Clinical feasibility of minimally invasive cervical laminoplasty

Exoscopic Minimally Invasive Open-Door Laminoplasty for Cervical Myelopathy: A Technical Note and Preliminary Analysis of Clinical Outcomes during the Acute Postoperative Period

Background/Objectives: Expansive open-door laminoplasty results in favorable clinical outcomes for cervical myelopathy. However, some postoperative complications associated with surgical invasiveness, such as axial neck pain and kyphosis, have not been resolved. The use of an exoscope, which is a recently introduced novel magnification tool, allows for traditional open-door laminoplasty with minimal invasiveness. Therefore, we propose the use of exoscopic minimally invasive open-door laminoplasty (exLAP) and present its clinical outcomes during the acute postoperative period. Methods: A total of 28 patients who underwent open-door laminoplasty at C3-C6 were reviewed. Of these patients, 17 underwent exLAP (group M) and 11 underwent conventional Hirabayashi open-door laminoplasty (group H). Outcomes were evaluated using numerical rating scale (NRS) scores for neck pain and the frequency of oral analgesic use from postoperative day 1 to 7. Results: The NRS score for neck pain was significantly lower for patients in group M than for those in group H. Conclusions: ExLAP is a novel, practical, and minimally invasive surgical technique that may alleviate the postoperative axial pain of patients with cervical myelopathy.

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.

Mental State Can Influence the Degree of Postoperative Axial Neck Pain Following Cervical Laminoplasty

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

To investigate factors influencing the incidence of moderate to severe postoperative axial neck pain following cervical laminoplasty.

METHODS

We reviewed 125 patients with cervical myelopathy who underwent double-door laminoplasty. The primary outcomes were the Numerical Rating Scale score (NRS score, 0-10) for neck pain, the Short Form 36 (SF-36) Health Survey score (Physical and Mental Component Summary scores [PCS and MCS, respectively]), and satisfaction. Imaging parameters on plain radiographs and magnetic resonance imaging were also evaluated. Patients with moderate to severe postoperative neck pain (NRS ≥ 5) were compared with those with no or mild neck pain (NRS ≤ 4).

RESULTS

One hundred and three patients (82%) with complete data were eligible for inclusion. There were 67 men and 36 women, with a mean age of 65 years (32-89 years). Twenty-five patients (23%) had moderate to severe postoperative axial pain (NRS ≥ 5) and were compared with the other 78 patients (NRS ≤ 4), which revealed several predictive factors, including female sex, the presence of preoperative neck pain, low postoperative PCS, low preoperative and postoperative MCS, and satisfaction with the treatment. Multivariable logistic regression analysis revealed that the postoperative MCS (P = .002) was a risk factor for postoperative neck pain, although the preoperative MCS did not reach statistical significance (P = .06).

CONCLUSIONS

Patients with a low mental state, possibly before surgery, are at a high risk for postoperative axial neck pain. None of the imaging parameters were statistically different.

Ozone injection with or without percutaneous microdiscectomy for treatment of cervical disc herniation

OBJECTIVE

This retrospective study compared the efficacy of combined percutaneous ozone injection and percutaneous discectomyto percutaneous ozone injection alone for the treatment of cervical disc herniation.

METHODS

Patients with cervical disc herniation who were enrolled in our hospital from October 2010 to June 2015 were divided into two groups: 1) treated with percutaneous ozone injection alone (control; n= 19); and 2) those treated with combined ozone injection and percutaneous microdiscectomy (combined treatment; n= 28). The efficacy of the combined treatment was evaluated relative to the control by visual analogue scale (VAS) and the modified Macnab standard. Effective treatment was defined as excellent or good, and ineffective as fair or poor.

RESULTS

No major complications occurred in either group. For the control group, the VAS scores dropped from 6.75 ± 2.34 before surgery to 2.78 ± 1.85 immediately after surgery, and to 4.18 ± 1.46 during the follow-ups. For patients who received the combined treatment, the VAS scores were 7.12 ± 2.03 before surgery, 3.86 ± 2.87 immediately after surgery, and 3.27 ± 1.53 during the follow-ups. At the 6-month follow-up, 73.7% (14 from 19 patients) in the control group and 89.2% (25 from 28 patients) in the treatment group were judged to have received effective treatment. Difference in efficacy between two groups of treatment was statistically significant (P= 0.033).

CONCLUSION

The rate of effective treatment in patients who received combined percutaneous microdiscectomy and ozone injection was higher than that of patients who received ozone injection alone. Combination of percutaneous microdiscectomy and ozone injection might be an effective method to treat patients with cervical disk hernia.

MINIMALLY INVASIVE SINGLE-DOOR PLATE LAMINOPLASTY WITH LATERAL MASS SCREW FIXATION FOR THE UNSTABLE SEGMENT. REPORT OF TWO CASES WITH LONG FOLLOW-UP

ABSTRACT Objective: To report two cases of multilevel cervical spondylotic myelopathy with monosegmental instability, in which we performed a minimally invasive microsurgical transmuscular approach with tubular retractors to create a single-door plate laminoplasty combined with fixation of the unstable segment with lateral mass screws. Methods: The surgical procedures were performed by the senior author. In both patients, the follow-up was performed using the Oswestry Disability Index (ODI), the Visual Analogue Scale for neck and radicular pain (radVAS, neckVAS), the Neck Disability Index (NDI) and the Short Form 36 (SF-36), in the preoperative (preop) and postoperative (postop) periods, and at 1, 3, 6, 12, 18 and 24 months. A radiological evaluation also was performed, which included AP, lateral and flexion-extension films at 6, 12 and 24 months and CT-scan at 12 months. Results: Case 1 - preop ODI: 40%, 24 months postop ODI: 4%; preop radVAS: 7, 24 months radVAS: 0; preop neckVAS: 8, postop 24 months neckVAS: 0; preopNDI: 43%, 24 months PostopNDI: 8%; SF-36 - preop Physical Functioning (PF): 40, preop Vitality (VT): 40, preop Emotional role functioning (RE): 33.3, Bodily pain (BP): 51, General Health (GH): 57, Social Functioning (SF): 75; postop PF: 95, VT: 95, RE: 100, BP: 74, GH: 87, SF: 100. Case 2 - preopODI: 46%, 24 months postopODI: 10%; preop radVAS: 7, 24m radVAS: 0; preop neckVAS: 9, postop 24 months neckVAS: 0; preopNDI: 56%, 24 months PostopNDI: 15%; SF-36 - preop PF: 39, VT: 45, RE: 33.3, BP: 50, GH: 49, SF: 70; postop PF: 90, VT: 100, RE: 100, BP: 82, GH: 87, SF: 100. No complications, cervical instability or signs of failed surgery were found trough and at final follow-up at 24 months. We found significant clinical improvement in both patients. Conclusions: Minimally invasive cervical laminoplasty combined with lateral mass screw fixation for the unstable segment is a useful technique in cases with multilevel cervical spondylotic myelopathy associated with monosegmental instability. Additional comparative studies are needed to establish its efficacy.

Current techniques in the management of cervical myelopathy and radiculopathy

Posterior decompressive procedures are a fundamental component of the surgical treatment of symptomatic cervical degenerative disease. Posterior approaches have the appeal of avoiding complications associated with anterior approaches such as esophageal injury, recurrent laryngeal nerve paralysis, dysphagia, and adjacent-level disease after fusion. Although open procedures are effective, the extensive subperiosteal stripping of the paraspinal musculature leads to increased blood loss, longer hospital stays, and more postoperative pain, and potentially contributes to instability. Minimally invasive access has been developed to limit approach-related morbidity. This article reviews current techniques in minimally invasive surgical management of cervical myelopathy and radiculopathy.

Cervical laminoplasty for multilevel cervical myelopathy

Cervical spondylotic myelopathy can result from degenerative cervical spondylosis, herniated disk material, osteophytes, redundant ligamentum flavum, or ossification of the posterior longitudinal ligament. Surgical intervention for multi-level myelopathy aims to decompress the spinal cord and maintain stability of the cervical spine. Laminoplasty was major surgical advancement as laminectomy resulted in kyphosis and unsatisfactory outcomes. Hirabayashi popularised the expansive open door laminoplasty which was later modified several surgeons. Laminoplasty has changed the way surgeons approach multilevel cervical spondylotic myelopathy.

Laminotomy in adults: technique and results

The objective of this study was to describe step by step our surgical technique of laminotomy and analyze our series with regard to spinal deformities (risk and predisposing factors), postoperative pain and rate of postoperative contusions. Data regarding patients who underwent our technique of laminotomy (N = 40, mean follow-up: 52 ms) (N = 40) between 2002 and 2006 were retrospectively evaluated. The technique used is illustrated in depth. Chronic pain was present in 30% with a mean score of 3/10 cm (Graphic Rating Scale). Postoperative kyphoses occurred in three patients, all below 35 years of age and with laminotomies which involved C2 and/or C7. None of these deformities required further surgical treatment because they were self-limiting or asymptomatic at a mean follow-up of 52 months. Based on the results, our technique proved to be safe and effective in terms of late deformities, blood loss, early and chronic postoperative pain and protection from postoperative accidents over the surgical site.