Is laminectomy and fusion the better choice than laminoplasty for multilevel cervical myelopathy with signal changes on magnetic resonance imaging? A comparison of two posterior surgeries

Cervical kyphosis after posterior cervical laminectomy with and without fusion

BACKGROUND

Cervical posterior instrumentation and fusion is often performed to avoid post-laminectomy kyphosis. However, larger comparative analyses of cervical laminectomy with or without fusion are sparse.

METHODS

A retrospective, two-center, comparative cohort study included patients after stand-alone dorsal laminectomy with (n = 91) or without (n = 46) additional fusion for degenerative cervical myelopathy with a median follow-up of 59 (interquartile range (IQR) 52) months. The primary outcome was the C2-7 Cobb angle and secondary outcomes were Neck Disability Index (NDI), modified Japanese Orthopaedic Association (mJOA) scale, revision rates, T1 slope and C2-7 sagittal vertical axis (C2-7 SVA) at final follow-up. Logistic regression analysis adjusted for potential confounders (i.e. age, operated levels, and follow-up).

RESULTS

Preoperative C2-7 Cobb angle and T1 slope were higher in the laminectomy group, while the C2-7 SVA was similar. The decrease in C2-7 Cobb angle from pre- to postoperatively was more pronounced in the laminectomy group (- 6° (IQR 20) versus -1° (IQR 7), p = 0.002). When adjusting for confounders, the decrease in C2-7 Cobb angle remained higher in the laminectomy group (coefficient - 12 (95% confidence interval (CI) -18 to -5), p = 0.001). However, there were no adjusted differences for postoperative NDI (- 11 (- 23 to 2), p = 0.10), mJOA, revision rates, T1 slope and C2-7 SVA.

CONCLUSION

Posterior cervical laminectomy without fusion is associated with mild loss of cervical lordosis of around 6° in the mid-term after approximately five years, however without any clinical relevance regarding NDI or mJOA in well-selected patients (particularly in shorter segment laminectomies of < 3 levels).

Results of laminoplasty versus laminectomy and posterior fusion for multilevel cervical spondylotic myelopathy

Background

The authors compared the clinical, MR, and clinical outcomes for patients with multilevel cervical spondylotic myelopathy (MCSM) who underwent laminoplasty (LP) versus laminectomy with fusion (LPSF).

Materials and methods

The authors evaluated 65 patients with MCSM (2019-2021) with 31 undergoing LP versus 34 having LPSF. Variables studied included JOA scores, T2W MR hyperintense cord signals, preoperative lordosis, number of stenotic levels, and neurological outcomes.

Results

Both groups showed similar preoperative JOA scores, number of stenotic levels, T2-weighted MR hyperintense cord signals, and nearly identifcal 12-month postoperative outcomes (good for 83.9 in the LP group vs. 85.3% in the LPSF group). Differences included: higher preoperative visual analog scale in the LPSF versus LP group, plus the LPSF patients significantly less preoperative cervical lordosis versus LP patients.

Conclusion

LP and LPSF used to treat MCSM resulted in similar clinical improvement and 1-year postoperative outcomes. However, our recommendation would be for patients with neck pain, instability, and/or cervical kyphosis to undergo LPSF.

Perioperative Complications of Laminoplasty in Degenerative Cervical Myelopathy -A Comparative Study Between Ossification of Posterior Longitudinal Ligament and Cervical Spondylotic Myelopathy Using a Nationwide Inpatient Database

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

Laminoplasty (LAMP) is one of the effective methods to successfully achieve surgical decompression in patients with degenerative cervical myelopathy (DCM). However, little evidence exists regarding the perioperative complications in LAMP for patients with ossification of the longitudinal ligament (OPLL) compared with cervical spondylotic myelopathy (CSM). We aimed to investigate the perioperative complication rates and medical costs of DCM, including OPLL and CSM patients who underwent LAMP using a large national inpatient database.

METHODS

This study identified patients who underwent LAMP for OPLL and CSM from 2010 to 2016 using the Japanese Diagnosis Procedure Combination database. We compared the incidence of perioperative complications (systemic and local), reoperation rates, medical costs during hospitalization, and mortality were between the OPLL and CSM groups after propensity score matching.

RESULTS

This study included 22,714 patients (OPLL: 7485 patients, CSM: 15,229 patients). Consequently, 7169 pairs were matched. More perioperative systemic complications were detected in the OPLL group (one complication: 9.1% vs 7.7%; P = .002), especially for pneumonia (.5% vs .2%; P = .001) and dysphagia (.5% vs .2%; P = .004). The local complication rate was also higher in the OPLL group (paralysis: 1.1% vs .6%, P = .006; spinal fluid leakage: .4% vs .1%, P = .002). The hospitalization costs were approximately $2300 higher ($19,024 vs $16,770; P < .001) in the OPLL group.

CONCLUSIONS

More perioperative complications and higher medical costs were noted in patients with OPLL than in patients with CSM who underwent LAMP.

Prognostic effect of increased postoperative MRI T2WI high signal intensity in degenerative cervical myelopathy

BACKGROUND CONTEXT

High cord signals (HCS) are common in patients undergoing surgery for degenerative cervical myelopathy (DCM). Few studies have investigated the prognostic effects of postoperative HCS changes.

PURPOSE

To investigate whether different changes in the postoperative magnetic resonance imaging (MRI) T2-weighted images (T2WIs) signal intensity ratio (SIR) is related to patient outcomes, predictors of unsatisfactory recovery, and the factors associated with changes in postoperative SIR.

STUDY DESIGN

A retrospective chart review at a single institution.

PATIENT SAMPLE

The study population included all consecutive patients who showed HCS in preoperative MRI T2WIs and underwent double-door laminoplasty for DCM from December 2017 to December 2020.

OUTCOME MEASURES

Patient self-reported measures included the Japanese Orthopedic Association (JOA) score, 36-Item Short Form Survey (SF-36) physical component score, and SF-36 mental component score. Imaging measures included SIR, length of HCS, and canal narrowing ratio (CNR).

METHODS

We reviewed patient records and analyzed the statistical associations of MRI T2WI measures with the JOA score, SF-36 physical, and mental component scores.

RESULTS

Fifty-three patients were categorized into three groups based on the postoperative HCS changes, identified from MRI T2WI before and after surgery: reduced (Group A, N=26); unchanged (Group B, N=12); and increased (Group C, N=15). The neurological recovery rates 12 months after surgery were 67.72%±17.45% in Group A, 51.53%±16.00% in Group B, and 13.35%±21.35% in Group C (p<.001). Significant differences across the three groups were found in symptom duration, postoperative SIR and length of HCS, pre- and postoperative CNR, recovery rate, JOA, SF-36 scores, with patients in Group C having the worst outcomes. Longer DCM symptom duration, greater preoperative CNR, and increased postoperative HCS were prognostic factors for a recovery rate<50%. Preoperative CNR, with an optimal threshold of 57.303%, was an independent risk factor for increased postoperative HCS.

CONCLUSIONS

Less than one-third of DCM patients with preoperative HCS exhibited an increase in HCS after double-door laminoplasty and reported worse outcomes at the 12-month follow-up when compared to patients with decreased or unchanged postoperative HCS.

Cervical Laminoplasty Versus Posterior Laminectomy and Fusion: Trends in Utilization and Evaluation of Complication and Revision Surgery Rates

INTRODUCTION

Cervical laminoplasty (LP) and laminectomy with fusion (LF) are common operations used to treat cervical spondylotic myelopathy. Conflicting data exist regarding which operation provides superior patient outcomes while minimizing the risk of complications. This study evaluates the trends of LP compared with LF over the past decade in patients with cervical myelopathy and examines long-term revision rates and complications between the two procedures.

METHODS

Patients aged 18 years or older who underwent LP or LF for cervical myelopathy from 2010 to 2019 were identified in the PearlDiver Mariner Database. Patients were grouped independently (LP versus fusion) and assessed for association with common medical and surgical complications. The primary outcome was the incidence of LP versus LF for cervical myelopathy over time. Secondary outcomes were revision rates up to 5 years postoperatively and the development of complications attributable to either surgery.

RESULTS

In total, 1,420 patients underwent LP and 10,440 patients underwent LF. Rates of LP (10.5% to 13.7%) and LF (86.3% to 89.5%) remained stable, although the number of procedures nearly doubled from 865 in 2010 to 1,525 in 2019. On matched analysis, LP exhibited lower rates of wound complications, surgical site infections, spinal cord injury, dysphagia, cervical kyphosis, limb paralysis, incision and drainage/exploration, implant removal, respiratory failure, renal failure, and sepsis. Revision rates for both procedures at were not different at any time point.

CONCLUSION

From 2010 to 2019, rates of LP have not increased and represent less than 15% of posterior-based myelopathy operations. Up to 5 years of follow-up, there were no differences in revision rates for LP compared with LF; however, LP was associated with fewer postoperative complications than LF.

LEVEL OF EVIDENCE

Level III retrospective cohort study.

Clinical and radiological efficacy of corpectomy and anterior stabilization with titanium mesh cages in patients with myelopathic syndrome associated with cervical spine degenerative di

The aim of this study was to research the clinical and radiological efficacy of  corpectomy and anterior stabilization with titanium mesh cages in patients with myelopathic syndrome associated with cervical spine degenerative diseases.

Material and methods. A retrospective observational cohort study was performed. The study included medical records of patients with cervical myelopathy associated with degenerative diseases of the cervical spine who underwent corpectomy and  anterior stabilization with titanium mesh cages. Clinical and instrumental parameters were assessed.

Results. The study included 28  medical records of respondents who underwent corpectomy and anterior stabilization with titanium mesh implants. The average age of patients was 61.9 ± 11.3 years, males prevailed (60.7 %). By the 3rd month of  postoperative follow-up, the severity of myelopathy significantly decreased (p˂0.001). After 12  months, the severity of cervical myelopathic syndrome also significantly decreased (p = 0.009). The neurological status of 18 (64.2 %) respondents improved in the first 3  months after corpectomy and anterior stabilization with titanium mesh implants and 6 months after the surgery, the status improved in the remaining 8 (30.7 %) patients (p˂0.001). Preoperative values of the Cobb sagittal angle allowed us to conclude the following. In 13 (46.4 %) patients, the normolordotic axis of the cervical spine was noted, in 12  (42.8  %) – the  hypolordotic axis, and in 3 (10.8 %) respondents, the Cobb angle values corresponded to the kyphotic axis of the cervical spine.

Conclusion. The technique of corpectomy and anterior fixation with mesh titanium implants in patients with myelopathic syndrome against the background of  degenerative diseases of the cervical spine makes it possible to improve the clinical status of the latter already 3 months after the operation was performed while maintaining normal biomechanical parameters of the cervical spine and complete decompression of the neural structures and supply their vessels. 

MRI T2WI High Signal Is a Risk Factor for Perioperative Complications in Patients with Cervical Spondylosis with Spinal Cord Compression: A Propensity Matching Score Analysis

Objective

The purpose of this study was to compare the perioperative complications and clinical efficacy of patients with cervical spondylosis with spinal cord compression (CSWSCC) with or without MRI T2WIHS (T2-weighted image high signal) by means of propensity matching score grouping.

Methods

We analyzed a single-center data of 913 surgical patients with CSWSCC by propensity matching score in this study, of which 326 patients had preoperative cervical MRI T2WIHS. The patient's general condition and perioperative indicators were collected. The MRI T2WIHS and normal groups were paired 1 : 1 to eliminate selection bias by propensity matching score. Finally, a total of 312 pairs were matched successfully. The results of perioperative complications and other outcome variables were compared between the two groups by Cox function analysis.

Results

The postoperative blood loss, operation time, blood transfusion volume, systemic complications, local complications, volume of drainage, abnormal use of antibiotic, length of hospital stay, and JOA (Japanese Orthopaedic Association) improvement rate were analyzed. As the only complication with significant statistical difference, the incidence of IRI (ischemia-reperfusion injury) in patients with MRI T2WIHS was significantly higher. The length of hospital stay was more significantly increased in patients with MRI T2WIHS; on the contrary, the JOA improvement rate decreased significantly.

Conclusion

This study confirmed that there was no significant difference in the incidence of perioperative complications in CSWSCC patients with or without MRI T2WIHS, except for the IRI. Moreover, the JOA improvement rate of patients without MRI T2WIHS was significantly better, with the length of hospital stay reduced.

Optimizing the Application of Surgery for Degenerative Cervical Myelopathy [AO Spine RECODE-DCM Research Priority Number 10]

STUDY DESIGN

Literature Review (Narrative).

OBJECTIVE

To introduce the number 10 research priority for Degenerative Cervical Myelopathy: Individualizing Surgery.

METHODS

This article summarizes the current recommendations and indications for surgery, including how known prognostic factors such as injury time, age, disease severity, and associated comorbidities impact surgical outcome. It also considers key areas of uncertainty that should be the focus of future research.

RESULTS

While a small proportion of conservatively managed patients may remain stable, the majority will deteriorate over time. To date, surgical decompression is the mainstay of treatment, able to halt disease progression and improve neurologic function and quality of life for most patients. Whilst this recognition has led to recommendations on when to offer surgery, there remain many uncertainties including the type of surgery, or timing in milder and/or asymptomatic cases. Their clarification has the potential to transform outcomes, by ensuring surgery offers each individual its maximum benefit.

CONCLUSION

Developing the evidence to better guide surgical decision-making at the individual patient level is a research priority for Degenerative Cervical Myelopathy.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Open-Door versus French-Door Laminoplasty for Patients with Multisegmental Cervical Spondylotic Myelopathy: A Systematic Review and Meta-analysis

This study aimed to evaluate the superiority of open-door versus French-door posterior cervical laminoplasty in the treatment of multisegmental cervical spondylotic myelopathy by comparing the intraoperative parameters and clinical and radiologic outcomes of these 2 procedures. PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure, the Wanfang database, the Weipu database, and China Biology Medicine disk were searched. Articles were retrieved from database establishment through May 22, 2020. Data analysis was carried out on the retrieved articles using RevMan 5.3 software. This meta-analysis included 14 studies involving 1010 patients, among which 6 were randomized controlled trials and 8 were retrospective analyses. Comparing the open-door and French-door groups, no statistically significant differences were found in operative time (weighted mean difference [WMD] = -4.47, 95% CI [-17.85, 8.92], P = 0.51), postoperative Japanese Orthopaedic Association score (WMD= -0.24, 95% CI [-0.87, 0.38], P = 0.45), recovery rate (WMD= -0.58, 95% CI [-3.61, 2.45], P = 0.71), postoperative cervical lordosis (WMD= -0.15, 95% CI [-1.93, 1.63], P = 0.87), cervical range of motion (WMD = -3.04, 95% CI [-8.68, 2.59], P = 0.29), sagittal diameter of the spinal canal (WMD = -0.24, 95% CI [-0.54, 0.07], P = 0.13), incidence of C5 palsy (OR = 1.78, 95% CI [0.64, 4.93], P = 0.27), or incidence of cerebrospinal fluid leakage (OR = 1.51, 95% CI [0.48, 4.71], P = 0.48). However, the French-door group was associated with less intraoperative bleeding (WMD = 54.96, 95% CI [21.37, 88.55], P = 0.001) and a lower incidence of axial symptoms (OR = 2.50, 95% CI [1.32, 4.72], P = 0.005). This analysis suggests that both methods can achieve good postoperative outcomes. However, less intraoperative bleeding and a lower incidence of postoperative axial symptoms were found in the French-door group. This requires further validation and investigation in larger sample-size and well-designed randomized controlled studies.

Identifying patients at risk for nonroutine discharge after surgery for cervical myelopathy: an analysis from the Quality Outcomes Database

OBJECTIVE

Optimizing patient discharge after surgery has been shown to impact patient recovery and hospital/physician workflow and to reduce healthcare costs. In the current study, the authors sought to identify risk factors for nonroutine discharge after surgery for cervical myelopathy by using a national spine registry.

METHODS

The Quality Outcomes Database cervical module was queried for patients who had undergone surgery for cervical myelopathy between 2016 and 2018. Nonroutine discharge was defined as discharge to postacute care (rehabilitation), nonacute care, or another acute care hospital. A multivariable logistic regression predictive model was created using an array of demographic, clinical, operative, and patient-reported outcome characteristics.

RESULTS

Of the 1114 patients identified, 11.2% (n = 125) had a nonroutine discharge. On univariate analysis, patients with a nonroutine discharge were more likely to be older (age ≥ 65 years, 70.4% vs 35.8%, p < 0.001), African American (24.8% vs 13.9%, p = 0.007), and on Medicare (75.2% vs 35.1%, p < 0.001). Among the patients younger than 65 years of age, those who had a nonroutine discharge were more likely to be unemployed (70.3% vs 36.9%, p < 0.001). Overall, patients with a nonroutine discharge were more likely to present with a motor deficit (73.6% vs 58.7%, p = 0.001) and more likely to have nonindependent ambulation (50.4% vs 14.0%, p < 0.001) at presentation. On multivariable logistic regression, factors associated with higher odds of a nonroutine discharge included African American race (vs White, OR 2.76, 95% CI 1.38-5.51, p = 0.004), Medicare coverage (vs private insurance, OR 2.14, 95% CI 1.00-4.65, p = 0.04), nonindependent ambulation at presentation (OR 2.17, 95% CI 1.17-4.02, p = 0.01), baseline modified Japanese Orthopaedic Association severe myelopathy score (0-11 vs moderate 12-14, OR 2, 95% CI 1.07-3.73, p = 0.01), and posterior surgical approach (OR 11.6, 95% CI 2.12-48, p = 0.004). Factors associated with lower odds of a nonroutine discharge included fewer operated levels (1 vs 2-3 levels, OR 0.3, 95% CI 0.1-0.96, p = 0.009) and a higher quality of life at baseline (EQ-5D score, OR 0.43, 95% CI 0.25-0.73, p = 0.001). On predictor importance analysis, baseline quality of life (EQ-5D score) was identified as the most important predictor (Wald χ2 = 9.8, p = 0.001) of a nonroutine discharge; however, after grouping variables into distinct categories, socioeconomic and demographic characteristics (age, race, gender, insurance status, employment status) were identified as the most significant drivers of nonroutine discharge (28.4% of total predictor importance).

CONCLUSIONS

The study results indicate that socioeconomic and demographic characteristics including age, race, gender, insurance, and employment may be the most significant drivers of a nonroutine discharge after surgery for cervical myelopathy.

Seesaw-Like Cervical Ossification of Posterior Longitudinal Ligament

Ossification of posterior longitudinal ligament (OPLL) is a pathological process in which lamellar bone is deposited at the posterior longitudinal ligament and can lead to a limited range of cervical motion and spinal cord compression. A 64-year-old man presented with a 10-month history of worsening clumsiness in the hands and impaired gait, and he occasionally had a feeling of an electric shock in the limbs when the neck was flexed. Physical examination revealed atrophy of the intrinsic hand muscles, rapid reflexes in the lower extremities, and positive Hoffman sign and Babinski sign results. Seesaw-like OPLL was observed on hyperextension and hyperflexion x-rays, which also showed that the OPLL involved the spinal canal; laminoplasty and laminectomy were not recommended for this specific type of OPLL, even though the K-line was positive on both x-rays.

Surgical Options in Treating Ossification of the Posterior Longitudinal Ligament: Single-Center Experience

BACKGROUND

Ossified posterior longitudinal ligament (OPLL) of the cervical spine can lead to spinal stenosis and become clinically symptomatic. The optimal approach in addressing OPLL is a debated topic and dependent on factors such as preoperative lordosis and levels affected.

METHODS

In this study, we retrospectively identified patients undergoing operative management for OPLL. Demographics, operative details, radiographic parameters, outcome measurements, and complications were compared between the different approaches for OPLL treatment.

RESULTS

We identified a total of 44 patients with 16 undergoing laminoplasty (Plasty), 18 anterior corpectomy and diskectomy (Ant), and 10 laminectomy and instrumentation (Linst). Ant had least OPLL levels with median (range) 3 (2-5), compared with Plasty 4 (2-7) and Linst 4 (3-6). Plasty was associated with the shortest operative time and hospital stay. Ant showed significant correction in kyphosis from 0.5° (-13 to 16°) to 9.5° (-7 to 20°). There was loss in lordosis in Plasty and Linst. Sagittal balance significantly increased irrespective of surgical approach with the least increase in the Ant group. Complications were least in the Plasty group with similar overall improvement in outcome measurements.

CONCLUSIONS

All 3 approaches in the management of OPLL were associated with clinical improvement without 1 approach surpassing the others. Laminoplasty had the advantage of addressing more levels of stenosis than the anterior approach and was associated with a shorter operating time. Laminoplasty patients had a shorter hospital stay than those undergoing laminectomy and instrumentation and appeared to have fewer complications than the other approaches. Laminoplasty is the preferred approach in patients with preserved motion and lordosis, with the anterior approach effective in the correction of kyphosis.