Efficacy of Posterior Segmental Decompression Surgery for Pincer Mechanism in Cervical Spondylotic Myelopathy: A Retrospective Case-controlled Study Using Propensity Score Matching

Axial Symptoms After Conventional and Modified Laminoplasty: A Meta-analysis

PURPOSE

The study aims to evaluate the impact of procedural variations in single-door laminoplasty on axial symptoms (AS) and neurologic outcomes.

METHODS

A comprehensive literature search was conducted across PubMed, EMBASE, and the Cochrane Library, adhering to specific inclusion criteria. We extracted data on the prevalence of AS in both the modified and conventional laminoplasty groups from the selected studies. Neurologic outcomes were assessed using the Japanese Orthopedic Association (JOA) recovery rate, which was subsequently converted to Hedge's g for analysis. Forest plots were generated to visualize the effect sizes, and publication bias was assessed using both funnel plots and Egger's test.

RESULTS

Fourteen studies comprising 1201 patients were included in this meta-analysis focused on AS. The aggregated SMD was -0.891 with a 95% CI of -1.146 to -0.631 (P < 0.01), denoting a statistically significant reduction in AS in the modified laminoplasty group compared with the conventional approach. Of the 14 studies, 10, encompassing 898 patients, contributed data for JOA recovery rate analysis. The overall effect size was 0.089, with a 95% CI ranging from -0.090 to 0.267, and a P value of 0.2901, indicating no significant difference in neurologic outcomes between the 2 techniques. No evidence of publication bias was detected.

CONCLUSIONS

This meta-analysis demonstrates that modified laminoplasty is associated with a significant reduction in the incidence and severity of axial symptoms, without compromising neurologic functionality.

Determinants of quality of life in degenerative cervical myelopathy: a systematic review

BACKGROUND

Degenerative cervical myelopathy (DCM) is the most common cause of chronic, progressive spinal cord impairment worldwide. Patients experience substantial pain, functional neurological decline and disability. Health-related quality of life (HRQoL) appears to be particularly poor, even when compared to other chronic diseases. However, the determinants of HRQoL are poorly understood. The objective was to perform a systematic review of the determinants of quality of life of people with DCM.

METHODS

A systematic search was conducted in MEDLINE and Embase following PRISMA 2020 guidelines (PROSPERO CRD42018115675). Full-text papers in English, exclusively studying DCM, published before 26 March 2020 were eligible for inclusion and were assessed using the Newcastle-Ottawa Scale and the Cochrane Risk of Bias 2 (RoB 2) tool. Study sample characteristics, patient demographics, cohort type, HRQoL instrument utilised, HRQoL score, and relationships of HRQoL with other variables were qualitatively synthesised.

RESULTS

A total of 1176 papers were identified; 77 papers and 13,572 patients were included in the final analysis. A total of 96% of papers studied surgical cohorts and 86% utilised the 36-Item Short Form Survey (SF-36) as a measure of HRQoL. HRQoL determinants were grouped into nine themes. The most common determinant to be assessed was surgical technique (38/77, 49%) and patient satisfaction and experience of pain (10/77, 13%). HRQoL appeared to improve after surgery. Pain was a negative predictor of HRQoL.

CONCLUSION

Current data on the determinants of HRQoL in DCM are limited, contradictory and heterogeneous. Limitations of this systematic review include lack of distinction between DCM subtypes and heterogenous findings amongst the papers in which HRQoL is measured postoperatively or post-diagnosis. This highlights the need for greater standardisation in DCM research to allow further synthesis. Studies of greater precision are necessary to account for HRQoL being complex, multi-factorial and both time and context dependent.

Long-term Clinical Outcomes of Microendoscopic Laminotomy for Cervical Spondylotic Myelopathy: A 5-Year Follow-up Study Compared With Conventional Laminoplasty

STUDY DESIGN

This was a retrospective cohort study.

OBJECTIVE

The objective of this study was to characterize the long-term clinical and radiographic results of articular segmental decompression surgery using endoscopy [cervical microendoscopic laminotomy (CMEL)] for cervical spondylotic myelopathy (CSM) and to compare outcomes to conventional expansive laminoplasty (ELAP).

SUMMARY OF BACKGROUND DATA

The spinal cord compression in CSM consists of a pincer mechanism due to bulging disk and a hypertrophied ligamentum flavum. The long-term clinical benefits of segmental decompression surgery, which removes the dorsal compressive elements of articular segment in CSM patients, have not yet been elucidated.

MATERIALS AND METHODS

Consecutive patients with CSM who required surgical treatment were enrolled. All enrolled patients (n=81) underwent CMEL or ELAP. All patients were followed postoperatively for >5 years. The preoperative and 5-year follow-up evaluation included neurological assessment [Japanese Orthopaedic Association (JOA) score], JOA recovery rates, axial neck pain (visual analog scale), and cervical sagittal alignment (C2-C7 subaxial cervical angle).

RESULTS

Sixty-four patients (CMEL group: 33, ELAP group: 31) were included for analysis. The preoperative JOA score was 10.1 points in the CMEL group and 11.1 points in the ELAP group (P=0.15). The JOA recovery rates were similar, 58.6% in the CMEL group and 55.2% in the ELAP group (P=0.55). The axial neck pain in the CMEL group was significantly lower than that in the ELAP group (P<0.01). At 5-year follow-up, cervical alignment was more favorable in the CMEL group, with an average 2.9 degrees gain in lordosis [vs. 2.3 degrees loss of lordosis in the ELAP group (P<0.05)] and lower incidence of postoperative kyphosis.

CONCLUSIONS

CMEL is a novel, less invasive, technique that allows for multilevel posterior cervical decompression for treatment of CSM. Our 5-year follow-up data demonstrates that patients after CMEL have similar neurological outcomes to conventional laminoplasty, with significantly less postoperative axial pain and improved subaxial cervical lordosis when compared with their traditional laminoplasty counterparts.

Cervical Single-Level Pincer Stenosis Causing Myelopathy: A Technical Note and Medium-term Results of a One-Session Microsurgical 360-Degree Treatment

BACKGROUND AND STUDY AIMS

 Single-level circumferential or pincer stenosis (PS) affects few patients with degenerative cervical myelopathy (DCM). The surgical technique and medium-term results of a one-session microsurgical 360-degree (m360°) procedure are presented.

PATIENTS

 Between 2013 and 2018, the data of 23 patients were prospectively collected out of 371 patients with DCM. The m360° procedure comprised a microsurgical anterior cervical decompression and fusion (ACDF), with additional plate fixation, followed by flipping the patient and performing a microsurgical posterior bilateral decompression via a unilateral approach in crossover technique.

RESULTS

 The mean age of the patients was 72 years (range: 50-84); 17 patients were males. The mean follow-up time was 12 months (range: 6-31). The patients filled in the patient-derived modified Japanese Orthopaedic Association (P-mJOA) questionnaire on average 53 months after surgery. One patient received a two-level ACDF. Lesions were mostly (92%) located at the C3/C4 (8/24), C4/C5 (7/24), and C5/C6 (7/24) levels. Functional X-rays showed segmental instability in 10 of 23 patients (44%). All preoperative T2-weighted magnetic resonance imaging (MRI) showed an intramedullary hyperintensity. The median preoperative mJOA score was 13 (range 3), and it improved to 16 (range 3) postoperatively. The mean improvement rate in the mJOA score was 73%. When available, postoperative MRI confirmed good circumferential decompression with persistent intramedullary hyperintensity. There were two complications: a long-lasting radicular paresthesia at C6 and a transient C5 palsy. No revision surgery was required.

CONCLUSION

 The one-session m360° procedure was found to be a safe surgical procedure for the treatment of PS, and the medium-term clinical outcome was satisfactory.

Anterior Decompression and Fusion Versus Laminoplasty for Cervical Myelopathy Caused by Soft Disk Herniation: A Long-term Prospective Multicenter Study

STUDY DESIGN

A prospective multicenter study.

OBJECTIVE

The purpose of this study was to determine whether laminoplasty (LP) is comparable for myelopathy caused by cervical disk herniation (CDH).

SUMMARY OF BACKGROUND DATA

Anterior decompression and fusion (ADF) has conventionally been used for myelopathy caused by CDH with stable outcomes. However, recurrence of myelopathy due to adjacent segment degeneration are its drawbacks. The efficacy of LP without discectomy has been sporadically reported, but no long-term prospective study has been conducted to verify it.

MATERIALS AND METHODS

Patients with cervical myelopathy caused by CDH were studied. The first 30 patients and the next 30 patients were treated with ADF and LP, respectively. The outcomes were compared between the 22 ADF patients and the 20 LP patients who had completed the follow-up examination scheduled 10 years after surgery.

RESULTS

There was no statistically significant difference in the postoperative severity or recovery rate of myelopathy between the 2 groups 10 years after surgery. One patient in the ADF group underwent LP for secondary myelopathy due to adjacent segment degeneration 2 years after the surgery. Reoperation was not required for patients in the LP group. Postoperative neck pain was significantly more severe in the LP group than in the ADF group.

CONCLUSIONS

ADF and LP for cervical myelopathy caused by CDH achieve similarly favorable outcomes. Recurrence of myelopathy caused by adjacent segment degeneration is a disadvantage of ADF while residual neck pain is a disadvantage of LP.

The effect of minimally invasive dorsal cervical decompression for myelopathy on spinal alignment and range of motion

OBJECTIVE

Minimally invasive dorsal cervical decompression (miDCD) has been reported as a novel alternative to open dorsal decompression techniques such as laminectomy, laminoplasty, or laminectomy and fusion. Only limited data have been presented regarding the effects of a minimally invasive approach on cervical motion and alignment. The object of the current study is to provide a more comprehensive analysis of radiographic outcomes following miDCD.

PATIENTS AND METHODS

Thirty-five patients who had undergone miDCD for myelopathy were included. Exclusion criteria included prior cervical spine surgery, prior cervical spine fracture, fusion of the cervical spine during miDCD, and/or acute spinal cord injury. Analysis of x-rays included the following data elements: degrees of flexion, degrees of extension, and total range of motion; C2-C7 angle as a measure of cervical lordosis; C2-C7 sagittal vertical axis; effective lordosis; and C7 slope. Patient reported outcome measures included neck Visual Analog Score (VAS), Neck Disability Index (NDI), SF-12 Physical Component Score (PCS), SF-12 Mental Component Score (MCS), Nurick score, and modified Japanese Orthopedic Association Myelopathy scale (mJOA).

RESULTS

Pre-operative to post-operative comparisons of all radiographic parameters - including total range of motion, C2-C7 Cobb angle, C2-C7 sagittal vertical axis, effective lordosis, and C7 slope angle - remained stable. Several clinical outcomes demonstrated statistical improvement, namely neck VAS, Nurick score, mJOA, NDI, and SF-12 PCS.

CONCLUSIONS

miDCD can maintain cervical range of motion and alignment better than traditional laminectomy or laminoplasty techniques.

Clinical and Radiological Outcomes of Anterior Approach Microscopic Surgery for the Pincer Mechanism in Cervical Spondylotic Myelopathy

Objective

We aimed to evaluate the efficacy of anterior approach microscopic surgery for patients with the pincer mechanism in cervical spondylotic myelopathy.

Methods

The clinical data of pincer cervical spondylotic myelopathy that received anterior cervical decompression and fusion in our hospital from Aug 2014 to Dec 2017 were analyzed retrospectively, including 12 males and 9 females, with an average age of 64.3 years (range 46-81 years). Occupying rate, anterior occupying rate, and posterior occupying rate were measured on pre- and postoperative mid-sagittal MRIs. Pre- and postoperative Japanese Orthopedic Association (JOA) scores, intervertebral space height, and C2 to C7 Cobb's angle were analyzed.

Result

Duration of follow-up was six months. The pre- and postoperative anterior occupying rate were averagely 38.6±8.5% and 12.9±5.5%, respectively, the posterior occupying rates were averagely 27.4±7.2% and 13.1±6.6%, respectively, and Cobb's angle changed from 15.3±8.0° to 22.7±7.9°. The intervertebral space height increased from 4.6±0.4mm to 6.5±0.4mm. JOA scores improved significantly by 59.4±34.0% at six months after surgery.

Conclusion

Decompression by anterior microscopic surgery can increase spinal canal volume directly, recover intervertebral space height, and resize Cobb's angle, but decrease the posterior compression by ligament Flava indirectly. Anterior decompression under the microscope may provide an alternative surgical option for partial patients with the pincer mechanism in cervical spondylotic myelopathy.

Microendoscopic Decompression for Lumbar Spinal Stenosis With Degenerative Spondylolisthesis: The Influence of Spondylolisthesis Stage (Disc Height and Static and Dynamic Translation) on Clinical Outcomes

STUDY DESIGN

This study was a retrospective subgroup analysis of prospective cohort data.

OBJECTIVE

The main objectives of this study were to develop a classification of degenerative spondylolisthesis (DS) and concurrent lumbar spinal stenosis (LSS) based on pathologic stage, and to determine how these subtypes of DS affect outcomes for minimally invasive (MIS) decompression SUMMARY OF BACKGROUND DATA:: DS with LSS is a common clinical scenario, yet there is no consensus on optimal treatment. Natural history of DS is described as early degenerative damage, followed by instability, and eventual restabilization via spondylotic changes. MIS decompression surgery has become increasingly popular, but the effect of DS subtypes on clinical outcomes after MIS decompression is unknown.

PATIENTS AND METHODS

From 2008 to 2013, all patients who underwent microendoscopic laminotomy for single-level LSS with DS were included. In total, 218 patients (91 male, 127 female individuals) were reviewed. DS pathologic staging was defined as early, advanced, or end stage, based on percent slippage (10% slippage), degree of dynamic instability (3 mm), and disc height. The following variables were evaluated preoperatively and >2 years postoperatively and compared among groups: Japanese Orthopaedic Association (JOA) score, JOA recovery rate, and Visual Analog Scale low back pain.

RESULTS

In total, 173 patients were included in final analysis. Final follow-up period was 2.3 years. Average JOA recovery rate was 63.8%. There were no significant differences in JOA recovery and Visual Analog Scale among 3 DS stages (P>0.05). In total, 9.8% of patients required additional spine surgery, with 5% requiring subsequent fusion. All patients who required subsequent fusion were in the advanced stage DS group.

CONCLUSIONS

Microendoscopic decompression is an effective treatment for patients with DS and concurrent LSS, with only 5% of patients requiring subsequent fusion at over 2-year follow-up, and another 5% requiring revision or adjacent segment decompression. The advanced stage DS group, indicating a >10% anterolisthesis and/or >3 mm of dynamic instability, was more likely to require additional surgery.

Minimally invasive spinal decompression for degenerative lumbar spondylolisthesis and stenosis maintains stability and may avoid the need for fusion

Aims

The aim of this study was to investigate the clinical and radiographic outcomes of microendoscopic laminotomy in patients with lumbar stenosis and concurrent degenerative spondylolisthesis (DS), and to determine the effect of this procedure on spinal stability.

Patients and Methods

A total of 304 consecutive patients with single-level lumbar DS with concomitant stenosis underwent microendoscopic laminotomy without fusion between January 2004 and December 2010. Patients were divided into two groups, those with and without advanced DS based on the degree of spondylolisthesis and dynamic instability. A total of 242 patients met the inclusion criteria. There were 101 men and 141 women. Their mean age was 68.1 years (46 to 85). Outcome was assessed using the Japanese Orthopaedic Association and Roland Morris Disability Questionnaire scores, a visual analogue score for pain and the Short Form Health-36 score. The radiographic outcome was assessed by measuring the slip and the disc height. The clinical and radiographic parameters were evaluated at a mean follow-up of 4.6 years (3 to 7.5).

Results

There were no significant differences in the preoperative measurements between the group and no significant differences between the clinical parameters at the final follow-up. The mean percentage slip was 17.1% preoperatively and 17.7% at the final follow-up (p = 0.35). Progressive instability was noted in 13 patients (8.2%) with DS and 6 patients (7.0%) with advanced DS, respectively (p = 0.81). There was radiological evidence of restabilization of the spine in 30 patients (35%) with preoperative instability. The success rate of microendoscopic laminotomy was good/excellent in 166 (69%), fair in 49 (20%) and poor in 27 patients (11%) in both groups.

Conclusion

Microendoscopic laminotomy is an effective form of surgical treatment for patients with DS and stenosis. Preservation of the stabilizing structures using this technique prevents postoperative instability. Cite this article: Bone Joint J 2018;100-B:499-506.

Microendoscopic laminotomy versus conventional laminoplasty for cervical spondylotic myelopathy: 5-year follow-up study

OBJECTIVE The goal of this study was to characterize the long-term clinical and radiological results of articular segmental decompression surgery using endoscopy (cervical microendoscopic laminotomy [CMEL]) for cervical spondylotic myelopathy (CSM) and to compare outcomes to conventional expansive laminoplasty (ELAP). METHODS Consecutive patients with CSM who required surgical treatment were enrolled. All enrolled patients (n = 78) underwent CMEL or ELAP. All patients were followed postoperatively for more than 5 years. The preoperative and 5-year follow-up evaluations included neurological assessment (Japanese Orthopaedic Association [JOA] score), JOA recovery rates, axial neck pain (using a visual analog scale), the SF-36, and cervical sagittal alignment (C2-7 subaxial cervical angle). RESULTS Sixty-one patients were included for analysis, 31 in the CMEL group and 30 in the ELAP group. The mean preoperative JOA score was 10.1 points in the CMEL group and 10.9 points in the ELAP group (p > 0.05). The JOA recovery rates were similar, 57.6% in the CMEL group and 55.4% in the ELAP group (p > 0.05). The axial neck pain in the CMEL group was significantly lower than that in the ELAP group (p < 0.01). At the 5-year follow-up, cervical alignment was more favorable in the CMEL group, with an average 2.6° gain in lordosis (versus 1.2° loss of lordosis in the ELAP group [p < 0.05]) and lower incidence of postoperative kyphosis. CONCLUSIONS CMEL is a novel, less invasive technique that allows for multilevel posterior cervical decompression for the treatment of CSM. This 5-year follow-up data demonstrates that after undergoing CMEL, patients have similar neurological outcomes to conventional laminoplasty, with significantly less postoperative axial pain and improved subaxial cervical lordosis when compared with their traditional ELAP counterparts.

A comparison of minimally invasive posterior cervical decompression and open anterior cervical decompression and instrumented fusion in the surgical management of degenerative cervical myelopathy

OBJECTIVE Minimally invasive posterior cervical decompression (miPCD) has been described in several case series with promising preliminary results. The object of the current study was to compare the clinical outcomes between patients undergoing miPCD with anterior cervical discectomy and instrumented fusion (ACDFi). METHODS A retrospective study of 74 patients undergoing surgery (45 using miPCD and 29 using ACDFi) for myelopathy was performed. Outcomes were categorized into short-term, intermediate, and long-term follow-up, corresponding to averages of 1.7, 7.7, and 30.9 months, respectively. Mean scores for the Neck Disability Index (NDI), neck visual analog scale (VAS) score, SF-12 Physical Component Summary (PCS), and SF-12 Mental Component Summary (MCS) were compared for each follow-up period. The percentage of patients meeting substantial clinical benefit (SCB) was also compared for each outcome measure. RESULTS Baseline patient characteristics were well-matched, with the exception that patients undergoing miPCD were older (mean age 57.6 ± 10.0 years [miPCD] vs 51.1 ± 9.2 years [ACDFi]; p = 0.006) and underwent surgery at more levels (mean 2.8 ± 0.9 levels [miPCD] vs 1.5 ± 0.7 levels [ACDFi]; p < 0.0001) while the ACDFi patients reported higher preoperative neck VAS scores (mean 3.8 ± 3.0 [miPCD] vs 5.4 ± 2.6 [ACDFi]; p = 0.047). The mean PCS, NDI, neck VAS, and MCS scores were not significantly different with the exception of the MCS score at the short-term follow-up period (mean 46.8 ± 10.6 [miPCD] vs 41.3 ± 10.7 [ACDFi]; p = 0.033). The percentage of patients reporting SCB based on thresholds derived for PCS, NDI, neck VAS, and MCS scores were not significantly different, with the exception of the PCS score at the intermediate follow-up period (52% [miPCD] vs 80% [ACDFi]; p = 0.011). CONCLUSIONS The current report suggests that the optimal surgical strategy in patients requiring dorsal surgery may be enhanced by the adoption of a minimally invasive surgical approach that appears to result in similar clinical outcomes when compared with a well-accepted strategy of ventral decompression and instrumented fusion. The current results suggest that future comparative effectiveness studies are warranted as the miPCD technique avoids instrumented fusion.

Does the microendoscopic technique reduce mortality and major complications in patients undergoing lumbar discectomy? A propensity score-matched analysis using a nationwide administrative database

OBJECTIVE Although minimally invasive spinal surgery has recently gained popularity, few nationwide studies have compared the adverse events that occur during endoscopic versus open spinal surgery. The purpose of this study was to compare perioperative complications associated with microendoscopic discectomy (MED) and open discectomy for patients with lumbar disc herniation. METHODS The authors retrospectively extracted from the Diagnosis Procedure Combination database, a national inpatient database in Japan, data for patients admitted between July 2010 and March 2013. Patients who underwent lumbar discectomy without fusion surgery were included in the analysis, and those with an urgent admission were excluded. The authors examined patient age, sex, Charlson Comorbidity Index, body mass index, smoking status, blood transfusion, duration of anesthesia, type of hospital, and hospital volume (number of patients undergoing discectomy at each hospital). One-to-one propensity score matching between the MED and open discectomy groups was performed to compare the proportions of in-hospital deaths, surgical site infections (SSIs), and major complications, including stroke, acute coronary events, pulmonary embolism, respiratory complications, urinary tract infection, and sepsis. The authors also compared the hospital length of stay between the 2 groups. RESULTS A total of 26,612 patients were identified in the database. The mean age was 49.6 years (SD 17.7 years). Among all patients, 17,406 (65.4%) were male and 6422 (24.1%) underwent MED. A propensity score-matched analysis with 6040 pairs of patients showed significant decreases in the occurrence of major complications (0.8% vs 1.3%, p = 0.01) and SSI (0.1% vs 0.2%, p = 0.02) in patients treated with MED compared with those who underwent open discectomy. Overall, MED was associated with significantly lower risks of major complications (OR 0.62, 95% CI 0.43-0.89, p = 0.01) and SSI (OR 0.29, 95% CI 0.09-0.87, p = 0.03) than open discectomy. There was a significant difference in length of hospital stay (11 vs 15 days, p < 0.001) between the groups. There was no significant difference in in-hospital mortality between MED and open discectomy. CONCLUSIONS The microendoscopic technique was associated with lower risks for SSI and major complications following discectomy in patients with lumbar disc herniation.

Laminoplasty with lateral mass screw fixation for cervical spondylotic myelopathy in patients with athetoid cerebral palsy: A retrospective study

Although several studies report various treatment solutions for cervical spondylotic myelopathy in patients with athetoid cerebral palsy, long-term follow-up studies are very rare. None of the reported treatment solutions represent a gold standard for this disease owing to the small number of cases and lack of long-term follow-up. This study aimed to evaluate the outcomes of laminoplasty with lateral mass screw fixation to treat cervical spondylotic myelopathy in patients with athetoid cerebral palsy from a single center.This retrospective study included 15 patients (9 male patients and 6 female patients) with athetoid cerebral palsy who underwent laminoplasty with lateral mass screw fixation for cervical spondylotic myelopathy at our hospital between March 2006 and June 2010. Demographic variables, radiographic parameters, and pre- and postoperative clinical outcomes determined by the modified Japanese Orthopedic Association (JOA), Neck Disability Index (NDI), and visual analog scale (VAS) scores were assessed.The mean follow-up time was 80.5 months. Developmental cervical spinal canal stenosis (P = 0.02) and cervical lordosis (P = 0.04) were significantly correlated with lower preoperative modified JOA scores. The mean modified JOA scores increased from 7.97 preoperatively to 12.1 postoperatively (P < 0.01). The mean VAS score decreased from 5.30 to 3.13 (P < 0.01), and the mean NDI score decreased from 31.73 to 19.93 (P < 0.01). There was a significant negative correlation between developmental cervical spinal canal stenosis and recovery rate of the modified JOA score (P = 0.01).Developmental cervical spinal canal stenosis is significantly related to neurological function in patients with athetoid cerebral palsy. Laminoplasty with lateral mass screw fixation is an effective treatment for cervical spondylotic myelopathy in patients with athetoid cerebral palsy and developmental cervical spinal canal stenosis.