Surgically treated cervical myelopathy: a functional outcome comparison study between multilevel anterior cervical decompression fusion with instrumentation and posterior laminoplasty

A Comparison of Clinical Outcomes Between Anterior Cervical Discectomy and Fusion Versus Posterior Cervical Laminoplasty for Multilevel Cervical Myelopathy

STUDY DESIGN

Retrospective Cohort.

OBJECTIVE

To compare patient-reported outcomes and surgical outcomes after anterior cervical discectomy and fusion (ACDF) versus cervical laminoplasty for multilevel cervical spondylotic myelopathy.

BACKGROUND

Treatment options for multilevel cervical spondylotic myelopathy include ACDF and cervical laminoplasty. Given that the literature has been mixed regarding the optimal approach, especially in patients without kyphosis, there is a need for additional studies investigating outcomes between ACDF and cervical laminoplasty.

METHODS

A retrospective review was conducted of adult patients undergoing 3 or 4-level surgery. Patients with preoperative kyphosis based on C2-C7 Cobb angles were excluded. The electronic medical record and institutional databases were reviewed for baseline characteristics, surgical outcomes, and patient-reported outcomes.

RESULTS

A total of 101 patients who underwent ACDF and 52 patients who underwent laminoplasty were included in the study. The laminoplasty cohort had a higher overall Charlson Comorbidity Index (3.10 ± 1.43 vs 2.39 ± 1.57, P = 0.011). Both groups had a comparable number of levels decompressed, C2-C7 lordosis, and diagnosis of myelopathy versus myeloradiculopathy. Patients who underwent laminoplasty had a longer length of stay (2.04 ± 1.15 vs 1.48 ± 0.70, P = 0.003) but readmission, complication, and revision rates were similar. Both groups had similar improvement in myelopathy scores (∆modified Japanese Orthopedic Association: 1.11 ± 3.09 vs 1.06 ± 3.37, P = 0.639). ACDF had greater improvement in Neck Disability Index (∆Neck Disability Index: -11.66 ± 19.2 vs -1.13 ± 11.2, P < 0.001), neck pain (∆Visual Analog Scale-neck: -2.69 ± 2.78 vs -0.83 ± 2.55, P = 0.003), and arm pain (∆Visual Analog Scale-arm: -2.47 ± 3.15 vs -0.48 ± 3.19, P = 0.010). These findings persisted in multivariate analysis except for Neck Disability Index.

CONCLUSION

ACDF and cervical laminoplasty appear equally efficacious at halting myelopathic progression. However, patients who underwent ACDF had greater improvements in arm pain at 1 year postoperatively. Longitudinal studies evaluating the efficacy of laminoplasty to mitigate adjacent segment disease are indicated to establish a robust risk-benefit assessment for these 2 procedures.

LEVEL OF EVIDENCE

III.

Impact of Metabolic Syndrome on Early Postoperative Outcomes After Cervical Disk Replacement: A Propensity-matched Analysis

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To compare the demographics, perioperative variables, and complication rates following cervical disk replacement (CDR) among patients with and without metabolic syndrome (MetS).

SUMMARY OF BACKGROUND DATA

The prevalence of MetS-involving concurrent obesity, insulin resistance, hypertension, and hyperlipidemia-has increased in the United States over the last 2 decades. Little is known about the impact of MetS on early postoperative outcomes and complications following CDR.

METHODS

The 2005-2020 National Surgical Quality Improvement Program was queried for patients who underwent primary 1- or 2-level CDR. Patients with and without MetS were divided into 2 cohorts. MetS was defined, according to other National Surgical Quality Improvement Program studies, as concurrent diabetes mellitus, hypertension requiring medication, and body mass index ≥30 kg/m 2 . Rates of 30-day readmission, reoperation, complications, length of hospital stay, and discharge disposition were compared using χ 2 and Fisher exact tests. One to 2 propensity-matching was performed, matching for demographics, comorbidities, and number of operative levels.

RESULTS

A total of 5395 patients were included for unmatched analysis. Two hundred thirty-six had MetS, and 5159 did not. The MetS cohort had greater rates of 30-day readmission (2.5% vs. 0.9%; P =0.023), morbidity (2.5% vs. 0.9%; P =0.032), nonhome discharges (3% vs. 0.6%; P =0.002), and longer hospital stays (1.35±4.04 vs. 1±1.48 days; P =0.029). After propensity-matching, 699 patients were included. All differences reported above lost significance ( P >0.05) except for 30-day morbidity (superficial wound infections), which remained higher for the MetS cohort (2.5% vs. 0.4%, P =0.02).

CONCLUSIONS

We identified MetS as an independent predictor of 30-day morbidity in the form of superficial wound infections following single-level CDR. Although MetS patients experienced greater rates of 30-day readmission, nonhome discharge, and longer lengths of stay, MetS did not independently predict these outcomes after controlling for baseline differences in patient characteristics.

LEVEL OF EVIDENCE

Level III.

Biomechanical Comparison of Anterior Cervical Corpectomy Decompression and Fusion, Anterior Cervical Discectomy and Fusion, and Anterior Controllable Antedisplacement and Fusion in the Surgical Treatment of Multilevel Cervical Spondylotic Myelopathy: A Finite Element Analysis

PURPOSE

Multilevel cervical spondylotic myelopathy poses significant challenges in selecting optimal surgical approaches, warranting a comprehensive understanding of their biomechanical impacts. Given the lack of consensus regarding the most effective technique, this study aims to fill this critical knowledge gap by rigorously assessing and comparing the biomechanical properties of three distinct surgical interventions, including anterior controllable antedisplacement and fusion (ACAF), anterior cervical corpectomy decompression and fusion (ACCF), and anterior cervical discectomy and fusion (ACDF). The study offers pivotal insights to enhance treatment precision and patient outcomes.

METHODS

The construction of the cervical spine model involved a detailed process using CT data, specialized software (Mimics, Geomagic Studio, and Hypermesh) and material properties obtained from prior studies. Surgical instruments were modeled (titanium mesh, anterior cervical plate, interbody cage, and self-tapping screws) to simulate three surgical approaches: ACAF, ACCF, and ACDF, each with specific procedures replicating clinical protocols. A 75-N follower load with 2 Nm was applied to simulate biomechanical effects.

RESULTS

The range of motion decreased more after surgery for ACAF and ACDF than for ACCF, especially in flexion and lateral bending. ACCF have higher stress peaks in the fixation system than those of ACAF and ACDF, especially in flexion. The maximum von Mises stresses of the bone-screw interfaces at C3 of ACCF were higher than those of ACAF and ACDF. The maximum von Mises stresses of the bone-screw interfaces at C6 of ACDF were much higher than those of ACAF and ACCF. The maximum von Mises stresses of the grafts of ACCF and ACAF were much higher than those of ACDF. The maximum von Mises stresses of the endplate of ACCF were much higher than those of ACAF and ACDF.

CONCLUSION

The ACAF and ACDF models demonstrated superior cervical reconstruction stability over the ACCF model. ACAF exhibited lower risks of internal fixation failure and cage subsidence compared to ACCF, making it a promising approach. However, while ACAF revealed improved stability over ACCF, higher rates of subsidence and internal fixation failure persisted compared to ACDF, suggesting the need for further exploration of ACAF's long-term efficacy and potential improvements in clinical outcomes.

Posterior endoscopic decompression combined with anterior cervical discectomy and fusion versus posterior laminectomy and fusion for multilevel cervical spondylotic myelopathy: a retrospective case-control study

OBJECTIVE

To compare the clinical efficacy of surgical treatment for multilevel cervical spondylotic myelopathy (MCSM) between the hybrid procedure, posterior endoscopic decompression (PED) combined with anterior cervical discectomy fusion (ACDF), and posterior cervical laminectomy and fusion (PCLF).

METHODS

A retrospective analysis was performed on 38 patients who received surgical treatment for MCSM from January 2018 to December 2021, including 19 cases in hybrid procedure group (13 males and 6 females), followed up for 10 to 22 (12.8 ± 10.3) months, and 19 cases in PCLF group (15 males and 4 females), followed up for 10 to 21 (11.7 ± 8.9) months. Perioperative information, including operation time, intraoperative blood loss, length of hospitalization, and complications, were compared between two groups. Visual analogue scale (VAS) of pain, neck disability index (NDI) and Japanese Orthopaedic Association (JOA) score were recorded to evaluate clinical efficacy. Cervical lordosis was calculated by radiographic examination.

RESULTS

Intraoperative blood loss, length of hospital stay were less in hybrid group than PCLF group, while operation time is longer in hybrid group, with a statistically significant difference (p < 0.05). Increased lordosis was better in hybrid group. There was no significant difference in preoperative VAS, JOA and NDI at pre-operation and final follow-up between two groups. But at post-operation and final follow-up, VAS was less in hybrid group than PCLF group (p < 0.05). There were 2 cases of neurostimulation symptoms in hybrid group, 2 cases of C5 nerve root palsy, 2 cases of subcutaneous fat necrosis and 1 case of dural tear in PCLF group, and all patients relieved with symptomatic treatment.

CONCLUSION

The hybrid procedure of PED combined with ACDF showed satisfied clinical outcome, with less intraoperative blood loss, shorter length of hospitalization and lower post-operative neck pain than PCLF. It is an effective surgical treatment for MCSM.

Efficacy of the PainVision apparatus for assessment of axial neck pain after cervical laminoplasty: a prospective study

BACKGROUND

Axial neck pain is one of the complications of posterior cervical surgeries such as laminoplasty. This study aimed to investigate the efficiency of the PainVision apparatus for axial neck pain assessment by comparing it with other methods.

METHODS

This prospective study included 118 patients (90 men and 28 women; average age: 66.9 (32-86) years) with cervical myelopathy who underwent open-door laminoplasty at our medical center between April 2009 and August 2019. Pain degree (PD) measured by PainVision, visual analog scale (VAS), and bodily pain (BP), a subitem of the MOS 36-Item Short-Form Health Survey (SF36), were used to evaluate axial neck pain, which was investigated preoperatively and at 3, 6, 12, 18, and 24 months postoperatively.

RESULTS

Comparison of the scores at each evaluation time point found significant improvement between the pre- and post-operative values for all assessment methods. Further, on comparing the amounts of change between pre- and post-operative scores in each pain assessment method, we found significant differences in PD and VAS but not in BP. We also found significant positive correlations between PD and VAS at each time point (all p < 0.001) and significant negative correlations between PD and BP (all p < 0.05) and between VAS and BP (all p < 0.01)  at each time point.

CONCLUSIONS

In this study, we demonstrated that PD and VAS are more sensitive indicators of changes in axial neck pain than BP and also that PD has an excellent correlation with VAS. These results suggest that the PainVision apparatus may be an effective instrument for quantifying axial neck pain after cervical laminoplasty, though its superiority over VAS needs to be verified in future studies.

Nationwide sample data analysis of additional surgery rate after anterior or posterior cervical spinal surgery

Surgical outcomes of degenerative cervical spinal disease are dependent on the selection of surgical techniques. Although a standardized decision cannot be made in an actual clinical setting, continued education is provided to standardize the medical practice among surgeons. Therefore, it is necessary to supervise and regularly update overall surgical outcomes. This study aimed to compare the rate of additional surgery between anterior and posterior surgeries for degenerative cervical spinal disease using the National Health Insurance Service-National Sample Cohort (NHIS-NSC) nationwide patient database. The NHIS-NSC is a population-based cohort with about a million participants. This retrospective cohort study included 741 adult patients (> 18 years) who underwent their first cervical spinal surgery for degenerative cervical spinal disease. The median follow-up period was 7.3 years. An event was defined as the registration of any type of cervical spinal surgery during the follow-up period. Event-free survival analysis was used for outcome analysis, and the following factors were used as covariates for adjustment: location of disease, sex, age, type of insurance, disability, type of hospital, Charles comorbidity Index, and osteoporosis. Anterior cervical surgery was selected for 75.0% of the patients, and posterior cervical surgery for the remaining 25.0%. Cervical radiculopathy due to foraminal stenosis, hard disc, or soft disc was the primary diagnosis in 78.0% of the patients, and central spinal stenosis was the primary diagnosis in 22.0% of them. Additional surgery was performed for 5.0% of the patients after anterior cervical surgery and 6.5% of the patients after posterior cervical surgery (adjusted subhazard ratio, 0.83; 95% confidence interval, 0.40-1.74). The rates of additional surgery were not different between anterior and posterior cervical surgeries. The results would be helpful in evaluating current practice as a whole and adjusting the health insurance policy.

Patient-Reported Outcomes Following Anterior and Posterior Surgical Approaches for Multilevel Cervical Myelopathy

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To compare health-related quality of life (HRQoL) outcomes between approach techniques for the treatment of multilevel degenerative cervical myelopathy (DCM).

SUMMARY OF BACKGROUND DATA

Both anterior and posterior approaches for the surgical treatment of cervical myelopathy are successful techniques in the treatment of myelopathy. However, the optimal treatment has yet to be determined, especially for multilevel disease, as the different approaches have separate complication profiles and potentially different impacts on HRQoL metrics.

MATERIALS AND METHODS

Retrospective review of a prospectively managed single institution database of patient-reported outcome measures after 3 and 4-level anterior cervical discectomy and fusion (ACDF) and posterior cervical decompression and fusion (PCDF) for DCM. The electronic medical record was reviewed for patient baseline characteristics and surgical outcomes whereas preoperative radiographs were analyzed for baseline cervical lordosis and sagittal balance. Bivariate and multivariate statistical analyses were performed to compare the two groups.

RESULTS

We identified 153 patients treated by ACDF and 43 patients treated by PCDF. Patients in the ACDF cohort were younger (60.1 ± 9.8 vs . 65.8 ± 6.9 yr; P < 0.001), had a lower overall comorbidity burden (Charlson Comorbidity Index: 2.25 ± 1.61 vs . 3.07 ± 1.64; P = 0.002), and were more likely to have a 3-level fusion (79.7% vs . 30.2%; P < 0.001), myeloradiculopathy (42.5% vs . 23.3%; P = 0.034), and cervical kyphosis (25.7% vs . 7.69%; P = 0.027). Patients undergoing an ACDF had significantly more improvement in their neck disability index after surgery (-14.28 vs . -3.02; P = 0.001), and this relationship was maintained on multivariate analysis with PCDF being independently associated with a worse neck disability index (+8.83; P = 0.025). Patients undergoing an ACDF also experienced more improvement in visual analog score neck pain after surgery (-2.94 vs . -1.47; P = 0.025) by bivariate analysis.

CONCLUSIONS

Our data suggest that patients undergoing an ACDF or PCDF for multilevel DCM have similar outcomes after surgery.

Post-operative dysphagia following ventral cervical approach: complication or side-effect? Retrospective analysis and review of the literature

OBJECTIVE

To ameliorate the clinical decision-making process when debating between a ventral or dorsal cervical approach by elucidating whether post-operative dysphagia be regarded as a complication or a transient side effect.

METHODS

A literature review of studies comparing complication rates following ventral and dorsal cervical approaches was performed. A stratified complication rate excluding dysphagia was calculated and discussed. A retrospective cohort of patients operated for degenerative cervical myelopathy in a single institution comprising 665 patients was utilized to analyze complication rates using a uniform definition for dysphagia.

RESULTS

Both the ventral and the dorsal approach groups exhibited comparable neurological improvement rates. Since transient dysphagia was not considered a complication, the dorsal approach was associated with higher level of overall complications.

CONCLUSIONS AND RELEVANCE

Inconsistencies in the definition of dysphagia following ventral cervical surgery impedes the interpretation of trials comparing dorsal and ventral complication rates. A uniform definition for complications and side effects may enhance the validity of medical trials.

Frailty as a Superior Predictor of Dysphagia and Surgically Placed Feeding Tube Requirement After Anterior Cervical Discectomy and Fusion Relative to Age

Frailty is a measure of physiological reserve that has been demonstrated to be a discriminative predictor of worse outcomes across multiple surgical subspecialties. Anterior cervical discectomy and fusion (ACDF) is one of the most common neurosurgical procedures in the United States and has a high incidence of postoperative dysphagia. To determine the association between frailty and dysphagia after ACDF and compare the predictive value of frailty and age. 155,300 patients with cervical stenosis (CS) who received ACDF were selected from the 2016-2019 National Inpatient Sample (NIS) utilizing International Classification of Disease, tenth edition (ICD-10) codes. The 11-point modified frailty index (mFI-11) was used to stratify patients based on frailty: mFI-11 = 0 was robust, mFI-11 = 1 was prefrail, mFI-11 = 2 was frail, and mFI-11 = 3 + was characterized as severely frail. Demographics, complications, and outcomes were compared between frailty groups. A total of 155,300 patients undergoing ACDF for CS were identified, 33,475 (21.6%) of whom were frail. Dysphagia occurred in 11,065 (7.1%) of all patients, and its incidence was significantly higher for frail patients (OR 1.569, p < 0.001). Frailty was a risk factor for postoperative complications (OR 1.681, p < 0.001). Increasing frailty and undergoing multilevel ACDF were significant independent predictors of negative postoperative outcomes, including dysphagia, surgically placed feeding tube (SPFT), prolonged LOS, non-home discharge, inpatient death, and increased total charges (p < 0.001 for all). Increasing mFI-11 score has better prognostic value than patient age in predicting postoperative dysphagia and SPFT after ACDF.

Efficacy and safety of anterior cervical discectomy and fusion (ACDF) through mini-incision and posterior laminoplasty (LAMP) for treatment of long-level cervical spondylosis: a retrospective cohort study

BACKGROUND

The efficacy and safety of anterior cervical discectomy and fusion (ACDF) through mini-incision and posterior laminoplasty for long-level cervical spondylosis were investigated.

METHOD

From January 2018 to September 2019, clinical patients data with 3-4 segments (C3-7) cervical spondylotic radiculopathy, cervical spondylotic myelopathy, or mixed cervical spondylosis who received ACDF (42 cases) throughwith mini-incision or LAMP (36 cases) treatment were retrospectively collected and analyzed. The operative time, bleeding volume, incisive length, and hospital stay were recorded. Moreover, the intervertebral height, functional segment height, cervical lordosis, cervical hyperextension and hyperflexion range-of-motion (ROM) and ROM in all directions of the cervical spine before and after the operation were measured. Additionally, all relevant postoperative complications were also recorded. Then, the therapeutic effects of both surgical methods were investigated.

RESULTS

Patients in the ACDF group had less bleeding, shorter incision, and fewer hospitalization days than the LAMP group. There was no significant difference in JOA, VAS score of the upper limb, NDI score after surgery between two groups. Postoperative intervertebral height and functional segment height in the ACDF group were significantly higher than those before the operation, and postoperative functional segment height of the ACDF group was significantly higher than that of the LAMP group. Moreover, the postoperative cervical lordosis angle in the ACDF group was significantly larger than the LAMP group. There was no significant difference between preoperative and postoperative ROM in all directions of the cervical spine for the two groups.

CONCLUSIONS

Both ACDF through mini-incision and LAMP are effective treatments for long-level cervical spondylosis. However, ACDF through mini-incision shows minor trauma, less bleeding, fast recovery, and it is beneficial for cervical lordosis reconstruction.

Double Dome Laminoplasty: A Novel Technique for C2 Decompression

Objective

To introduce a new surgical technique - double dome laminoplasty for decompression of the entire C2 lamina and preservation of an extensor muscle insertion.

Methods

Eleven consecutive cervical myelopathy patients due to ossification of the posterior longitudinal ligament involving the Axis (C2) area were contained at this study. Direct decompression was evaluated as an increasing rate in space available cord (%) and posterior cord shift (mm) at C2 level. The Japanese Orthopaedic Association (JOA) score, visual analogue scale, and C2–7 Cobb angle in a neutral lateral x-ray were analyzed.

Results

The mean increase in space available for spinal cord at the C2 level, average posterior cord shift, and JOA recovery rate were 69.7%, 5.3±0.15 mm, and 58.0%, respectively. Cervical lordotic angle was maintained in all patients. One patient reported neck pain (visual analogue scale 6) postoperatively. No specific complications such as C2 laminar fracture or insufficient decompression were observed.

Conclusion

We recommend double dome laminoplasty for treating patients with cervical myelopathy involving the C2 area to avoid C2 laminectomy, reduce postoperative neck pain, and maintain lordotic cervical spine alignment.

ACDF and posterior spinal fusion revision for posterior nonunion with deformity, myelopathy, and osteoporosis in an 87-year-old: A case report and literature review

Introduction

Cervical spondylotic myelopathy (CSM) is a spinal degenerative disorder that can ultimately lead to compression of the vertebral column with neurological sequelae. Although CSM is the most common spine pathology in the elderly American population, it remains a challenging disorder to treat among older patients.

Case presentation

We report an 86 year old female patient with CSM with a history of posterior cervical fusion attempt on C3-C6 that progressed to C3-C6 nonunion with loose instrumentation. The patient had severe osteoporosis. With these indications, the patient underwent a combined anterior-posterior decompression and fusion (CAPDF) consisting of anterior cervical discectomy and fusion (ACDF) of the C3-C5, corpectomy of C6 and C7 with off FDA label use of polymethyl methacrylate augmentation (PMMA) fixation of T1 screws anteriorly for C3-T1 plate fixation and second stage instrumented posterior spinal fusion (PSF) of C3-T3. The patient had a successful fusion and reduction of her cervical spine pain with preservation of her neurological status.

Discussion

We report this case of multi-stage combined anterior and posterior fusion as a corrective measure for pseudarthrosis of a prior posterior cervical spinal fusion attempt.

Conclusion

In the event of posterior spinal fusion instrumentation failure in patients with severe osteoporosis, combined multi-stage anterior-posterior fusion is a viable corrective intervention in octogenarians. This case also illustrated the utility of using PMMA for anterior cervical plate and screw stabilization in osteoporotic bone. The authors are not aware of the prior use of PMMA for screw fixation augmentation in the anterior cervical spine.

•

Combined anterior-posterior cervical fusion for cervical spondylotic myelopathy and pseudarthrosis of prior intended fusion.

•

Polymethylmethacrylate (PMMA) demonstrated as safe and effective for screw purchase augmentation in anterior cervical spine

•

Multi stage spinal fusion to limit prolonged one-stage anesthesia identified to be safe and effective for this patient

•

Management of cervical fusion pseudarthrosis in the setting of osteoporosis in the elderly

Current concepts of spondylosis and posterior spinal motion preservation for radiologists

Spinal fusion is performed to eliminate motion at a degenerated or unstable segment. However, this is associated with loss of motion at the fused levels and increased stress on adjacent levels. Motion-preserving implants have been designed in effort to mitigate the limitations of fusion. This review will focus on posterior spinal motion-preserving technologies. In the cervical spine, laminoplasty is a posterior motion-preserving procedure used in the management of myelopathy/cord compression. In the lumbar spine, motion-sparing systems include interspinous process devices (also referred to as interspinous process spacers or distraction devices), posterior dynamic stabilization devices (also referred to as pedicle screw/rod fixation-based systems), and posterior element replacement systems (also referred to as total facet replacement devices). Knowledge of the intended physiologic purpose, hardware utilized, and complications is important in the assessment of imaging in those who have undergone posterior motion preservation procedures.

Potential of intraoperative ultrasonographic assessment of the spinal cord central echo complex in predicting postoperative neurological recovery of degenerative cervical myelopathy

BACKGROUND AND PURPOSE

The spinal cord central echo complex (SCCEC) is a special ultrasonography-based intramedullary structure, but its clinical significance in degenerative cervical myelopathy (DCM) is undefined. This study aimed to explore the potential of the SCCEC in predicting postoperative neurological recovery in DCM.

METHODS

Thirty-two DCM patients who underwent intraoperative ultrasonography-guided French-door laminoplasty were prospectively enrolled. The modified Japanese Orthopaedic Association (mJOA) score was evaluated preoperatively and 12 months postoperatively. SCCEC width (SCCEC-W), and anteroposterior diameter (APD) and transverse diameter (TD) of the spinal cord were measured on transverse ultrasonographic images, while the tissue widths from anterior and posterior borders of the spinal cord to the SCCEC were measured on sagittal ultrasonographic images. The APD of the spinal cord and occupying rate of the spinal canal were measured on preoperative magnetic resonance imaging (MRI).

RESULTS

All patients achieved improvements in mJOA scores, with an average recovery rate (RR) of 68.69 ± 20.22%. Spearman correlation analysis revealed that SCCEC-W, and ratios between the SCCEC-W and APD/TD based on ultrasonography, correlated moderately with mJOA score RR, with coefficients of -0.527, -0.605 and -0.514, respectively. The ratio between SCCEC-W and ultrasonographic TD correlated moderately with preoperative APD of the spinal cord. The MRI measurements and ultrasonography-based tissue widths showed no significant correlation with mJOA score RR.

CONCLUSIONS

The SCCEC may have predictive potential as an intraoperative indicator of neurological recovery in treating DCM. SCCEC-W may be related to spinal cord compression in DCM.

Inadequate spinal cord expansion in intraoperative ultrasound after decompression may predict neurological recovery of degenerative cervical myelopathy

OBJECTIVE

To compare the neurological recovery between patients with adequate and inadequate immediate spinal cord expansion after sufficient decompression in degenerative cervical myelopathy (DCM).

METHODS

Twenty-seven patients subjected to French-door laminoplasty underwent the guidance of intraoperative ultrasound (IOUS) and were prospectively included. The modified Japanese Orthopedic Association (mJOA) score was evaluated before surgery and at 12 months postoperatively. The maximum spinal cord compression (MSCC) after sufficient decompression was calculated on the IOUS image; patients were divided into adequate (MSCC ≥ 0.95) and inadequate (MSCC < 0.95) expansion groups according to the MSCC. The mJOA score, spinal cord hyperechogenicity, age at surgery, symptom duration, occupational rate of the spinal canal, and the minimum anteroposterior diameter of the spinal cord between the two groups were compared.

RESULTS

Initially, 2 cases showed residual compression on IOUS; after further decompression, all patients acquired sufficient decompression. All patients achieved improvements in mJOA scores with an average recovery rate of 68.6 ± 20.3%. The recovery rate of the mJOA score of the inadequate expansion group was significantly inferior to that of the adequate expansion group (59.2 ± 21.7% versus 76.2 ± 16.2%, p = 0.028). The spinal cord hyperechogenicity was more common in the inadequate expansion group, while the spinal cord anteroposterior diameter of the inadequate expansion group was significantly smaller than that of the adequate expansion group.

CONCLUSIONS

The application of IOUS in French-door laminoplasty could help to confirm sufficient decompression for the treatment of DCM. Inadequate spinal cord expansion after sufficient decompression had the high possibility of predicting less satisfactory neurological recovery of DCM.

KEY POINTS

• The intraoperative ultrasound revealed that not all degenerative cervical myelopathy patients acquired adequate spinal cord expansion after sufficient decompression. • Patients who failed to acquire adequate spinal cord expansion commonly combined with spinal cord hyperechogenicity and trended to achieve less satisfactory neurological recovery after surgical decompression. • Inadequate spinal cord expansion after sufficient decompression had the high possibility of predicting less satisfactory neurological recovery of patients with degenerative cervical myelopathy.

Is anterior decompression and fusion superior to laminoplasty for cervical myelopathy due to ossification of posterior longitudinal ligament? A systematic review and meta-analysis

Context: Considerable controversy exists over surgical procedures for ossification of the posterior longitudinal ligament (OPLL).Objective: The purpose of the meta-analysis was to compare the clinical outcome of anterior decompression and fusion (ADF) with laminoplasty (LAMP) in treatment of cervical myelopathy due to OPLL.Methods: PubMed, EMBASE and the Cochrane Register of Controlled Trials database were searched to identify potential clinical studies compared ADF with LAMP for cervical myelopathy owing to OPLL. We also manually searched the reference lists of articles and reviews for possible relevant studies. Thirteen studies with 1120 patients were included in our analysis. Subgroup analyses were performed by the canal occupying ratio of OPLL.Results: Overall, the mean preoperative Japanese Orthopaedic Association (JOA) score was similar between two groups. Compared with LAMP group, ADF group was higher at the mean postoperative JOA scores and mean recovery rate, reoperation rate, and longer at mean operation time. There was not significantly different in mean blood loss and complication rate between two groups. In subgroup analysis, ADF had a higher mean postoperative JOA score and recovery rate than LAMP in cases of OPLL with occupying ratios ≥ 50%, while those difference were not found in cases of OPLL with occupying ratios < 50%.Conclusion: ADF achieves better neurological improvement compared with LAMP in treatment of cervical myelopathy due to OPLL, especially in cases of OPLL with occupying ratios ≥ 50%. Complication rate is similar between two groups, but ADF can increase the risk of reoperation.

Multiple level anterior cervical discectomy and fusion versus posterior laminectomy for the management of multilevel cervical spondylotic myelopathy: clinical and radiological outcome

Background

Though both anterior and posterior approach are used for the management of multilevel cervical spondylotic myelopathy (CSM), the choice between both approaches remains to be of considerable debate.

Aim of the work

The aim of the study was to evaluate the clinical and radiographic outcomes of patients with multiple level CSM who underwent posterior laminectomy (PL) versus anterior cervical discectomy and fusion (ACDF).

Methods

This is a retrospective comparative study of 30 patients, with multiple level CSM managed by the authors, either by PL (n = 15) or ACDF (n = 15). Clinical outcome was assessed at 1, 3, 6, and 12 months postoperatively using the modified Japanese Orthopedic Association scale (mJOA) while the postoperative radiographic changes represented by the Cobb’s angle variation was recorded at 12 months postoperatively and compared with preoperative values. Also, the incidence of postoperative complications and neurological deterioration was recorded and studied between the two groups. Study duration was for 2 years from December 2014 to December 2016.

Results

Both the ACDF and PL groups showed an improvement in the mJOA score mean value at 1 year after surgery in comparison with the preoperative evaluation data; however, on comparing between both groups at 1 year postoperatively, the median percent of increase in mJOA score was significantly higher in the ACDF group compared with the PL group (33.3% vs 22.2% respectively). On the other hand, the Cobb’s angle percent of change 1 year after surgery showed a median percent of increase of 18.7% in the ACDF group in contrast to a median decrease of − 11.1% in the PL group which was statistically significant. Minimal complications were reported in both groups.

Conclusion

Both PL and ACDF are effective modalities for the surgical management of multilevel CSM showing good clinical outcome; however, when compared with the posterior approach, there was a statistical significant difference favoring ACDF regarding the median percent of increase in mJOA score and the postoperative Cobb’s angle improvement.

Double crush syndrome: Epidemiology, diagnosis, and treatment results

BACKGROUND

Double Crush Syndrome (DCS) is a clinical condition that involves multiple compression sites along a single peripheral nerve. The present study aims to describe the epidemiology of DCS and surgical results.

METHODS

A retrospective observational analytic study included patients with clinical diagnosis of cervical radiculopathy and carpal tunnel syndrome who underwent surgery between January 2009 and January 2019. General demographic characteristics were noted, and 3 groups were distinguished: spinal surgery, carpal tunnel release, and bimodal decompression (BD); statistical differences were analyzed between them.

RESULTS

The sample comprised 32 patients. DCS prevalence was 10.29%. Mean age at presentation was 59.25±10.98 years. There was female predominance (75%). Paresthesia was the main symptom (65.6%). Post-surgical results of BD showed significant improvement in sensory nerve conduction velocity, motor nerve conduction velocity (both P=0.008), and disability on Douleur Neuropathique 4 questions, Neck Disability Index, and Boston Carpal Tunnel Questionnaire (P=0.001, 0.004, 0.008, respectively).

CONCLUSIONS

Diagnosis and management of DCS are a challenge. It is necessary to determine the site with maximal compression and risk of complications to decide on treatment. If first-line surgery is adequate, proximal and distal symptomatology can be improved. To maximize success, we recommend BD, according to the present results.

Surgical outcomes of cervical myelopathy due to ossification of posterior longitudinal ligament: Anterior decompression and fusion versus posterior laminoplasty

BACKGROUND

The purpose of this study was to compare the surgical outcomes of anterior decompression and fusion (ADF) with that of posterior laminoplasty (LAMP) for cervical myelopathy caused by ossification of posterior longitudinal ligament (OPLL).

METHODS

We retrospectively assessed the medical records of patients who underwent surgery for cervical myelopathy owing to OPLL between 2007 and 2016 at our institution. Fifty patients were included in this study, including 17 patients in ADF group and 33 patients in LAMP group. Surgical outcomes were assessed under the Japanese Orthopaedic Association (JOA) score. The radiologic and clinical data were compared between two groups.

RESULTS

There was no significant difference in age, follow-up time, operation time, blood loss, length of stay, preoperative JOA score, occupying ratio of OPLL, diameter of spinal canal, preoperative and final follow-up C2-C7 Cobb angles, and the change of C2-C7 Cobb angle before and after operation between ADF and LAMP groups. The final follow-up JOA score and the neurological recovery rate were significantly higher in ADF group than in LAMP group, particularly in patients with segmental-type OPLL. Cerebrospinal fluid leakage is a major complication after ADF, C5 paralysis, and axial pain frequently results from LAMP.

CONCLUSION

Compared with LAMP, ADF shows better improvement of neurological function in patients with cervical myelopathy due to OPLL, especially in patients with segmental-type cervical OPLL.

Comparison of Perioperative Complications Between Anterior Decompression With Fusion and Laminoplasty For Cervical Spondylotic Myelopathy: Propensity Score-matching Analysis Using Japanese Diagnosis Procedure Combination Database

STUDY DESIGN

A retrospective comparative study with a large national database.

OBJECTIVE

The objective of this study was to compare the perioperative complications and costs of anterior decompression with fusion (ADF) and laminoplasty (LAMP) for patients who had cervical spondylotic myelopathy (CSM).

SUMMARY OF BACKGROUND DATA

CSM is the most common spinal cord disorder in the upper middle-aged people in Japan. ADF and LAMP represent 2 major treatments; however, few studies have reported large-scale investigations for perioperative complications with CSM. Thus, it is controversial which surgical approach will lead to the best clinical outcome in CSM.

MATERIALS AND METHODS

All data in this study were collected from the Japanese Diagnosis Procedure Combination database for patients diagnosed with CSM. We adjusted for known confounding biases with propensity score matching. One-to-one matched pairs between each surgical procedure were analyzed for the purposes of comparing systemic complication rates, local complication rates, medical costs, and mortality.

RESULTS

After propensity score matching, 1638 pairs of patients undergoing ADF and LAMP were made. More perioperative systemic complications were observed in the ADF group, such as atrial fibrillation (ADF/LAMP=0.7%/0.2%, P=0.032), respiratory failure (1.4%/0.1%, P<0.001), dysphagia (2.2%/0.2%, P<0.001), and sepsis (0.5%/0.1%, P=0.019). In contrast, a high rate of pulmonary embolism was observed with LAMP groups (ADF/LAMP=0%/0.2%, P=0.045). Local complications, such as infection (ADF/LAMP=0.8%/1.7%, P=0.026) and meningitis (0%/0.2%, P<0.045), were more common in the LAMP group. Conversely, spinal fluid leakage (ADF/LAMP=0.6%/0%, P=0.003) was more common in the ADF group. The costs (P<0.001) were higher in the ADF group.

CONCLUSIONS

More systemic complications, such as respiratory disease, cardiovascular events, and sepsis, were observed in the ADF group, although local infection was more frequently seen in the LAMP group. Medical costs were higher in the ADF group. The findings in this study will contribute to each CSM patient by allowing suitable adaptation of cervical surgeries.

LEVEL OF EVIDENCE

Level III.

Clinical outcomes for anterior cervical discectomy and fusion with silicon nitride spine cages: a multicenter study

BACKGROUND

Intervertebral spacers made of silicon nitride (Si3N4) are currently used in cervical and thoracolumbar fusion. While basic science data demonstrate several advantages of Si3N4 over other biomaterials, large-scale clinical results on its safety and efficacy are lacking. This multicenter retrospective study examined outcomes for anterior cervical discectomy and fusion (ACDF) using Si3N4 cages. Results were compared to compiled metadata for other ACDF materials.

METHODS

Pre-operative patient demographics, comorbidities, changes in visual analog scale (VAS) pain scores, complications, adverse events, and secondary surgical interventions were collected from the medical records of 860 patients who underwent Si3N4 ACDF at four surgical centers. For comparison, MEDLINE/PubMed and Google Scholar searches were performed for ACDF using other cage or spacer materials. Nine studies with 13 cohorts and 736 patients met the inclusion criteria for this control group.

RESULTS

Overall, the mean last-follow-up for all patients was 319±325 days (10.6±10.8 months), with the longest follow-up being 6.5 years. In comparison to the metadata, patients from the Si3N4 groups were older (57.9±12.2 vs. 56.8±11.1 y, P=0.06) and had higher BMI values (30.0±6.3 vs. 28.1±6.5, P<0.01), but gender and smoking were not different. The Si3N4 patients reported significant improvements in VAS pain scores at last follow-up (i.e., pre-op of 71.0±22.1 vs. follow-up of 36.4±31.5, P<0.01). Although both preoperative and last-follow-up pain scores were higher for Si3N4 patients than the control, the overall change in scores (ΔVAS) was similar. From pre-op to last-follow up, ΔVAS values were 35.4±34.3 for patients receiving the Si3N4 implants versus 34.4±27.3 for patients from the meta-analysis (P=0.56). The complication and reoperation rate for the Si3N4 and the metadata were also comparable (i.e., 7.39% and 0.31% versus 9.79% and 0%, P=0.17 and 0.25, respectively).

CONCLUSIONS

ACDF outcomes using Si3N4 implants matched the clinical efficacy of other cage biomaterials.

Comparison of the effect of anterior and posterior neurosurgical treatment for cervical spondylotic myelopathy: a clinical outcome

Cervical degenerative disease is the most common cause of acquired disability in patients over the age of 50. The incidence of cervical spondylotic myelopathy (CSM) is increasing with aging of the population. Surgical decompression is indicated for severe CSM. There is, however, insufficient evidence to prefer anterior over posterior surgical decompression technique for CSM. Our purpose was to identify groups of patients that would benefit from a chosen surgical approach with a better clinical outcome. We conducted a retrospective analysis of patients operated for CSM between 2007 and 2011. Patients were assessed according to the Nurick grading system. Preoperative and postoperative clinical details and MR imaging were analyzed. Treatment consisted of either anterior cervical discectomy with fusion (ACDF) or laminectomy without fusion. Over a period of 4 years, 90 patients were included. The mean age of patients was 64.5 ± 1.3 years. Of 90 included patients, 42 patients were treated with ACDF and 48 with laminectomy. Mean total Nurick grade recovery rate (NGRR) was 29.6% with 31.2% in ACDF and 27.7% in laminectomy. Mid-sagittal diameter of the cervical canal measured on MRI-T2 increased significantly more with laminectomy (4.4 mm) than ACDF (2.2 mm) (p < 0.001). The presence of preoperative spasticity or quadriparesis or a multilevel compression indicated a higher recovery on the Nurick scale. Surgical treatment of CSM leads to a significant improvement of the functional neurological status of the patient as well as an increase in the diameter of the cervical canal. No significant difference in Nurick recovery was found between ACDF and laminectomy indicating that clinical decision-making in our series was adequate. We were able to demonstrate that even severely disabled patients have a good chance of neurologic recovery after surgical treatment for CSM.

Safety and Efficacy of the VariLift-C® Cervical Standalone Interbody Fusion Device with Emphasis on Multiple-level and Prior Fusion Cases

Introduction

The VariLift-C^® is a stand-alone, expandable, cervical interbody fusion device, not requiring the addition of anterior plating. Because of the access and placement technique, as well as not needing a plate, the device could potentially be used preferentially for patients with prior anterior fusions or for multiple, non-contiguous vertebral segments.

Methods

A retrospective chart review was conducted and all cases of anterior cervical discectomy and fusion (ACDF) using VariLift-C^® implants by a single surgeon were included. Patient baseline and operative characteristics were collected, and their follow-up notes were searched for outcomes. Descriptive statistics are provided.

Results

Seventy-one patients were included in this study, 14 of which had had a prior fusion, and 32 underwent a multilevel ACDF. A total of 108 cervical levels were fused. Mean age (± SD) at surgery was 50.3 ± 11.4 years and mean (± SD) follow-up was 6.5 ± 10.7 months. There were 39 single-level, 27 two-level and five three-level fusions. Four cases (5.6%) underwent multilevel re-operations. Thirty-three patients (80.3%) reported substantial improvement in their symptoms on follow-up, 19 of whom (26.8%) had no residual symptoms. Only two patients (2.8%) reported a worsened condition after surgery. There were 10 cases (12.8%) of postoperative neurologic deficit, one case of dysphagia and three cases of vocal cord paresis.

Conclusions

These results display the use of VariLift-C^® for symptomatic cervical degenerative disorders, with a focus on fusion extension or multiple-segment ACDF procedures. Our experience with favorable self-reported outcomes and low complication rates showcases the safety and efficacy of the VariLift-C^® device for ACDF.

Which NDI domains best predict change in physical function in patients undergoing cervical spine surgery?

BACKGROUND CONTEXT

Physical function is a critical aspect of patient outcomes. NDI is a widely validated outcome measure in cervical spine disease, yet to what extent its individual domains predict changes in physical function remains unknown.

PURPOSE

To examine the impact of individual NDI domains on changes in physical function in patients undergoing cervical spine surgery.

STUDY DESIGN/SETTING

Prospective Cohort Study.

PATIENT SAMPLE

Adult patients undergoing cervical spine surgery, excluding those undergoing surgery for instability due to trauma.

OUTCOME MEASURES

Absolute change in outcome measures (Patient Reported Outcomes Measurement Information System [PROMIS] Physical Function [PF], Short Form 36 [SF-36] Physical Component Score [PCS], and Neck Disability Index [NDI]) from pre- to postoperatively, correlation of NDI individual domains with PROMIS PF and SF-36 PCS (preoperatively, postoperatively, and change from pre- to postoperatively).

METHODS

Patients undergoing cervical spine surgery between 2016 and 2018 were prospectively enrolled. Patients completed questionnaires (NDI, SF-36 PCS, and PROMIS PF) preoperatively and at 6 months postoperatively. Patient demographics, including age, body mass index, Charlson Comorbidity Index, and underlying diagnoses were collected. Comparisons between NDI scores preoperatively versus postoperatively were conducted using Wilcoxon signed rank sum test. Correlations of NDI individual items and PROMIS/SF-36 were assessed using Pearson correlation. A stepwise linear regression analysis was performed to identify NDI items that are independently predictive of PROMIS PF and SF-36 PCS.

RESULTS

A total of 137 patients were included in the study, with mean age 56.9 years (range 24.4-84.9). Each of the NDI domains as well as PROMIS PF and SF-36 PCS demonstrated significant improvement following cervical spine surgery (p<.001). Changes in all NDI domains demonstrated significant negative correlation with changes in PROMIS PF, with recreation (R=-0.537, p<.001), work (R=-0.514, p<.001), and pain intensity (R=-0.488, p<.001) having the greatest negative correlation. Changes in all NDI domains demonstrated significant negative correlation with changes in SF-36 PCS, with recreation (R=-0.451, p<.001), work (R=-0.443, p<.001), lifting (R=-0.373, p<.001), and driving (R=-0.373, p<.001) having the greatest negative correlation. For PROMIS PF, the NDI domains that were independently associated with changes in PF were work (R=-0.092, p=.001), pain intensity (R=-0.089, p=.003), and recreation (R=-0.067, p=.004). For SF-36 PCS, the NDI items that were independently associated with changes in PCS were work (R=-0.269, p=.003) and recreation (R=-0.215, p=.002).

CONCLUSIONS

All NDI domains improve significantly after cervical spine surgery and demonstrate significant correlation with changes in PROMIS PF and SF-36 PCS. The work, recreation, and pain intensity domains were the only independent predictors of physical function changes postoperatively. Considering physical function, our findings highlight the importance of presenting changes in individual NDI domains in addition to the total score.

SF36 Is a Reliable Patient-Oriented Outcome Evaluation Tool in Surgically Treated Degenerative Cervical Myelopathy Cases: A Systematic Review and Meta-Analysis

Background

Degenerative spinal disorders have adverse impacts on patients’ quality of life. Because the main objectives of any surgical intervention are to improve health-related quality of life and to reduce disability, instruments capable of measuring patient-oriented outcomes are now increasingly used. The aim of this study was to evaluate the use of the Short Form 36 Health Survey Questionnaire (SF36) for assessing patient-oriented outcomes of degenerative cervical myelopathy surgery.

Material/Methods

A literature search was conducted in electronic databases (Google Scholar, Ovid SP, PubMed, Science Direct, and Springer). Studies were included if they reported SF36 scores by following patients for at least 12 months. Random effects meta-analyses were performed to estimate changes in SF36 physical/mental component summary (SF36-PCS/MCS), SF36 dimensional, Japanese Orthopedics Association (JOA)/modified JOA (mJOA), and Neck Disability Index (NDI) scores by latest follow-up.

Results

Fourteen studies (1966 patients; age 58.2 years [95% confidence interval (CI), 56.6 to 59.9]; 60% males [95% CI, 55 to 64]; follow-up 24.8 months [95% CI, 20.9 to 28.7]) were included in meta-analysis. SF36-PCS (6.60 [95% CI, 4.91 to 8.28]; p<0.00001), SF36-MCS (6.33 [95% CI, 4.31 to 8.35]; p<0.00001) and SF36 dimensional (p<0.05) scores improved significantly at latest follow-up. Surgery significantly improved JOA/mJOA (3.43 [95% CI, 2.80 to 4.06]; p<0.00001) and NDI (−13.70 [95% CI, −17.35 to −10.06]; p<0.00001) scores also. Change in SF36-PCS score were correlated (r=−0.554) with change in NDI score, whereas change in SF36-MCS score was correlated with change in JOA score (r=0.550).

Conclusions

Surgery for degenerative cervical myelopathy is associated with significantly improved SF36-measured patient-oriented outcomes.

Cervical Range of Motion after Anterior Corpectomy and Fusion versus Laminoplasty for Multilevel Cervical Spondylotic Myelopathy: A Three-Dimensional Comparison Based on the Coda Motion System

OBJECTIVE

To compare the change in cervical range of motion (CROM) after the 2 most widely used techniques for multilevel cervical spondylotic myelopathy (CSM): anterior cervical corpectomy and fusion (ACCF) and laminoplasty.

METHODS

Patients with multilevel CSM treated in our hospital between 2014 and 2018 were divided into an ACCF group and a laminoplasty (LAMP) group according to the treatment received. Their demographic data, preoperative and postoperative Japanese Orthopedic Association (JOA) scores, and CROM, measured using the Coda Motion system, were analyzed and compared.

RESULTS

A total of 53 patients were enrolled, including 29 patients in the ACCF group and 24 patients in the LAMP group. Age, sex, duration of follow-up, and preoperative and postoperative JOA scores were comparable in the 2 groups. Compared with preoperative measurements, ACCF group lost an average of 9.8%, 28.5%, 8.9%, 9.9%, 10.6%, and 7.8% of their CROM in flexion, extension, left and right lateral flexion, and left and right rotation, respectively, at the latest follow-up. For the LAMP group, these average losses were 3.5%, 16.4%, 3.2%, 6.3%, 7.0%, and 5.7%, respectively. Thus, the ACCF group exhibited greater average CROM loss than the LAMP group in all directions at the latest follow-up.

CONCLUSIONS

Both ACCF and laminoplasty cause significant CROM loss in patients with multilevel CSM. The laminoplasty technique preserved more CROM than ACCF in all 6 directions after at least 1 year of follow-up. These results can be used when counseling patients undergoing surgery.

Sagittal Alignment Outcomes in Lordotic Cervical Spine: Does Three-Level Anterior Cervical Discectomy and Fusion Outperform Laminoplasty?

STUDY DESIGN

A prospective cohort study.

OBJECTIVE

To compare the radiological outcomes between three-level anterior cervical discectomy and fusion (ACDF) and plate-only open-door laminoplasty (LAMP) in patients with lordotic cervical spine.

SUMMARY OF BACKGROUND DATA

Both three-level ACDF and LAMP are important surgical methods for multilevel cervical spondylotic myelopathy, but the cervical sagittal alignment outcomes and the lordosis preserving abilities between the two specific approaches have not been carefully compared.

METHODS

Sixty patients, all of whom had lordotic cervical spines and underwent three-level ACDF (n = 22) or LAMP (n = 38) for the treatment of multilevel cervical spondylotic myelopathy, were prospectively studied. Upright neutral cervical lateral radiographs were assessed preoperatively, at 3 days after surgery, and at the last follow-up (1.5 years). The primary radiological outcomes are C2-7 Cobb angle, and the secondary outcomes include C2-7 sagittal vertical axis , disc height, Harrison angle, and Ishihara index. The relationship between preoperative parameters and follow-up outcomes were assessed.

RESULTS

Preoperative cervical sagittal alignment parameters were similar between the two groups. Patients in the ACDF group obtained larger C2-7 Cobb angles than those the LAMP group early after surgery. However, the lordosis in the ACDF group decreased significantly during follow-up, leading to similar outcomes between the two groups. The lordosis-preserving ability of ACDF is significantly poorer than that of LAMP. Secondary radiological parameters also showed similar trends. In both groups, the preoperated Ishihara index was significantly related to follow-up C2-7 Cobb angles. For patients with Ishihara index less than 20, ACDF is more likely to produce a larger C2-7 Cobb angled at the time of follow-up.

CONCLUSION

In patients with lordotic cervical spine, the sagittal alignment outcomes of the two approaches were similar, and the lordosis-preserving ability was poorer in ACDF. Further research should focus on the factors related to the lordosis-preserving ability of multilevel ACDF.

LEVEL OF EVIDENCE

3.

Anterior cervical discectomy and fusion with stand-alone anchored cages versus posterior laminectomy and fusion for four-level cervical spondylotic myelopathy: a retrospective study with 2-year follow-up

Background

The optimal treatment for multi-level cervical spondylotic myelopathy (CSM) remains controversial. Posterior approach is most commonly used, but complicated with insufficient decompression and postoperative axial neck pain. The anterior approach is effective in neural decompression with less surgical trauma. However, the profile of the plate or the possible construct failure may cause dysphagia after surgery. Recently, anterior cervical discectomy and fusion (ACDF) with self-anchored cage is reported to have a superior result over ACDF with anterior plates and screws in three-level CSM. The purpose of the study is to compare the clinical and radiological outcomes of ACDF using stand-alone anchored cages to that of laminectomy with fusion (LF) for treating four-level CSM.

Methods

Twenty-six patients underwent four-level ACDF (Group A) and 32 patients with four-level LF (Group B) were retrospectively reviewed and followed-up for 24 months. Clinical efficacy was evaluated by comparing pre- and post-operative Japanese Orthopedic Association (JOA) and Neck Disability Index (NDI) scores. Operative time, blood loss, fusion, lordosis change and complications were evaluated.

Results

There was significantly less blood loss in Group A (163.4 ± 72.1 ml) than Group B (241.0 ± 112.3 ml) (P < 0.05). Both groups demonstrated significant improvements in JOA and NDI scores after surgery with similar operative time. Improvements in cervical lordosis and fused segment lordosis were more pronounced in Group A (11.3 ± 5.9°, 9.7 ± 5.3°) than Group B (5.8 ± 4.6°, 5.5 ± 4.5°) (P < 0.05). Loss of lordosis in the cervical spine and fused segment was more prominent in Group A (11.7 ± 2.2°, 6.7 ± 3.2°) than Group B (7.5 ± 3.8°, 3.7 ± 3.4°) (P < 0.05) at the final follow-up. Complication rate in Group A and Group B was 57.69 and 18.75%, respectively.

Conclusions

ACDF using a stand-alone anchored cage showed similar clinical results to LF for the treatment of four-level CSM, with better lordosis correction and less blood loss. However, ACDF was associated with more loss of lordosis after surgery and more non-unions.

Cervical Sagittal Range of Motion as a Predictor of Symptom Severity in Cervical Spondylotic Myelopathy

STUDY DESIGN

A retrospective review of radiographic data and functional outcomes.

OBJECTIVE

The aim of this study was to evaluate whether myelopathy symptom severity upon presentation corresponds to sagittal plane alignment or nonmyelopathy symptoms, such as pain, in patients with cervical spondylotic myelopathy (CSM).

SUMMARY OF BACKGROUND DATA

Cervical sagittal balance is an important parameter in the outcome of surgical reconstruction. However, the effect of sagittal alignment on symptom severity in patients who have not undergone spine surgery is not well defined.

METHODS

A consecutive series of CSM patients was identified at an academic institution. Preoperative radiographs were analyzed for sagittal vertical axis (C2SVA), C7 slope (C7S), C2-C7 angle in neutral (C27N), flexion (C27F), and extension (C27E), and range of motion (C27ROM). Neutral alignment was categorized as lordotic, kyphotic, or sigmoid/straight. Outcomes collected were SF-12, neck disability index, arm pain, neck pain, and modified JOA (mJOA). Pearson coefficients determined correlations between radiographic and outcome parameters. Multivariate regression evaluated predictive factors of mJOA.

RESULTS

Radiographic parameters did not correlate with pain. Increasing age, smaller C27ROM, and smaller flexion angles correlated to lower (more severe) baseline mJOA scores. ROM (and not static alignment) was the only significant predictor of mJOA in the multivariate regression. Despite significant radiographic differences between lordotic, kyphotic, and sigmoid/straight alignment groups, myelopathy severity did not differ between these groups.

CONCLUSION

Static, neutral alignment, including SVA and lordosis, did not correlate with myelopathy or pain symptoms. Greater C27ROM and increased maximal flexion corresponded to milder myelopathy symptoms, suggesting that patients with myelopathy may compensate for cervical stenosis with hyperflexion, similar to that which is observed in the lumbar spine. In a CSM patient population, dynamic motion and compensatory deformities may play a more significant role in myelopathy symptom severity than what can be discerned from standard, neutral position radiographs.

LEVEL OF EVIDENCE

3.

Factors associated with surgical outcomes of cervical ossification of the posterior longitudinal ligament

To investigate factors associated with surgical outcomes of cervical ossification of the posterior longitudinal ligament (OPLL). This retrospective study included patients (662 males and 251 females; mean age 55.8 years) with symptomatic OPLL. All patients had been diagnosed with OPLL based on cervical magnetic resonance imaging and computed tomography scans. Demographic, surgical outcome was measured using visual analog scale (VAS) and Japanese Orthopedic Association (JOA) scale scores. The results of our study indicated radicular pain was more common in segmental and circumscribe OPLL subtypes (P < 0.05). An anterior approach was favored in patients with less than 3 involved vertebral levels (P < 0.05). All surgical methods showed good outcomes (P < 0.05). Continuous and mixed OPLL subtypes showed worse surgical outcome with higher VAS and JOA scores (P < 0.05). Laminoplasty and anterior cervical discectomy and fusion were significantly associated with a higher recovery rate (P < 0.05). Among these patients, there were more complications with the anterior approach (P < 0.05). Male gender, open door laminoplasty ipsilateral, and ipsilateral-to-symptom-side opening were associated with postoperative C5 palsy (P < 0.05). Cervical OPLL may cause myelopathy, surgery is a safe and effective treatment for OPLL. There were no differences in clinical outcome according to surgical type, but complication rates varied depending on sex and surgical approach to symptom.

Combined Laminoplasty and Posterior Fusion for Cervical Spondylotic Myelopathy Treatment: A Literature Review

Study Design

A literature review.

Purpose

To explore the utility of laminoplasty in combination with instrumented fusion, with a focus on neurological outcomes and changes in kyphotic deformity.

Overview of Literature

Management of cervical spondylotic myelopathy (CSM) to reduce morbidity within the neurosurgical population.

Methods

A US National Library of Medicine PubMed search was conducted for manuscripts pertaining to cervical laminoplasty and fusion for the management of CSM. Several relevant studies were shortlisted for review, and the bibliographies of the articles were searched for additional references. The search was limited to human studies, English-language literature, and reports on more than one patient.

Results

Combined laminoplasty and fusion was found to provide at least comparable, if not superior, neurological outcomes in specific patient populations with CSM. The Japanese Orthopedic Association scores, local kyphosis, and C2–C7 angle have been reviewed in several manuscripts, and improvement in each of these categories was found with laminoplasty and fusion.

Conclusions

The treatment of CSM necessitates an individualized approach based on the pathoanatomical variation. Laminoplasty and fusion can be appropriately used for patients with CSM in a setting of local kyphotic deformity, ossification of the posterior longitudinal ligament, associated segmental instability, and the need for strong stabilization.

Is there a role for postoperative physiotherapy in degenerative cervical myelopathy? A systematic review

Objective:

To review peer-reviewed literature relating to postoperative physiotherapy for degenerative cervical myelopathy (DCM), to determine efficacy in improving clinical outcome and recovery.

Data sources:

MEDLINE, EMBASE, CENTRAL, PEDro, ISRCTN registry, WHO ICTRP and Clinicaltrials.gov . References and citations of relevant articles were searched.

Methods:

A systematic search was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (PROSPERO CRD42016039511) from the origins of the databases till 15 February 2018. Included were all studies investigating physiotherapy as an intervention after surgical treatment of DCM to determine effect on clinical outcome and recovery. Study quality was determined using the Grades of Recommendation, Assessment, Development and Evaluation guidelines.

Results:

In all, 300 records were identified through tailored systematic searches, after removing duplicates. After screening, only one investigated postoperative rehabilitation using physiotherapy for DCM; however, this was retrospective with no controls. This study suggested that rehabilitation including physiotherapy improved postoperative recovery. There are currently two registered trials investigating the use of postoperative physiotherapy for DCM.

Conclusions:

The literature provides insufficient evidence to make any evidence-based recommendations regarding postoperative physiotherapy use in DCM.

Cervical Laminoplasty: Indications, Surgical Considerations, and Clinical Outcomes

Cervical laminoplasty was initially described for the management of cervical myelopathy resulting from multilevel stenosis secondary to ossification of the posterior longitudinal ligament. The general concepts are preservation of the dorsal elements, preservation of segmental motion, and expansion of the spinal canal via laminar manipulation. No clear evidence suggests that laminoplasty is superior to either posterior laminectomy or anterior cervical diskectomy and fusion. However, laminoplasty has its own advantages, indications, and complications. Surgeons have refined the technique to decrease complication rates and improve efficacy. Recent efforts have highlighted less invasive approaches that are muscle sparing and associated with less postoperative morbidity. Although the long-term outcomes suggest that cervical laminoplasty is safe and effective, continued research on the development of novel modifications that decrease common complications, such as C5 nerve palsy, axial neck pain, and loss of lordosis, is required.

Differences in Cervical Sagittal Alignment Changes in Patients Undergoing Laminoplasty and Anterior Cervical Discectomy and Fusion

OBJECTIVE

Anterior cervical discectomy and fusion (ACDF) and laminoplasty (LP) are the most commonly performed procedures for degenerative cervical spondylosis. Cervical sagittal alignment (CSA) has recently been studied as an important predictor of clinical and radiological outcomes. The data from previous studies are insufficient for analysis using the recently designed CSA parameters, T1 slope (T1s), and T1s minus cervical angle (T1sCA).

METHODS

We retrospectively collected data from patients who underwent ACDF and LP from January 2013 to May 2016. The CSA parameters included CA, sagittal vertical axis, T1s, and T1sCA. T1sCA values were used to evaluate the preoperative cervical balance (T1sCA>20°: imbalance). Clinical results were evaluated using the neck disability index (NDI) and recovery rate (RR) according to the Japanese Orthopedic Association scoring system.

RESULTS

We analyzed the data of 72 patients (ACDF, n=39; LP, n=33). Imbalance on ACDF was associated with an increase in CA (balance: preoperative [PRE], 15.64° → follow-up [F/U], 15.74°, p=0.953; imbalance: PRE, -1.14° → F/U, 8.045°, p=0.008), whereas balance on LP was associated with a significant decrease in CA (balance: PRE, 16.26°→ F/U, 11.59°, p=0.009; imbalance: PRE, 5.36°→ F/U, 2.38°, p=0.249). No significant difference was found in the RR and NDI changes in the ACDF group based on balance, but a significant difference was found in RR in the LP group (balance: 61.65%±19.88%, imbalance: 46.90%±15.71%, p=0.046).

CONCLUSION

We found a significant difference in postoperative alignment in cases of ACDF and LP according to preoperative cervical sagittal balance. The postoperative clinical results of the LP group were more affected by F/U alignment than by the degree of alignment change.

Correlation of Clinical and Radiological Outcome After Anterior Cervical Discectomy and Fusion With a Polyetheretherketone Cage

Background

Anterior cervical discectomy and fusion (ACDF) with a polyetheretherketone (PEEK) cage is considered as the gold standard for patients with cervical disc disease. However, there are limited in vivo data on the impact of ACDF on the cervical kinematics and its association with patient-reported clinical outcomes. The purpose of this study was to investigate the impact of altered cervical sagittal alignment (cervical lordosis) and sagittal range of motion (ROM) on patients’ self-reported pain and functional disability, after ACDF with a PEEK cage.

Methods

We prospectively studied 74 patients, who underwent single-, or consecutive two-level ACDF with a PEEK interbody cage. The clinical outcomes were assessed by using the pain numeric rating scale (NRS) and the neck disability index (NDI). Radiological outcomes included cervical lordosis and C2-C7 sagittal ROM. The outcome measures were collected preoperatively, at the day of patients’ hospital discharge, and also at 6 and 12 months postoperatively.

Results

There was a statistically significant reduction of the NRS and NDI scores postoperatively at each time point (P < 0.005). Cervical lordosis and also ROM significantly reduced until the last follow-up (P < 0.005). There was significant positive correlation between NRS and NDI preoperatively, as well as at 6 and 12 months postoperatively (P < 0.005). In regard to the ROM and the NDI scores, there was no correlation preoperatively (P = 0.199) or postoperatively (6 months, P = 0.322; 12 months, P = 0.476). Additionally, there was no preoperative (P = 0.134) or postoperative (6 months, P = 0.772; 12 months, P = 0.335) correlation between the NDI scores and cervical lordosis.

Conclusions

In our study, reduction of cervical lordosis and sagittal ROM did not appear to significantly influence on patients’ self-reported disability. Such findings further highlight the greater role of pain level over the mechanical limitations of ACDF with a PEEK cage on patients’ own perceived recovery.

Long-term results of a prospective study of anterior decompression with fusion and posterior decompression with laminoplasty for treatment of cervical spondylotic myelopathy

BACKGROUND

There have been no prospective studies comparing anterior surgery and posterior method in terms of long-term outcomes. The purposes of this study is to clarify whether there is any difference in long-term clinical and radiologic outcomes of anterior decompression with fusion (ADF) and laminoplasty (LAMP) for the treatment of cervical spondylotic myelopathy (CSM).

METHODS

Ninety-five patients were prospectively treated with ADF or LAMP for CSM in our hospital from 1996 through 2003. On alternate years, patients were enrolled to receive ADF (1997, 1999, 2001, and 2003: ADF group, n = 45) or LAMP (1996, 1998, 2000, and 2002: LAMP group, n = 50). We excluded 19 patients who died during follow-up, and 25 who were lost to follow-up. Clinical outcomes were evaluated by the recovery rate of the Japanese Orthopaedic Association (JOA) score between the two groups. Sagittal alignment of the C2-7 lordotic angle and range of motion (ROM) in flexion and extension on plain X-ray were measured.

RESULTS

Mean age at the time of surgery was 58.3 years in the ADF group and 57.9 years in the LAMP group. Mean preoperative JOA score was 10.0 and 10.5, respectively. Mean recovery rate of the JOA score at 3-5 years postoperatively was significantly higher in the ADF group (p < 0.05). Reoperation was required in 1 patient for pseudarthrosis and in 1 patient for recurrence of myelopathy in the ADF group; no patient in the LAMP group underwent a second surgery. There was a significant difference in maintenance of the lordotic angle in the ADF group compared with the LAMP group (p < 0.05), but not in ROM.

CONCLUSIONS

Both ADF and LAMP provided similar good outcomes at 10-year time-point whereas ADF could achieve more satisfactory outcomes and better sagittal alignment at the middle-term. However, the incidence of reoperation and complication in the ADF group were higher than those in the LAMP group.

STUDY DESIGN

A prospective comparative study (not randomized).

Modified Laminoplasty Preserving the Posterior Deep Extensor Insertion into C2 Improves Clinical and Radiologic Results Compared with Conventional Laminoplasty: A Meta-Analysis

BACKGROUND

Whether modified laminoplasty is better than conventional laminoplasty is unclear. Thus, a meta-analysis comparing the outcomes of preserving or repairing the posterior deep extensor insertion to C2 in laminoplasty was conducted for patients with multilevel cervical spondylotic myelopathy (MCSM).

METHODS

Several electronic databases were chosen to search for relevant studies. The primary indices included preoperative and postoperative Japanese Orthopaedic Association (JOA) scores, JOA recovery rate, muscle atrophy rate, preoperative and postoperative range of motion (ROM), ROM decrease rate, and incidence of axial pain. Results are expressed as odds ratios with 95% confidence intervals for the dichotomous outcomes and mean differences for continuous outcomes.

RESULTS

Eight studies involving 763 patients were included in this study. The postoperative cervical ROM was significantly higher in the modified group (P = 0.01, MD = 3.0 [0.66, 5.35]), as was the cervical posterior muscle volume (P = 0.02, MD = 28.28 [4.42, 52.3]) and the operation time (MD = -45.04, 95% CI -49.79, -40.29; P < 0.01). The incidence of axial symptoms in the modified group was lower than that in the conventional group (P < 0.01, OR 0.28 [0.17, 0.46]), as was the rate of decrease of cervical ROM (P = 0.004, MD = -6.72 [-11.25, 2.19]). There was no significant difference (P > 0.05) between the groups in blood loss, preoperative and postoperative JOA score, or JOA recovery rate.

CONCLUSIONS

Modified laminoplasty had shorter operation times, a lower incidence of axial pain, a higher cervical ROM, and a lower atrophy rate compared with conventional laminoplasty. The clinical and radiologic results of modified laminoplasty have been partly superior to those of conventional laminoplasty to date.

A Novel Technique for Cervical Facet Joint Hyperplasia-Spondylotic Radiculopathy by Laminar and Lateral Mass Screw Cofixations

OBJECTIVE

We sought to describe the novel technique and report the outcomes of cervical spondylotic radiculopathy caused by facet joint hyperplasia treated with minimally invasive surgery by laminar and lateral mass screw cofixations.

METHOD

In this retrospective study, patients with spondylotic radiculopathy caused by facet joint hyperplasia underwent this technique in our unit between January 2010 and June 2015. Hospital charts, magnetic resonance imaging studies, and follow-up records for all the patients were reviewed. Outcomes were assessed on the basis of neurologic status, magnetic resonance imaging, and visual analog scale for neck and radicular pain and by the short form-36 health survey questionnaire.

RESULTS

Thirteen men and 5 women, aged 47-73 years (mean, 61.8 years), were included in this study. The follow-up time ranged from 19-50 months (mean, 32.4 months). The mean visual analog scale scores for radicular pain and neck pain, as well as the scores for all 8 domains of the short form-36 health survey questionnaire, showed significant improvements (P < 0.05). Cervical lordosis showed bending, whereas the height of the targeted disk segment showed no change (P > 0.05). Complications included 2 cases of neck pain that lasted for 3 months.

CONCLUSION

Minimally invasive surgery by lamina and lateral mass screw cofixation is safe and effective for the treatment of cervical spondylotic radiculopathy caused by facet joint hyperplasia. In addition to sufficient decompression, this technique provides relative stability to the cervical spine.

Comparison of Anterior and Posterior Surgery for Degenerative Cervical Myelopathy: An MRI-Based Propensity-Score-Matched Analysis Using Data from the Prospective Multicenter AOSpine CSM North America and International Studies

BACKGROUND

Surgeons often choose between 2 different approaches (anterior and posterior) for surgical treatment of degenerative cervical myelopathy on the basis of imaging features of spinal cord compression, the number of levels affected, and the spinal alignment. However, there is a lack of consensus on which approach is preferable. The objective of the present study was to use magnetic resonance imaging (MRI)-based propensity-score-matched analysis to compare postoperative outcomes between the anterior and posterior surgical approaches for degenerative cervical myelopathy.

METHODS

A total of 757 patients were enrolled in 2 prospective multicenter AOSpine studies, which involved 26 international sites. Preoperative MRIs were reviewed to characterize the causes of the cord compression, including single-level disc disease, multilevel disc disease, ossification of the posterior longitudinal ligament, enlargement of the ligamentum flavum, vertebral subluxation/spondylolisthesis, congenital fusion, number of compressed levels, or kyphosis. The propensity to choose anterior decompression was calculated using demographic data, preoperative MRI findings, and the modified Japanese Orthopaedic Association (mJOA) scores in a logistic regression model. We then performed 1-to-1 matching of patients who had received anterior decompression with those who had the same propensity score but had received posterior decompression to compare 2-year postoperative outcomes and 30-day perioperative complication rates between the 2 groups after adjustment for background characteristics.

RESULTS

A total of 435 cases were included in the propensity score calculation, and 1-to-1 matching resulted in 80 pairs of anterior and posterior surgical cases; 99% of these matched patients had multilevel compression. The anterior and posterior groups did not differ significantly in terms of the postoperative mJOA score (15.1 versus 15.3, p = 0.53), Neck Disability Index (20.5 versus 24.1, p = 0.44), or Short Form-36 (SF-36) Physical Component Summary (PCS) score (41.9 versus 40.9, p = 0.30). The overall rates of perioperative complications were similar between the 2 groups (16% versus 11%, p = 0.48); however, dysphagia/dysphonia was reported only in the anterior group whereas surgical site infection and C5 radiculopathy were reported only in the posterior group.

CONCLUSIONS

Anterior and posterior decompression for degenerative cervical myelopathy resulted in similar postoperative outcomes and rates of complications.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Meta-Analysis of Cervical Laminoplasty Techniques: Are Mini-Plates Superior?

STUDY DESIGN

Meta-analysis and systematic review of literature.

OBJECTIVE

In the late 1990s, spinal surgeons experimented by using maxillofacial fixation plates as an alternative to sutures, anchors, and local spinous process autografts to provide a more rigid and lasting fixation for laminoplasty. This eventually led to the advent of laminoplasty mini-plates, which are currently used. The objective is to compare laminoplasty techniques with plate and without plate with regard to functional outcome results.

METHODS

Qualitative and quantitative analyses were performed to evaluate the currently available studies in an attempt to justify the use of a plate in laminoplasty.

RESULTS

The principal finding of this study was that there was no statistically significant difference in clinical outcome between the 2 different techniques of laminoplasty.

CONCLUSION

There is not enough evidence in the literature to support one technique over the other, and hence, there is no evidence to support change in practice (using or not using the plate in laminoplasty). A randomized controlled trial will give a better comparison between the 2 groups.

Regression of Anterior Disk-Osteophyte Complex Following Cervical Laminectomy and Fusion for Cervical Spondylotic Myelopathy

STUDY DESIGN

A retrospective case-control study.

OBJECTIVE

To investigate whether posterior cervical laminectomy and fusion modifies the natural course of anterior disk-osteophyte complex in patients with multilevel cervical spondylotic myelopathy.

SUMMARY OF BACKGROUND DATA

Dorsal migration of the spinal cord is the main purported mechanism of spinal cord decompression following cervical laminectomy and fusion but other potential mechanisms have received scant attention in the literature. This study was conducted to investigate whether cervical laminectomy and fusion affects the size of anterior disk-osteophyte complex.

METHODS

The medical records and radiographic imaging of 44 patients who underwent cervical laminectomy and fusion for cervical spondylotic myelopathy between 2006 and 2013 were analyzed. The size of the anterior disk-osteophyte complex was measured preoperatively and postoperatively on MR images taken at an interval of >3 months apart. A control group consisted of 20 nonoperatively treated advanced cervical spondylosis patients. Patients in the control met the same inclusion and exclusion criteria and also had sequential magnetic resonance imaging (MRI) taken at an interval of >3 months apart.

RESULTS

The nonoperative and operative groups were statistically similar in the pertinent patient demographics and characteristics including sex, age, time to second MRI, size of anterior disk-osteophyte complex on baseline MRI, mean number of levels affected, and percentage of patients with T2 signal change. As expected the mJOA scores were significantly lower in the operative versus nonoperative cohort (13.6 vs. 16.5, P<0.01). A significant decrease in the size of anterior disk osteophyte was observed in the operative group postoperatively (P<0.01). In comparison, there was no statistically significant change in the size of the anterior disk-osteophyte complex in the control group (P>0.05). The magnitude of the change in disk size between the 2 groups was statistically significant (P<0.01).

CONCLUSIONS

The findings of this study suggest that regression of anterior disk-osteophyte complex occurs following cervical laminectomy and fusion, and likely provides another mechanism of spinal cord decompression.

Cervical disc replacement surgery: indications, technique, and technical pearls

PURPOSE OF REVIEW

Cervical disc replacement (CDR) is a surgical option for appropriately indicated patients, and high success rates have been reported in the literature. Complications and failures are often associated with patient indications or technical variables, and the goal of this review is to assist surgeons in understanding these factors.

RECENT FINDINGS

Several investigations have been published in the last 5 years supporting the use of CDR in specific patient populations. CDR has been shown to be comparable or favorable to anterior cervical discectomy and fusion in several meta-analyses and mid-term follow-up studies. CDR was developed as a technique to preserve motion following a decompression procedure while minimizing several of the complications associated with fusion and posterior cervical spine procedures. Though success with cervical fusion and posterior foraminotomy has been well documented in the literature, high rates of mid- and long-term complications have been clearly established. CDR has also been associated with several complications and challenges with regard to surgical technique, though improvements in implant design have lead to an increase in utilization. Several devices currently exist and vary in terms of material, design, and outcomes. This review paper discusses indications, surgical technique, and technical pearls and reviews the CDR devices currently available.