis at C2 and C4-C7 levels showed no significant difference in the modified group and decreased significantly in the control group compared with preoperation. Changes in the C2-C7 Cobb angle and cSVA were both correlated with the CSA loss of the semispinalis cervicis (r=0.282, p=.003; r=0.267, p=.005, respectively). Moreover, the CSA loss of the semispinalis cervicis also correlated with the CCI loss rate and the changes in ROM (r=0.312, p=.001; r=0.287, p=.002, respectively). Clinical outcomes such as VAS and NDI scores, improved significantly more in the modified group versus the controls (p<.001 and p=.005, respectively), while JOA scores improved similarly in both groups (p=.132). The incidence of axial symptoms was significantly lower in the modified group versus controls (5.4% vs 9.5%, respectively; p=.023).

CONCLUSIONS

C3 laminectomy combined with modified unilateral laminoplasty is effective for treating patients with multilevel cord compression. This modified technique reconstructs the midline structures and may lead to improved alignment and less axial pain.

Sagittal alignment of the cervical spine: do we know enough for successful surgery?

Over the past decade, there has been growing interest in the sagittal alignment of the cervical spine and its correlation to clinical outcomes. It is now known that cervical lordosis is not universally physiological and should not be pursued in all patients undergoing surgery. Rather, it is increasingly understood that it is how these angular parameters (lordosis or kyphosis) interact with translational parameters that is reflective of overall cervical spine and whole spine balance, which in turn impacts patient outcomes. This review synthesises currently available evidence relating to the sagittal alignment of the cervical spine. Radiographic assessment of the cervical spine including horizontal gaze is discussed and alignment in physiological and pathological states analysed. The interdependence of spinal segments is reviewed, with cervical alignment correction influencing the adjacent thoracic spine, and similarly lumbar lordosis (LL) and global balance correction changing cervical spine alignment. Cervical kyphosis with associated cervical sagittal imbalance is known to lead to poorer post-operative outcomes, and this dichotomy in outcomes has not been shown to improve even with alignment correction. Further work is required to uncover the extent to which cervical spine alignment correction should be attempted toward improved patient outcomes, in order to plan and deliver patient-specific surgical realignment targets.

The change of cervical sagittal parameters plays an important role in clinical outcomes of cervical spondylotic myelopathy after multi-level anterior cervical discectomy and fusion

BACKGROUND

Cervical sagittal parameters were closely related with clinical outcomes after multi-level ACDF. Our purpose was to evaluate the clinical outcomes and cervical sagittal parameters in patients with MCSM after ACDF and to identify the risk factors of poor clinical outcomes.

MATERIAL AND METHODS

ACDF was performed in 89 patients with MCSM. Based on average JOA recovery rate, patients were divided good-outcome group (group GO) and poor-outcome group (group PO). The cervical sagittal parameters including Cobb angle, SVA, T1S, cranial tilt and cervical tilt were measured. Multivariate logistic regression was used to identify risk factors.

RESULTS

Fifty-four patients (60.67%) were divided into group GO, while 35 patients (39.33%) were divided into group PO. Cobb angle, SVA and T1S was corrected from preoperative average 11.80° ± 9.63°, 23.69 mm ± 11.69 mm and 24.43° ± 11.78° to postoperative average 15.08° ± 9.05°, 18.79 mm ± 10.78 mm and 26.92° ± 11.94° respectively (p < 0.001). △Cobb angle (p = 0.008) and △SVA (p = 0.009) showed significantly statistical differences between two groups. Longer symptom duration, lower preoperative JOA score, smaller △Cobb angle and larger △SVA were identified as risk factors of poor clinical outcomes.

CONCLUSION

Multi-level ACDF is an effective surgical method to treat patients with MCSM. However, long duration of preoperative symptoms, lower preoperative JOA score, smaller △Cobb angle and larger △SVA are risk factors for poor outcomes in patients with MCSM after ACDF. Sagittal parameters should be paid attention to in surgery.

Risk factor analysis of axial symptoms after single-segment anterior cervical discectomy and fusion: A retrospective study of 113 patients

Objective

This retrospective study was performed to investigate the risk factors for axial symptoms (AS) after single-segment anterior cervical discectomy and fusion (ACDF).

Methods

One hundred thirteen patients with cervical spondylosis who had undergone single-segment ACDF from January 2012 to December 2015 were divided into those with and without AS (n = 34 and n = 79, respectively). Clinical data and radiological evaluation results were recorded.

Results

The occurrence rate of AS was 30.1% (34/113), and the average visual analog scale score was 4.5 points. Bony fusion was achieved in all cases during follow-up. There were no differences in age, sex, disease duration, diagnostic categories, operative segment, Japanese Orthopaedic Association score, or adjacent segment degeneration. However, cervical range of motion (CROM), cervical curvature, and disc space enlargement significantly differed between the groups. Logistic regression analysis revealed that CROM, cervical curvature, and disc space enlargement were independently associated with AS.

Conclusions

AS after single-segment ACDF is not rare. Disc space enlargement is a risk factor for AS, while higher CROM and lordotic cervical curvature are protective factors. Excessive or insufficient disc space enlargement could increase the incidence of AS. Maintaining CROM within the normal range and restoring cervical lordosis might help to prevent AS.

Clinical Investigation of the Association of Opening Size with Sagittal Canal Diameter Based on Single-Door Cervical Laminoplasty

Background

Many clinical studies have assessed the association of laminoplasty opening size (LOS) with sagittal canal diameter (SCD) based on single-door cervical laminoplasty (SDCL). Nevertheless, the “worn-off” lamina extracted in SDCL was neglected in these reports. We aimed to develop a simple mathematical model to analyze the relationship between the effective LOS and SCD, taking into consideration the worn-off lamina.

Material/Methods

A total of 106 patients treated by SDCL at our hospital were included in this study. Pre-operative and post-operative SCDs were assessed using a picture archiving and communication system (PACS) based on computed tomography scans. Mini-plate sizes as well as drill bit diameters were recorded in detail in order to determine the effective LOS for each vertebral lamina involved.

Results

SCD in all patients was increased significantly after SDCL (P<0.01). A linear correlation was found between effective LOS and the post-operative SCD increment from C3 to C7 (R²>0.933, P<0.001). The 12 mm mini-plate was most often used in SDCL, accounting for 64.45% of all cases, whereas 10 mm and 16 mm mini-plates were the least used, accounting for 3.85% and 3.00%, respectively.

Conclusions

There is a strong linear correlation between effective LOS and the post-operative SCD increment. The SCD was increased by about 0.5 mm per mm increase in effective LOS. Thus, post-operative SCD could be precisely calculated and predicted, enabling the selection of optimal mini-plate prior to SDCL.

Serial plasma DNA levels as predictors of outcome in patients with acute traumatic cervical spinal cord injury

BACKGROUND

Acute traumatic cervical spinal cord injury (SCI) is a leading cause of disability in adolescents and young adults worldwide. Evidence from previous studies suggests that circulating cell-free DNA is associated with severity following acute injury. The present study determined whether plasma DNA levels in acute cervical SCI are predictive of outcome.

METHODS

In present study, serial plasma nuclear DNA (nDNA) and mitochondrial DNA (mtDNA) levels were obtained from 44 patients with acute traumatic cervical SCI at five time points from day 1 to day 180 post-injury. Control blood samples were obtained from 66 volunteers.

RESULTS

Data showed a significant increase in plasma nDNA and mtDNA concentrations at admission in SCI patients compared to the control group. Plasma nDNA levels at admission, but not plasma mtDNA levels, were significantly associated with the Japanese Orthopaedic Association (JOA) score and Injury Severity Score in patients with acute traumatic cervical SCI. In patients with non-excellent outcomes, plasma nDNA increased significantly at days 1, 14 and 30 post-injury. Furthermore, its level at day 14 was independently associated with outcome. Higher plasma nDNA levels at the chosen cutoff point (> 45.6 ng/ml) predicted poorer outcome with a sensitivity of 78.9% and a specificity of 78.4%.

CONCLUSIONS

These results indicate JOA score performance and plasma nDNA levels reflect the severity of spinal cord injury. Therefore, the plasma nDNA assays can be considered as potential neuropathological markers in patients with acute traumatic cervical SCI.

Posterior Surgical Techniques for Cervical Spondylotic Myelopathy: WFNS Spine Committee Recommendations

Objective

This study was conducted to determine and recommend the most up-to-date information on the indications, complications, and outcomes of posterior surgical treatments for cervical spondylotic myelopathy (CSM) on the basis of a literature review.

Methods

A comprehensive literature search was performed, using the MEDLINE (PubMed), the Cochrane Register of Controlled Trials, and Web of Science databases, for peer-reviewed articles published in English during the last 10 years.

Results

Posterior techniques, which include laminectomy alone, laminectomy with fusion, and laminoplasty, are often used in patients with involvement of 3 or more levels. Posterior decompression for CSM is effective for improving patients’ neurological function. Complications resulting from posterior cervical spine surgery include injury to the spinal cord and nerve roots, complications related to posterior screw fixation or instrumentation, C5 palsy, spring-back closure of lamina, and postlaminectomy kyphosis.

Conclusion

It is necessary to consider multiple factors when deciding on the appropriate operation for a particular patient. Surgeons need to tailor preoperative discussions to ensure that patients are aware of these facts. Further research is needed on the cost-to-benefit analysis of various surgical approaches, the comparative efficacy of surgical approaches using various techniques, and long-term outcomes, as current knowledge is deficient in this regard.

Comparative effectiveness of all levels miniplate fixation versus a modified hybrid fixation in cervical expansive open-door laminoplasty

In this study, we first reported of a modified hybrid fixation method in expansive open-door laminoplasty (EOLP) in order to reduce medical costs. The purpose of the present study is to compare the surgical outcomes and cost-effectiveness of the modified fixation with all levels miniplate fixation in EOLP for multilevel cervical spondylotic myelopathy.Data of 67 patients who underwent EOLP from July 2015 to June 2016 were retrospectively analyzed, with 33 in the modified group and 34 in the all miniplate group based on their surgical approaches. Laminae were kept open with alternate levels miniplate and anchor fixation in the modified group, while with all levels miniplate fixation in the all miniplate group. Medical costs and clinical results including Japanese Orthopedic Association (JOA) scores, Visual Analogue Scale (VAS) scores and occurrences of complications were investigated and compared between the 2 groups. After evaluation on X-ray, CT, and MRI, radiographic data reflecting cervical alignments, spinal canal enlargement and spinal cord decompression were collected and compared within each group and between the 2 groups.After a follow-up period of about 18 months, no significant differences in operation time, intraoperative blood loss, complication rates, VAS scores, neurological recovery rates and postoperative hospital stays were observed between the 2 groups. However, EOLP with the modified fixation costed less. When comparing the 2 groups, cervical curvature index (CCIs) which reflected cervical alignments and anteroposterior diameters (APDs) reflecting spinal canal enlargement at all the follow-ups had no significant differences. Postoperative open angles which reflected spinal cord decompression of C4 and C6 were significantly smaller in the modified group. However, that difference was no longer detected at the final follow-up. Within each group, APDs increased significantly after surgery. However, no significant differences in CCIs and open angles at different follow-ups were observed in each group.Compared with all miniplate fixation, the modified hybrid fixation in EOLP showed almost the same clinical and radiographic results. However, the modified hybrid fixation method could reduce costs.

Influence of Fusion on the Behavior of Adjacent Disc Arthroplasty in Contiguous 2-Level Hybrid Surgery In Vivo

OBJECTIVE

To investigate whether the behavior of disc arthroplasty in 2-level hybrid surgery (HS) was affected by adjacent fusion in vivo compared with cervical disc arthroplasty (CDA) alone.

METHODS

Seventy-nine patients undergoing either a 1-level CDA or contiguous 2-level HS were retrospectively reviewed. Radiologic assessments included segmental lordosis (SL), intervertebral disc height (IDH), changes in SL and IDH, range of motion (ROM) of the disc replacement and its adjacent segments, migration and subsidence of the prosthesis, heterotopic ossification (HO), and adjacent segment degeneration (ASD) adjacent to the arthroplasty level. Clinical features and outcome scores were also recorded.

RESULTS

Compared with 1-level CDA, the increased SL and IDH immediately after surgery in 2-level HS were more likely to be lost throughout the follow-up period. However, both groups generally maintained the SL and IDH of the arthroplasty segment postoperatively. Two-level HS did not exhibit hypermobility of the disc prosthesis and preserved preoperative ROM of the adjacent segment of the device. The HS group showed adverse effects on the prosthesis stability, but there was no significant difference in the number of cases of obvious migration or subsidence between the groups. The differences in HO, ASD, and clinical outcomes between the groups were not significant at the final follow-up.

CONCLUSIONS

Although the fusion in 2-level HS partially affected the behavior of adjacent disc arthroplasty compared with CDA alone, it did not cause severe complications and adverse clinical outcomes. However, large-scale and long follow-up trials are warranted.

Relationship Between Sagittal Balance and Axial Symptoms in Patients with Cervical Spondylotic Myelopathy Treated with Anterior Cervical Discectomy and Fusion

Purpose: The purpose of this study was to investigate the sagittal balance of the cervical spine and the clinical outcomes of anterior cervical discectomy and fusion (ACDF) for the treatment of cervical spondylotic myelopathy and to explore whether sagittal balance is related to the incidence of postoperative axial symptoms. Methods: Sixty-seven consecutive patients who underwent ACDF for the treatment of cervical spondylotic myelopathy from January 2014 to December 2016 were enrolled in our study. Sagittal balance parameters (global lordotic angle, segmented lordotic angle, T1 slope, and C2-7 sagittal vertical axis [C2-7 SVA] were recorded in the preoperative period and at 1 month, 3 months, and 1 year postoperatively. Clinical outcomes (JOA and NDI scores) and incidence of axial symptoms were also evaluated before and after surgery. Subgroup analysis included 20 patients with preoperative abnormal sagittal balance group (C2-7 SVA larger than 20 mm), and these patients were divided into two groups, namely axial symptom group and nonaxial symptom group. Result: The sagittal balance parameters (global lordotic angle, segmented lordotic angle, and TI slope) and the clinical outcomes after surgery significantly improved. The subgroup analysis within the preoperative abnormal sagittal balance group showed significant differences in postoperative and change in C2-7 SVA between patients with and without postoperative axial symptoms. Conclusion: ACDF can be applied to restore the sagittal alignment of the cervical spine and effectively improve clinical outcomes for the treatment of cervical spondylotic myelopathy. Sagittal balance improvement may be associated with the low incidence of postoperative axial symptoms for patients with abnormal cervical sagittal balance before surgery.

Comparison of laminectomy and fusion vs laminoplasty in the treatment of multilevel cervical spondylotic myelopathy: A meta-analysis

PURPOSE

The purpose of this study is to evaluate the clinical safety and efficacy between laminectomy and fusion (LF) versus laminoplasty (LP) for the treatment of multi-level cervical spondylotic myelopathy (CSM).

METHODS

The authors searched electronic databases using PubMed, MEDLINE, Embase, Cochrane Controlled Trial Register, and Google Scholar for relevant studies that compared the clinical effectiveness of LF and LP for the treatment of patients with multilevel CSM. The following outcome measures were extracted: the Japanese Orthopaedic Association (JOA) scores, cervical curvature index (CCI), visual analog scale (VAS), Nurich grade, reoperation rate, complications, rate of nerve palsies. Newcastle Ottawa Quality Assessment Scale (NOQAS) was used to evaluate the quality of each study. Data analysis was conducted with RevMan 5.3.

RESULTS

A total of 14 studies were included in our meta-analysis. No significant difference was observed in terms of postoperative Japanese Orthopaedic Association score (P = .29), visual analog scale neck pain (P = .64), cervical curvature index (P = .24), Nurich grade (P = .16) and reoperation rate (P = .21) between LF and LP groups. Compared with LP group, the total complication rate (OR 2.60, 95% CI 1.85, 3.64, I = 26%, P < .00001) and rate of nerve palsies (OR 3.18, 95% CI 1.66, 6.11, I = 47%, P = .0005) was higher in the LF group.

CONCLUSIONS

Our meta-analysis reveals that surgical treatments of multilevel CSM are similar in terms of most clinical outcomes using LF and LP. However, LP was found to be superior than LF in terms of nerve palsy complications. This requires further validation and investigation in larger sample-size prospective and randomized studies.

Clinical comparison between simple laminectomy and laminectomy plus posterior instrumentation in surgical treatment of cervical myelopathy

BACKGROUND

Posterior stabilization in patients treated with laminectomy for spondylotic cervical myelopathy is still a debate. Despite both being reported in literature by several authors, some controversies still exist. The aim of this study is to compare clinical and radiological outcomes in patients treated with laminectomy or laminectomy with posterior stabilization.

MATERIAL AND METHODS

We retrospectively evaluated 42 patients affected by cervical myelopathy (mean age 70.43 ± 5.03 years), 19 treated with laminectomy (group A) and 23 with laminectomy and posterior instrumentation (group B). Neurological status was assessed with Nurick scale, pain with VAS and radiological parameters with C2-C7 SVA, T1 slope and C2-C7 lordosis, clinical function with modified Japanese Orthopaedic Association score (JOA). Also, surgery time and blood loss were recorded. Student's t test was used for continuous variables, while Kruskal-Wallis test was used for categorical values.

RESULTS

No differences were found in postoperative Nurick scale (p = 0.587), VAS (p = 0.62), mJOA (p = 0.197) and T1 slope (p = 0.559), while laminectomy with fusion showed better postoperative cervical lordosis (p = 0.007) and C2-C7 SVA (p < 0.00001), but higher blood loss (p < 0.00001) and surgical time (p < 0.00001). Both groups showed better Nurick scale (p = 0.00017 for group A and p = 0.00081 for group B), VAS (p = 0.02 for group A and p = 0.046 for group B) and mJOA (p < 0.00001 for both groups) than preoperative values.

CONCLUSIONS

Both treatments are a valuable choice, offering some benefits and disadvantages against each other. Each procedure must be carefully evaluated on the basis of patients' general status, preoperative pain, signs of instability and potential benefits from cervical alignment correction.

Comparison of clinical outcomes and safety between laminectomy with instrumented fusion versus laminoplasty for the treatment of multilevel cervical spondylotic myelopathy

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVES

Posterior laminectomy with instrumented fusion and laminoplasty are widely used for the treatment of multilevel cervical spondylotic myelopathy (MCSM). There is great controversy over the preferred surgical method. The purpose of this study is to evaluate the clinical outcomes and safety between laminectomy with instrumented fusion and laminoplasty for the treatment of MCSM.

METHODS

Related studies that compared the effectiveness of laminectomy with instrumented fusion and laminoplasty for the treatment of MCSM were acquired by a comprehensive search in PubMed, Embase, the Cochrane library, CNKI, VIP, and WANFANG up to April 2018. Included studies were evaluated according to eligibility criteria. The main endpoints included: preoperative and postoperative Japanese Orthopedic Association (JOA) scores, preoperative and postoperative visual analog scale (VAS), preoperative and postoperative cervical range of motion (ROM), preoperative and postoperative cervical curvature index (CCI), overall complication rate, C5 nerve palsy rate, axial symptoms rate, operation time and blood loss.

RESULTS

A total of 15 studies were included in this meta-analysis. All of the selected studies were of high quality as indicated by the Newcastle-Ottawa scale (NOS). Among 1131 patients, 555 underwent laminectomy with instrumented fusion and 576 underwent laminoplasty. The results of this meta-analysis indicated no significant difference in preoperative and postoperative JOA scores, preoperative and postoperative VAS, preoperative and postoperative CCI, preoperative ROM and axial symptoms rate. However, compared with laminoplasty, laminectomy with instrumented fusion exhibited a higher overall complication rate [RR = 1.99, 95% confidence intervals (CI) (1.24, 3.21), P <.05], a higher C5 palsy rate [RR = 2.22, 95% CI (1.30, 3.80), P <.05], a decreased postoperative ROM [SMD = -1.51, 95% CI (-2.14, -0.88), P <.05], a longer operation time [SMD = 0.51, 95% CI (0.12, 0.90), P <.05] and increased blood loss [SMD = 0.47, 95% CI (0.30, 0.65), P <.05].

CONCLUSION

These results suggested that both posterior laminectomy with instrumented fusion and laminoplasty were determined to be effective for MCSM. However, laminoplasty appeared to allow for a greater ROM, lower overall complication and C5 palsy rates, shorter operation time and lower blood loss. Future well-designed, randomized controlled trials are still needed to further confirm our results.

The Efficacy of Posterior Cervical Laminectomy for Multilevel Degenerative Cervical Spondylotic Myelopathy in Long Term Period

Study Design:

This was a retrospective analysis.

Background:

Surgical decompression is the gold standard for preventing the progression of neurological deficit in degenerative multilevel cervical spondylotic myelopathy (CSM). The efficacy of posterior laminectomy in the surgical management of CSM has been described in the past, but long-term follow-up data are scanty.

Objective:

The aim of this study is to assess the long-term clinical-radiological outcomes following posterior cervical decompressive laminectomy in multilevel degenerative CSM.

Materials and Methods:

A retrospective analysis of 110 patients with degenerative multilevel CSM who underwent posterior cervical laminectomy alone in a single hospital by a single surgeon from 2009 to 2013 with minimum 5-year follow-up. Pre- and post-operative clinical parameters (visual analog scale [VAS], Nurick and modified Japanese orthopedic association [mJOA]), radiological parameter (Sagittal cervical Cobb's Angle), perioperative complications (time, blood loss, and hospital stay), postoperative complications (infection, C5 palsy, and neurological worsening) were evaluated.

Results:

Totally 110 patients (males – 68 and females – 42) with age varying from 46 to 80 (mean-57) years, and the mean duration of illness was 3 months were evaluated. Mean clinical parameters are VAS (preoperative = 5 ± 1.31, postoperative = 1.49 ± 0.687), Nurick grading (preoperative = 3.23 ± 71, postoperative = 1.924 ± 0.75), and mJOA (preoperative = 6.32 ± 0.87, postoperative = 9.89 ± 1.37). The mean blood loss was 93.95 ± 19.18 ml, and the mean time taken for surgery was 83.65 ± 10.18 min. About 13% (n = 15) patients developed cervical kyphosis and 29% (n = 32) developed changes in cervical spine alignment and 10% (n = 11) developed worsening of neurology at final follow-up. Two patients developed a superficial infection which was managed with antibiotics. Three patients developed C5 palsy which recovered with due time.

Conclusions:

With the proper selection of patients, posterior cervical laminectomy is effective in offering a clinical improvement to patients with degenerative multilevel CSM with a low incidence of clinically significant radiological deterioration.

Is the behavior of disc replacement adjacent to fusion affected by the location of the fused level in hybrid surgery?

BACKGROUND CONTEXT

Hybrid surgery (HS), consisting of cervical disc arthroplasty (CDA) at the mobile level, along with anterior cervical discectomy and fusion at the spondylotic level, could be a promising treatment for patients with multilevel cervical degenerative disc disease (DDD). An advantage of this technique is that it uses an optimal procedure according to the status of each level. However, information is lacking regarding the influence of the relative location of the replacement and the fusion segment in vivo.

PURPOSE

We conducted the present study to investigate whether the location of the fusion affected the behavior of the disc replacement and adjacent segments in HS in vivo.

STUDY DESIGN

This is an observational study.

PATIENT SAMPLE

The numbers of patients in the arthroplasty-fusion (AF) and fusion-arthroplasty (FA) groups were 51 and 24, respectively.

OUTCOME MEASURES

The Japanese Orthopedic Association (JOA), Neck Disability Index (NDI), and Visual Analog Scale (VAS) scores were evaluated. Global and segmental lordosis, the range of motion (ROM) of C2-C7, and the operated and adjacent segments were measured. Fusion rate and radiological changes at adjacent levels were observed.

METHODS

Between January 2010 and July 2016, 75 patients with cervical DDD at two contiguous levels undergoing a two-level HS were retrospectively reviewed. The patients were divided into AF and FA groups according to the locations of the disc replacement. Clinical outcomes were evaluated according to the JOA, NDI, and VAS scores. Radiological parameters, including global and segmental lordosis, the ROM of C2-C7, the operated and adjacent segments, and complications, were also evaluated.

RESULTS

Although the JOA, NDI, and VAS scores were improved in both the AF and the FA groups, no significant differences were found between the two groups at any follow-up point. Both groups maintained cervical lordosis, but no difference was found between the groups. Segmental lordosis at the fusion segment was significantly improved postoperatively (p<.001), whereas it was maintained at the arthroplasty segment. The ROM of C2-C7 was significantly decreased in both groups postoperatively (AF p=.001, FA p=.014), but no difference was found between the groups. The FA group exhibited a non-significant improvement in ROM at the arthroplasty segment. The ROM adjacent to the arthroplasty segment was increased, although not significantly, whereas the ROM adjacent to the fusion segment was significantly improved after surgery in both groups (p<.001). Fusion was achieved in all patients. No significant difference in complications was found between the groups.

CONCLUSIONS

In HS, cephalic or caudal fusion segments to the arthroplasty segment did not affect the clinical outcomes and the behavior of CDA. However, the ROM of adjacent segments was affected by the location of the fusion segment; segments adjacent to fusion segments had greater ROMs than segments adjacent to arthroplasty segments.

Limited laminectomy and foraminal decompression combined with internal fixation for treating multi-segment cervical spondylotic myelopathy: Does it effectively improve neurological function and prevent C5 palsy?

Laminectomy is an effective surgical treatment for multi-segment cervical spondylotic myelopathy (M-CSM) but usually results in C5 palsy. Some surgical techniques to restore the spinal sequence, increase the intervertebral foramen diameter, and limit the spinal cord drift distance have been proposed; however, it is unclear whether these procedures can avoid this complication.To investigate the clinical efficacy of limited laminectomy and foraminal decompression with fixation (LLFDF) for improving neurological recovery and preventing C5 palsy.A total of 71 patients with M-CSM were retrospectively analyzed. Thirty-nine of them were treated with LLFDF (group A) and 32 with normal laminectomy with fixation (NLF; group B) after 3 months of formal conservative treatment. Pre- and postoperative neurological function, spinal cord drift distance, cervical curvature index (CCI), and number of C5 palsy cases were recorded and analyzed.There was no significant intergroup difference in the surgical time or intraoperative blood loss (P >.05). The laminectomy widths in groups A and B were 16.7 ± 2.6 mm and 21.8 ± 2.9 mm, respectively (P <.01), while the spinal cord drift distances were 2.3 ± 0.4 mm and 3.6 ± 0.7 mm, respectively (P <.01). The mean Japanese Orthopedic Association score of both groups increased significantly after surgery (P <.01), and no significant difference was noted at any observation time points (P >.05). Both groups demonstrated significant CCI improvements after surgery compared with those before surgery (P <.01). There were 2 cases of C5 palsy in group A (5.1%) and 8 cases in group B (25.0%), and the difference was significant (P <.05).LLFDF can relieve spinal compression and considerably promote neurological recovery. Moreover, it restricts excessive spinal cord back drifting and decreases the incidence of C5 palsy.

Comparison of 6-year Follow-up Result of Hybrid Surgery and Anterior Cervical Discectomy and Fusion for the Treatment of Contiguous Two-segment Cervical Degenerative Disc Diseases

STUDY DESIGN

A retrospective study.

OBJECTIVE

To compare the mid-term outcomes of hybrid surgery (HS) and anterior cervical discectomy and fusion (ACDF) for the treatment of contiguous two-segment cervical degenerative disc diseases.

SUMMARY OF BACKGROUND DATA

HS has become one of the most controversial subjects in spine communities, and the comparative studies of HS and ACDF in the mid- and long-term follow-up are rarely reported.

METHODS

From 2009 to 2012, 42 patients who underwent HS (n = 20) or ACDF (n = 22) surgery for symptomatic contiguous two-level cervical degenerative disc diseases were included. Clinical and radiological records, including Japanese Orthopedic Association (JOA), Neck Disability Index (NDI), Visual Analogue Scale (VAS), local cervical lordosis, and range of motion (ROM), were reviewed retrospectively. Complications were recorded and evaluated.

RESULTS

Mean follow-up was 77.25 and 79.68 months in HS group and ACDF group, respectively (P > 0.05). Both in HS group and ACDF group, significant improvement for the mean JOA, NDI, and VAS scores was found at 2-week postoperation and at the last follow-up (P < 0.05). However, there were no significant differences between the two groups (P > 0.05). At the last follow-up, the range of motion (ROM) of superior adjacent segments in ACDF group was significantly larger than HS group (P < 0.05), while the ROM of C2-C7 was significantly smaller (P < 0.05). In the HS group, two (10%) sagittal wedge deformities, one (5%) heterotopic ossification, and one (5%) anterior migration of the Byran disc prosthesis were found. No symptomatic adjacent segment degeneration occurred in two groups.

CONCLUSION

HS appears to be an acceptable option in the management of contiguous two-segment cervical degenerative disc diseases. It yielded similar mid-term clinical improvement to ACDF, and demonstrated better preservation of cervical ROM. The incidence of postoperative sagittal wedge deformity was low; however, it can significantly reduce the cervical lordosis.

LEVEL OF EVIDENCE

4.