Surgical Approaches for the Treatment of Multilevel Cervical Ossification of the Posterior Longitudinal Ligament: Results of a Decision Analysis

The CT Classification of Multilevel Cervical Ossification of the Posterior Longitudinal Ligament to Guide Hybrid Anterior Controllable Antedisplacement and Fusion vs. Posterior Laminoplasty

OBJECTIVE

For precise and minimally invasive treatment of ossification of the posterior longitudinal ligament of the cervical spine, the lifting segment is minimized, anterior controllable antedisplacement and fusion (ACAF) was refined and improved. In addition, the development of appropriate surgical procedures for the ossification of each segment was rarely reported. Therefore, this study aimed to compare the efficacy and safety of hybrid anterior controlled antedisplacement fusion (Hybrid ACAF) with laminoplasty for multilevel ossification of the posterior longitudinal ligament (OPLL).

METHODS

Between May 2018 and May 2021, 70 patients with multilevel OPLL were divided into a hybrid ACAF group and a laminoplasty group according to surgical methods. All patients were followed up for at least 1 year. Japanese Orthopaedic Association (JOA) score and recovery rate (JOARR), (VAS, NDI) score and C2-C7 Cobb angle, the sagittal vertical axis of the neck (SVA), and complications (cerebrospinal fluid leakage, C5 paralysis, etc.) were compared between the two groups by t test or non-parametric test.

RESULTS

The operation time of hybrid ACAF was longer. C5 paralysis and axial pain were more common in the laminoplasty group, while dysphagia and hoarseness were more common in the hybrid ACAF group. At the last follow-up, the hybrid ACAF group had better recovery and maintenance of cervical lordosis and sagittal plane balance and a higher JOA score and recovery rate than the laminoplasty group.

CONCLUSIONS

Hybrid ACAF can reduce the number of vertebral bodies and expand the decompression range, which is safe, effective, and tailored to local conditions. Compared with laminoplasty, hybrid ACAF is a precise alternative for patients with OPLL.

Instrumented fusion versus instrumented non-fusion following expansive open-door laminoplasty for multilevel cervical ossification of the posterior longitudinal ligament

PURPOSE

To compare the outcomes of expansive open-door laminoplasty with instrumented fusion (ELIF) and expansive open-door laminoplasty with instrumented non-fusion (ELINF) for multilevel cervical ossification of the posterior longitudinal ligament (OPLL).

METHODS

Patients who underwent ELIF or ELINF due to multilevel cervical OPLL from June 2013 to June 2019 were identified. Clinical and radiological outcomes were compared between the two groups.

RESULTS

A total of 78 patients were enrolled in this study with a minimum follow-up of 24 months, including 42 patients in the ELIF group and 36 patients in the ELINF group. At the final follow-up, sagittal vertical axis (SVA) and C2-C7 Cobb angle in the ELIF group were significantly better than those in the ELINF group, and cervical range of movement (ROM) in the ELIF group decreased significantly than that in the ELINF group. The incidence of OPLL progression at the final follow-up was 4.76% (2/42) in the ELIF group and 27.78% (10/36) in the ELINF group. Postoperative Japanese Orthopaedic Association (JOA) score, neck disability index (NDI), and visual analog scale (VAS) score improved significantly in each group, but JOA score and recovery rate (RR) in the ELIF group were significantly better than those in the ELINF group at the final follow-up. When K-line was positive, the difference in the final JOA score between the two groups was not significant, but the RR in the ELIF group was significantly better than that in the ELINF group. When K-line was negative, the final JOA score and RR in the ELIF group were significant higher than those in the ELINF group.

CONCLUSIONS

ELIF and ELINF were two effective surgical procedures for treating multilevel cervical OPLL. However, ELIF was superior to ELINF due to better postoperative JOA score and RR, significant improvement of C2-C7 Cobb angle and maintenance of SVA, and suppressant effect on OPLL progression, especially for patients with K-line ( - ) OPLL.

The Rare Occurrence of Reoperation After Cervical Laminoplasty: A 14-Year Retrospective Review of Reoperative Rates at a Single Institution

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To determine the rate of recurrent or adjacent-level stenosis requiring reoperation after single-door cervical laminoplasty for spondylotic myelopathy at our institution.

SUMMARY OF BACKGROUND DATA

Adjacent-level stenosis requiring reoperation is a commonly evaluated condition for anterior or posterior arthrodesis, however, there are few studies that evaluate adjacent-level stenosis in the case of cervical laminoplasty.

METHODS

Retrospective review of adults undergoing cervical laminoplasty for spondylotic myelopathy between January 2005 and May 2018 at our institution. Demographics, symptom duration, stenotic levels, preoperative and postoperative Medical Research Council motor, American Spinal Injury Association, modified Japanese Orthopaedic Association scores, and Nurick grade were obtained. Postoperative data included presence of C5 palsy, infection rate, alleviation or persistence of symptoms, and rate of recurrent or adjacent-level stenosis.

RESULTS

A total of 102 patients underwent cervical laminoplasty; mean age was 56.7 years (±12.96). Most were men (n=76, 74.5%), with myelopathy (n=64, 63.4%), C4 (n=94, 93.1%), and C5 (n=92, 91.1%) cervical stenosis; mean symptom duration was 55 days (7 d to 2.8 y). Average follow-up was 6.4 months (±3.4). After surgery, there was statistically significant improvement in Nurick grade (3.1±2.2 vs. 2.7±2.4, P=0.002) and modified Japanese Orthopaedic Association score (11.4±3.7 vs. 13.9±3.6, P<0.001); American Spinal Injury Association scores also improved (P<0.001). Rate of postoperative C5 palsy was 7.8% (n=8); postoperative infection rate was 1.96% (n=2). Reoperation rate was 4.9% (n=5); reoperation for recurrent or adjacent-level stenosis was 1.96% (n=2).

CONCLUSIONS

Recurrent or adjacent-level stenosis requiring reoperation after cervical laminoplasty is rare. Longitudinal studies are needed to verify correlation between motion preservation and incidence of adjacent or recurrent stenosis.

LEVEL OF EVIDENCE

Level III-treatment benefits: nonrandomized controlled cohort/follow-up study.

Surgical decision-making for ossification of the posterior longitudinal ligament versus other types of degenerative cervical myelopathy: anterior versus posterior approaches

Background

The debate between anterior or posterior approach for pathologies such as cervical spondylotic myelopathy (CSM) and ossification of the posterior longitudinal ligament (OPLL) have drawn heated debate but are still inconclusive.

Main body of the abstract

A narrative review was performed specifically to study the differences pertaining to OPLL and other causes of degenerative cervical myelopathy (DCM). Current evidence suggests that anterior approach is preferred for K-line (−) OPLL, K-line (+) with canal occupying ratio > 60% and DCM with pre-existing cervical kyphosis. Posterior approach is preferred for K-line (+) OPLL with canal-occupying ratio < 50–60%, and multi-level CSM. No particular advantage for either approach was observed for DCM in a lordotic cervical spine. Anterior approach is generally associated with more complications and thus needs to be weighed carefully during decision-making. The evidence is not convincing for comparing single versus multi-level involvement, and the role of patients' co-morbidity status, pre-existing osteoporosis and co-existent spinal pathologies in influencing patient outcome and surgical options. This should be a platform for future research directives.

Conclusion

From this review, evidence is still inconclusive but there are some factors to consider, and DCM and OPLL should be considered separately for decision-making. Anterior approach is considered for pre-existing cervical kyphosis in DCM, for K-line (−) regardless of canal-occupying ratio, and K-line (+) and canal-occupying ratio > 60% for OPLL patients. Posterior approach is considered for patients with multi-level pathology for DCM, and K-line (+) and canal-occupying ratio < 50–60% for OPLL.

Is Lumbar Fusion Necessary for Chronic Low Back Pain Associated with Degenerative Disk Disease? A Meta-Analysis

OBJECTIVE

We sought to evaluate the efficacy and safety of lumbar fusion versus nonoperative care for the treatment of chronic low back pain associated with degenerative disk disease.

METHODS

A comprehensive duplicate electronic database search including PubMed, Embase, Cochrane Library, and China National Knowledge Infrastructure was conducted to identify relevant prospective studies published up to June 30, 2020. The main outcomes including clinical results, complications, and all-cause additional surgeries were presented in the form of short- (<2 years) and long-term (≥2 years) follow-up results. Analyses were performed in Review Manager software 5.3.

RESULTS

Six prospective studies involving 159 patients for short-term follow-up and 675 for long-term follow-up were included. The 2 interventions exhibited little difference in regard to short- and long-term Oswestry Disability Index and visual analog scale scores for back and leg pain, except that lumbar fusion might bring about lower additional surgery rate (risk ratio, 0.40; 95% confidence interval, 0.17 to 0.98; P = 0.04), and higher complication rate (risk ratio, 21.46; 95% confidence interval, 4.34 to 106.04; P = 0.0002) in the long term.

CONCLUSIONS

The present meta-analysis determined that fusion surgery was no better than nonoperative treatment in terms of the pain and disability outcomes at either short- or long-term follow-up. It is necessary for clinicians to weigh the risk of complications associated with fusion surgery against additional surgeries after nonoperative treatment. Considering lax patient inclusion criteria in the existing randomized clinical trials, the result needs to be further confirmed by high-quality research with stricter selection criteria in the future.

The Clinical Implications and Complications of Anterior Versus Posterior Surgery for Multilevel Cervical Ossification of the Posterior Longitudinal Ligament; An Updated Systematic Review and Meta-Analysis

OBJECTIVE

Theoretically, the optimal approach is determined by the status of ossification of the posterior longitudinal ligament (OPLL) and sagittal alignment. However, there have long been disputes about the optimum surgical approach of OPLL. This study is to compare risk-effectiveness between anterior decompression and fusion (ADF) and laminoplasty and laminectomy with fusion (LP/LF) for the patient with cervical myelopathy due to multilevel cervical OPLL.

METHODS

We searched core databases, and compared complication and outcomes between ADF and LP/LF for patients with multiple OPLL for the cervical spine. The incidence of complications such as neurologic deterioration, C5 palsy, and dura tear was assessed. Changes in JOA score between baseline and final evaluations were assessed for 2 groups. The minimal clinically important difference (MCID) was utilized for evaluating clinical significance. We calculated Peto odds ratio (POR) and mean difference for the incidence and continuous variables, respectively.

RESULTS

We included data from 21 articles involving 3,872 patients with cervical myelopathy with OPLL. Major neurologic deficits such as paraplegia, quadriplegia developed 2.17% in the ADF group and 1.11% in the LP/LF group, and POR was 2.16. Mean difference of JOA score improvement of 2 groups was 1.30, and the mean difference showed a statistical significance. However, 1.3 points of JOA improvement cannot reach 2.5 points of the MCID.

CONCLUSION

Anterior surgery often led to rare but critical complications, and the difference of neurological improvement between 2 groups was below a clinically meaningful level. Posterior surgeries may be appropriate in the treatment of multilevel cervical myelopathy with OPLL.

Anterior decompression and fusion versus laminoplasty for cervical myelopathy due to ossification of posterior longitudinal ligament: A meta-analysis

BACKGROUND

Both anterior decompression and fusion (ADF) and laminoplasty (LAMP) are frequently used for the treatment of cervical myelopathy due to ossification of the posterior longitudinal ligament (OPLL). However, some controversies still remained in surgical options. We investigated whether ADF had better neurological outcome than LAMP in the treatment of cervical myelopathy due to OPLL. Secondary outcomes included operation time, blood loss, rate of complication and reoperation.

METHODS

PubMed, EMBASE and the Cochrane Register of Controlled Trials database were searched to identify potential clinical studies compared ADF with LAMP for treatment of cervical myelopathy owing to OPLL. We also manually searched the reference lists of articles and reviews for possible relevant studies. Quality assessment was performed according to Cochrane Handbook and meta-analysis was conducted using Stata 12.0 software.

RESULTS

Nine studies involving 712 patients were finally included in this analysis. Compared with LAMP, ADF was associated with an increase of the Japanese Orthopaedic Association (JOA) score (WMD = 1.86, 95% CI 0.43 to 3.29, P = .011) and recovery JOA score at final follow-up (WMD = 30.94, 95% CI 20.56 to 41.33, P = .000). And, ADF was associated with a decrease of the late neurologic deterioration than LAMP group (RR = 0.34, 95% CI 0.12 to 0.92, P = .003). However, ADF was associated with an increase of the postoperative cervical lordosis (WMD = 4.47, 95% CI 1.58 to 7.36, P = .002) than LAMP. There was no significant difference between the complication, reoperation rate (P > .05). What's more, ADF was associated with an increase of the operation time than LAMP (P < .05).

CONCLUSIONS

ADF yields better neurological improvement, but higher cervical lordosis and longer operation time compared with LAMP for cervical myelopathy caused by OPLL. No significant difference was found in the complication and re-operation rate.

Variations in Practice among Asia-Pacific Surgeons and Recommendations for Managing Cervical Myelopathy: The First Asia-Pacific Spine Society Collaborative Study

STUDY DESIGN

Surgeon survey.

PURPOSE

To study the various surgical practices of different surgeons in the Asia-Pacific region.

OVERVIEW OF LITERATURE

Given the diversity among Asia-Pacific surgeons, there is no clear consensus on the preferred management strategies for cervical myelopathy. In particular, the role of prophylactic decompression for silent cervical spinal stenosis is under constant debate and should be addressed.

METHODS

Surgeons from the Asia-Pacific Spine Society participated in an online questionnaire comprising 50 questions. Data on clinical diagnosis, investigations and outcome measures, approach to asymptomatic and silent cervical spinal stenosis, guidelines for surgical approach, and postoperative immobilization were recorded. All parameters were analyzed by the Mantel-Haenszel test.

RESULTS

A total of 79 surgeons from 16 countries participated. Most surgeons used gait disturbance (60.5%) and dyskinetic hand movement (46.1%) for diagnosis. Up to 5.2% of surgeons would operate on asymptomatic spinal stenosis, and 18.2% would operate on silent spinal stenosis. Among those who would not operate, most (57.1%) advised patients on avoidance behavior and up to 9.5% prescribed neck collars. For ossification of the posterior longitudinal ligament (OPLL), anterior removal was most commonly performed for one-level disease (p<0.001), whereas laminoplasty was most commonly performed for two- to four-level disease (p=0.036). More surgeons considered laminectomy and fusion for multilevel OPLL. Most surgeons generally preferred to use a rigid neck collar for 6 weeks postoperatively (p<0.001).

CONCLUSIONS

The pooled recommendations include prophylactic or early decompression surgery for patients with silent cervical spinal stenosis, particularly OPLL. Anterior decompression is primarily suggested for one- or two-level disease, whereas laminoplasty is preferred for multilevel disease.