Axial neck pain after cervical laminoplasty

Effectiveness of additional C2 decompression of the cervical spinal canal after cervical laminoplasty: a retrospective cohort study

PURPOSE

This study aimed to assess the effects of additional C2 decompression of the cervical spinal canal on the postoperative outcomes after cervical laminoplasty in patients with cervical stenosis caused by ossification of the posterior longitudinal ligament (OPLL).

MATERIALS AND METHODS

This retrospective cohort study included patients with cervical stenosis due to OPLL and treated between April 2014 and December 2015. The patients who underwent C2-7 (additional C2 decompression) and C3-7 posterior decompression were compared using the Japanese Orthopedic Association (JOA) scores, visual analog scale (VAS) scores, axial symptom scores, and intervals between the posterior margin of the vertebral body and the K-line.

RESULTS

There were 36 and 24 patients in the additional C2 decompression and control groups, respectively. The JOA scores were higher in the additional C2 decompression group than the controls at 1 and 3 years (p < 0.05). Upper extremity motor function after the operation and at 1 and 3 years and lower extremity motor function after operation were improved in the additional C2 decompression group (all p < 0.05 vs. controls). VAS scores were lower in the additional C2 decompression group than controls at 1 year (p < 0.05). Axial symptom scores in the additional C2 decompression group were decreased postoperatively but increased at 1 and 3 years (p < 0.05 vs. controls). Finally, the posterior shift of the K-line in the additional C2 decompression group was significant (from 0.98 to 1.68 cm, p < 0.05).

CONCLUSIONS

Additional C2 decompression might improve the effectiveness of cervical laminoplasty in patients with cervical stenosis caused by OPLL.

The Frequency of Symptoms in Patients With a Diagnosis of Degenerative Cervical Myelopathy: Results of a Scoping Review

STUDY DESIGN

Delayed diagnosis of degenerative cervical myelopathy (DCM) is associated with reduced quality of life and greater disability. Developing diagnostic criteria for DCM has been identified as a top research priority.

OBJECTIVES

This scoping review aims to address the following questions: What is the diagnostic accuracy and frequency of clinical symptoms in patients with DCM?

METHODS

A scoping review was conducted using a database of all primary DCM studies published between 2005 and 2020. Studies were included if they (i) assessed the diagnostic accuracy of a symptom using an appropriate control group or (ii) reported the frequency of a symptom in a cohort of DCM patients.

RESULTS

This review identified three studies that discussed the diagnostic accuracy of various symptoms and included a control group. An additional 58 reported on the frequency of symptoms in a cohort of patients with DCM. The most frequent and sensitive symptoms in DCM include unspecified paresthesias (86%), hand numbness (82%) and hand paresthesias (79%). Neck and/or shoulder pain was present in 51% of patients with DCM, whereas a minority had back (19%) or lower extremity pain (10%). Bladder dysfunction was uncommon (38%) although more frequent than bowel (23%) and sexual impairment (4%). Gait impairment is also commonly seen in patients with DCM (72%).

CONCLUSION

Patients with DCM present with many different symptoms, most commonly sensorimotor impairment of the upper extremities, pain, bladder dysfunction and gait disturbance. If patients present with a combination of these symptoms, further neuroimaging is indicated to confirm the diagnosis of DCM.

Relationship between hinge fracture and postoperative axial symptoms after cervical laminoplasty

OBJECTIVE

To identify the clinical characteristics of fractured hinges after open-door cervical laminoplasty for cervical canal stenosis and explore the relationship between hinge fractures and axial symptoms.

METHODS

This was a retrospective study of patients with cervical myelopathy who underwent open-door laminoplasty between November 2014 and November 2016 at the Affiliated Hospital of Qingdao University. Cervical CT scans were performed after surgery and the Takeuchi criteria were applied to evaluate the postoperative axial symptoms.

RESULTS

Of 223 opened laminae in 67 patients, 67 laminae (30.0%) in 30 patients (44.8%) showed fracture. The frequency of hinge fractures was higher at C6 (53.7%). Forty-nine fractured laminae (73.13%) were non-displaced and 18 were displaced. At 3 months, 33 fractured laminae (49.3%) showed bony union on CT, and union rates were 86.6% and 91.0% at 6 and 12 months, respectively, indicating that the union rate was lower for displaced fractures than for non-displaced fractures. Among the 67 patients, 14 had axial symptoms: three of 37 (8.1%) patients without hinge fractures and 11 of 30 (36.7%) patients with hinge fractures. One year later, the hinge fractures were healed in 24/30 patients. Among the six unhealed patients, five still suffered from axial symptoms. The frequency of axial symptoms was higher in the patients with three or more hinge fractures (66.7%) than in the patients with only one (16.7%) or two (46.7%) hinge fractures.

CONCLUSIONS

Patients with hinge fractures may have an increased risk for axial symptoms after open-door cervical laminoplasty. The frequency of axial symptoms decreases with fracture healing.

Comparative effectiveness and functional outcome of C3 & C7 dome-hybrid open-door laminoplasty with traditional unilateral open-door laminoplasty for cervical spondylotic myelopathy

OBJECTIVE

The C3 & C7 dome-hybrid open-door laminoplasty was proven to be an effective treatment for multi-levels cervical spondylotic myelopathy (CSM). However, its superiority over traditional unilateral open-door laminoplasty (UOLP) remains questionable, and no studies have compared the efficacy of this technique with traditional UOLP. This study aimed to compare the effectiveness of C3 & C7 dome-hybrid open-door laminoplasty with traditional UOLP in treating multi-levels CSM.

METHODS

A retrospective study of multi-levels CSM with laminoplasty was performed, including 35 cases of traditional UOLP and 27 cases of C3 & C7 dome-hybrid open-door laminoplasty. Radiographic evaluation parameters and clinical outcomes were recorded to evaluate the surgical effectiveness.

RESULTS

There was no significant difference in demographic baseline parameters. At the final follow-up, the C2-C7 Cobb angle of the modified group was significantly greater than that of the traditional group (p = 0.026). Meanwhile, the C2-C7 SVA of the modified group was significantly smaller than that of the traditional group (p = 0.009). Clinical outcomes such as VAS, NDI, and SF-12 scores, improved significantly in the modified group compared to the traditional group, while the JOA scores had no significant difference in both groups. There was no significant difference in the overall rate of complications between the two groups.

CONCLUSION

Both techniques have satisfactory outcomes in treating multi-levels CSM. Comparing with traditional UOLP, C3 & C7 dome-hybrid open-door laminoplasty has a greater superiority in reducing postoperative neck pain and maintaining the cervical sagittal alignment. It is proven to be a feasible management for patients with multi-levels CSM.

Favorable cervical extension capacity preventing loss of cervical lordosis after laminoplasty due to spontaneous restoration of initial lordosis

BACKGROUND CONTEXT

Cervical laminoplasty is a common approach for the treatment of multilevel cervical spondylotic myelopathy (CSM). Postoperative loss of cervical lordosis (LCL) was associated with lower extension motion of the cervical spine before laminoplasty.

PURPOSE

To analyze the possible causes of preoperative cervical extension capacity affecting LCL after laminoplasty by evaluating the changes in cervical lordosis (CL) at different stages.

STUDY DESIGN/SETTING

Retrospective study.

PATIENT SAMPLE

Seventy-two patients undergoing laminoplasty due to multilevel CSM.

OUTCOME MEASURES

Radiographic parameters included CL, extension CL (eCL), flexion CL (fCL), range of motion (ROM), extension ROM (eROM), flexion ROM (fROM) and LCL. Clinical outcomes were assessed using the Japanese Orthopedic Association (JOA) and neck disability index (NDI) score.

METHODS

The data were recorded before surgery and at 3- and 24-month follow-up. All patients completed a cervical extension test preoperatively. A receiver operating characteristic (ROC) curve of eROM was constructed to discriminate the patients with and without postoperative kyphotic deformity.

RESULTS

According to the optimal cut-off value of eROM, the patients were divided into two groups: extension group (eROM≥9.3°) and control group (eROM<9.3°). The radiographic outcomes demonstrated no significant differences in CL, eCL, fCL and ROM between the two groups. Both eROM and fROM were significantly different in the two groups. There was a significant change in CL in the extension group at 3-month follow-up and in the control group at 24-month follow-up. The extension group exhibited significantly lower LCL compared with the control group at follow-up. No significant difference between the two groups was noted in the JOA recovery rate, while the NDI score was significantly different at 24-month follow-up. The positivity ratio of the extension test was significantly greater in the extension group than that in the control group.

CONCLUSIONS

eROM in patients with favorable preoperative cervical extension capacity (eROM≥9.3°) consisted of the actual extension capacity and compensatory flexion. The cervical alignment would be spontaneously restored to its initial lordosis in the short term after laminoplasty. These patients had no substantial LCL at 24-month follow-up and would be good candidates for laminoplasty.

Inpatient opioid use varies by construct length among laminoplasty versus laminectomy and fusion patients

Background

Laminoplasty (LP) and laminectomy and fusion (LF) are utilized to achieve decompression in patients with symptomatic degenerative cervical myelopathy (DCM). Comparative analyses aimed at determining outcomes and clarifying indications between these procedures represent an area of active research. Accordingly, we sought to compare inpatient opioid use between LP and LF patients and to determine if opioid use correlated with length of stay.

Methods

Sociodemographic information, surgical and hospitalization data, and medication administration records were abstracted for patients >18 years of age who underwent LP or LF for DCM in the Mass General Brigham (MGB) health system between 2017 and 2019. Specifically, morphine milligram equivalents (MME) of oral and parenteral pain medication given after arrival in the recovery area until discharge from the hospital were collected. Categorical variables were analyzed using chi-squared analysis or Fisher exact test when appropriate. Continuous variables were compared using Independent samples t tests and Mann-Whitney U tests.

Results

One hundred eight patients underwent LF, while 138 patients underwent LP. Total inpatient opioid use was significantly higher in the LF group (312 vs. 260 MME, p=.03); this difference was primarily driven by higher postoperative day 0 pain medication requirements. Furthermore, more LF patients required high dose (>80 MME/day) regimens. While length of stay was significantly different between groups, with LF patients staying approximately 1 additional day, postoperative day 0 MME was not a significant predictor of this difference. When operative levels including C2, T1, and T2 were excluded, the differences in total opioid use and average length of stay lost significance.

Conclusions

Inpatient opioid use and length of stay were significantly greater in LF patients compared to LP patients; however, when constructs including C2, T1, T2 were excluded from analysis, these differences lost significance. Such findings highlight the impact of operative extent between these procedures. Future studies incorporating patient reported outcomes and evaluating long-term pain needs will provide a more complete understanding of postoperative outcomes between these 2 procedures.

Axial Neck Pain after Cervical Laminoplasty with Preserving C7 Spinous Process Using C7 Arcocristectomy: A Prospective Study

STUDY DESIGN

Single-blinded, randomized, single-center, prospective study.

PURPOSE

This study aims to compare the radiographical and clinical outcomes between C7 laminoplasty and C7 arcocristectomy, which preserves the C7 spinous process.

OVERVIEW OF LITERATURE

Laminoplasty is a widely used surgical method that decompresses the cervical spinal cord. However, axial neck pain is one of the major factors of dissatisfaction, and still, it is not clearly solved the reduction method of postoperative axial neck pain.

METHODS

Thirty-one patients with multilevel cervical spondylotic myelopathy who required C6-C7 level decompression surgery were operated and followed up for 24 months. One group (15 patients) received C7 arcocristectomy without laminoplasty, and the other group (16 patients) received C7 laminoplasty. Flexion, neutral, and extension angles were measured using the Cobb method at C2-C7 to evaluate preoperative and postoperative radiographic parameters. Range of motion (ROM), ROM preservation rate of the cervical spine, C2-C7 sagittal vertical axis (SVA), and T1 slope were measured using C-spine lateral X-ray. The Visual Analog Scale (VAS) and modified Japanese Orthopedic Association (JOA) score were used to compare preoperative and postoperative clinical symptoms.

RESULTS

Flexion, neutral, extension angles of the cervical spine, C2-C7 SVA, T1 slope, ROM, ROM preservation rate, and modified JOA score were not significantly different between the two groups (p>0.05). In the C7 arcocristectomy group, the average postoperative VAS for axial neck pain was increased in 13.3% (2/15) of the patients, whereas in the C7 laminoplasty group, the average postoperative VAS was increased in 43.8% (7/16) of the patients (p=0.018).

CONCLUSIONS

C7 arcocristectomy, which preserves the C7 spinous process and posterior structures, is a useful technique for relieving axial neck pain.

Clinical parameters of laminoplasty and laminectomy with fusion in the treatment of cervical spondylosis and analysis of postoperative sagittal balance

Background/aim

Cervical spondylosis is a progressive disease that causes degenerative changes affecting the spine, intervertebral discs, facets, and ligaments. With anterior and posterior surgical interventions, effective treatments can be applied in cervical spondylotic myelopathy (CSM). The relationship between regional and global spinal alignment and functional and pain outcomes was examined and it was revealed that these parameters play a significant role in obtaining good results. The aim of this study was to compare the perioperative and follow-up results of patients with CSM who underwent laminoplasty or laminectomy with fusion.

Materials and method

CSM patients who were operated on between 2015 and 2020 and had at least 2 years of clinical and radiological follow-up were analyzed retrospectively. The patients were divided into 2 groups as the laminoplasty group and the laminectomy with fusion group, according to a simple random method. Demographic, clinical, radiological, and perioperative parameters were examined. Measurements were made by an independent observer using Surgimap and 2 years was considered to be sufficient time for the spine to take its final shape.

Result

A total of 112 patients, including 68 males and 44 females, were included. Of these patients, 69 were in the laminectomy with fusion group, and 43 were in the laminoplasty group. Patient ages ranged from 39 to 85 years. The mean follow-up period was 36.28 months. In both groups, at the 3-month follow-up, a statistically significant improvement in the clinical parameters (neck disability index, visual analogue scale, modified Japanese Orthopaedic Association scores) was observed. When the preoperative cervical radiological parameters were evaluated, no statistically significant difference was found between the groups. The C2-C7 lordotic angles and the cervical SVA values were increased in the postoperative period, for both groups (p < 0.001). Although it is noteworthy that the increases were higher in the laminectomy with fusion group, no statistically significant difference was found between the groups.

Conclusion

Deformity in a spinal segment may indirectly affect another segment. Being aware of the compensatory mechanisms and radiological parameters will help in determining the effective treatment plan.

Quantitatively biomechanical response analysis of posterior musculature reconstruction in cervical single-door laminoplasty

BACKGROUND AND OBJECTIVE

The current trend of laminoplasty is developing toward the goal of muscle preservation and minimum tissue damage. Given this, muscle-preserving techniques in cervical single-door laminoplasty have been modified with protecting the spinous processes at the sites of C2 and/or C7 muscle attachment and reconstruct the posterior musculature in recent years. To date, no study has reported the effect of preserving the posterior musculature during the reconstruction. The purpose of this study is to quantitatively evaluate the biomechanical effect of multiple modified single-door laminoplasty procedures for restoring stability and reducing response level on the cervical spine.

METHODS

Different cervical laminoplasty models were established for evaluating kinematics and response simulations based on a detailed finite element (FE) head-neck active model (HNAM), including ① C3 - C7 laminoplasty (LP_C37), ② C3 - C6 laminoplasty with C7 spinous process preservation (LP_C36), ③ C3 laminectomy hybrid decompression with C4 - C6 laminoplasty (LT_C3 + LP_C46) and ④ C3 - C7 laminoplasty with unilateral musculature preservation (LP_C37 + UMP). The laminoplasty model was validated by the global range of motion (ROM) and percentage changes relative to the intact state. The C2 - T1 ROM, axial muscle tensile force, and stress/strain levels of functional spinal units were compared among the different laminoplasty groups. The obtained effects were further analysed by comparison with a review of clinical data on cervical laminoplasty scenarios.

RESULTS

Analysis of the locations of concentration of muscle load showed that the C2 muscle attachment sustained more tensile loading than the C7 muscle attachment, primarily in flexion-extension (FE) and in lateral bending (LB) and axial rotation (AR), respectively. Simulated results further quantified that LP_C36 primarily produced 10% decreases in LB and AR modes relative to LP_C37. Compared with LP_C36, LT_C3 + LP_C46 resulted in approximately 30% decreases in FE motion; LP C37 + UMP also showed a similar trend. Additionally, when compared to LP_C37, LT_C3 + LP_C46 and LP C37 + UMP reduced the peak stress level at the intervertebral disc by at most 2-fold as well as the peak strain level of the facet joint capsule by 2-3-fold. All these findings were well correlated with the result of clinical studies comparing modified laminoplasty and classic laminoplasty.

CONCLUSIONS

Modified muscle-preserving laminoplasty is superior to classic laminoplasty due to the biomechanical effect of the posterior musculature reconstruction, with a retained postoperative ROM and loading response levels of the functional spinal units. More motion-sparing is beneficial for increasing cervical stability, which probably accelerates the recovery of postoperative neck movement and reduces the risk of the complication for eventual kyphosis and axial pain. Surgeons are encouraged to make every effort to preserve the attachment of the C2 whenever feasible in laminoplasty.

Incidence of complications associated with cervical spine surgery and post-operative physical therapy and implications for timing of initiation of post-operative physical therapy: a retrospective database study

PURPOSE

To describe the incidence of complications associated with cervical spine surgery and post-operative physical therapy (PT), and to identify if the timing of initiation of post-operative PT impacts the incidence rates.

METHODS

MOrtho PearlDiver database was queried using billing codes to identify patients who had undergone Anterior Cervical Discectomy and Fusion (ACDF), Posterior Cervical Fusion (PCF), or Cervical Foraminotomy and post-operative PT from 2010-2019. For each surgical procedure, patients were divided into three 12-week increments for post-operative PT (starting at post-operative weeks 2, 8, 12) and then matched based upon age, gender, and Charlson Comorbidity Index score. Each group was queried to determine complication rates and chi-square analysis with adjusted odds ratios, 95% confidence intervals, and p-values were used.

RESULTS

Following matching, 3,609 patients who underwent cervical spine surgery at one or more levels and had post-operative PT (ACDF:1784, PCF:1593, and cervical foraminotomy:232). The most frequent complications were new onset cervicalgia (2-14 weeks, 8-20 weeks, 12-24 weeks): ACDF (15.0%, 14.0%, 13.0%), PCF (18.8%, 18.0%, 19.9%), cervical foraminotomy (16.8%, 16.4%, 19.4%); revision: ADCF (7.9%, 8.2%, 7.4%), PCF (9.3%, 10.6%, 10.2%), cervical foraminotomy (11.6%, 10.8% and 13.4%); wound infection: ACDF (3.3%, 3.4%, 3.1%), PCF (8.3%, 8.0%,7.7%), cervical foraminotomy (5.2%, 6.5%, < 4.7%). None of the comparisons were statistically significant.

CONCLUSION

The most common post-operative complications included new onset cervicalgia, revision and wound infection. Complications rates were not impacted by the timing of initiation of PT whether at 2, 8, or 12 weeks post-operatively.

Changes in cervical sagittal alignment and the effects on cervical parameters in patients with cervical spondylotic myelopathy after laminoplasty

Objective:

To monitor changes in cervical parameters before and after laminoplasty surgery. Cervical parameters and health-related quality-of-life (HRQOL) values that may be affected after laminoplasty were examined before and after surgery. The clinical and radiological course of these values was monitored, and their interaction with all spinal radiological parameters was revealed.

Materials and Methods:

Nineteen patients who underwent clinical and radiological evaluation for 2 years were followed in this study. Neck disability index, visual analog scale, and short form 36 scores were determined to evaluate HRQOL. For radiological parameters, the C0-C2 angle, C2-C7 angle, cervical sagittal vertical axis, T1 slope angle, neck tilt (NT) and thoracic inlet angle were used. The results of the 4-month, 1 year and 2-year follow-ups were statistically evaluated.

Results:

Both the HRQOL and cervical radiological parameters deteriorated in the first 4 months and returned to normal in the 2^nd year. Statistically, all parameters were meaningful (P < 0.05), except for NT.

Conclusion:

Cervical parameters and HRQOL values, which deteriorated in the early period, recovered in the late period in the long-term follow-up of patients undergoing laminoplasty. The important point is that preoperative cervical parameters suitable for laminoplasty should be present, and spinopelvic parameters should be normal.

Laminoplasty versus laminectomy with fusion for treatment of multilevel cervical compressive myelopathy: an updated meta-analysis

BACKGROUND

Multilevel cervical spondylotic myelopathy (CSM) and ossification of the posterior longitudinal ligament (OPLL) are debilitating degenerative diseases. If conservative treatment is ineffective, surgical options for multilevel CSM and OPLL include laminoplasty (LP) and laminectomy with fusion (LF). In this updated meta-analysis, we aimed to compare the clinical outcomes and complications of both approaches.

METHODS

We searched PubMed, the Cochrane Library and Embase datasets from their inception to 31 March 2020, to identify all eligible studies comparing LP versus LF for multilevel CSM and OPLL. Data were extracted according to predefined endpoints. We summarised data by the random-effects or fixed-effect models, as necessary.

RESULTS

Of 533 eligible studies, 16 were identified, which included 638 patients who underwent LP and 671 patients who underwent LF. No significant differences were observed between preoperative and postoperative scores of the Japanese Orthopaedic Association (p=1.0 and 0.20, respectively); Visual Analogue Scale (p=0.24 and 0.89, respectively); sagittal vertical axis ((p=0.16 and 0.87, respectively); Nurick Scale (p=0.59 and 0.17, respectively); and range of motion (p=0.67 and 0.63, respectively). However, total complications were higher for LF compared with LP (p=0.006). A significantly higher incidence of C5 palsy was observed in the LF group (p=0.004). The postoperative Neck Disability Index (NDI) was also higher in the LF group (p<0.001).

CONCLUSIONS

Although LP and LF shared similar clinical improvement, LP had fewer complications, a lower incidence of C5 palsy, and better NDI scores and recovery outcomes than LF. Randomised studies are warranted to validate these findings.

Analysis of Cervical Spine Alignment Change after Modified Kurokawa Cervical Laminoplasty in the Patients with Cervical Myelopathy and Straight Cervical Spine

Laminoplasty is widely used to decompress the spinal cord in patients with multilevel cervical lesions. Straight cervical alignment may not be a good candidate for laminoplasty because of postoperation progression of kyphosis and loss of cervical spine range of motion (ROM). However, clinical outcomes of laminoplasty did not show a strong and consistent effect based on cervical sagittal alignment. Moreover, the kyphosis progression and ROM change after operation for the patients with preoperative strange cervical alignment are still unclear. This study is to evaluate the change of cervical alignment and ROM in patients with straight cervical alignment after modified Kurokawa cervical laminoplasty. Thirty patients with multiple-level cervical spondylosis (CSM) and straight cervical alignment were included. All patients underwent laminoplasty with the reconstruction of the spinous process-ligament-muscular complex (SPLMC). The modified JOA score was analyzed for clinical assessment. The change of cervical alignment, ROM, T1 slope, and intervertebral disc space Cobb angle were analyzed for radiological assessment. The average JOA score at preoperative and 2 years follow-up were 7.8 ± 1.4 and 13.6 ± 2.1, respectively. The recovery ratio was 63%. At the 2 years follow-up, there were 18 patients who acquired lordotic cervical alignment. 10 patients remained as straight cervical curve, and 2 patients' cervical alignment developed mild kyphosis. 28 out of 30 patients showed improvement of cervical alignment. The cervical alignment was improved from 1.29 ± 10.04° preoperative to 9.58 ± 8.65° postoperative. However, the ROM decreased from 36.8 ± 18.92 preoperative to 25.08 ± 12.10° postoperative. A positive correlation was found between the C2/4 angle change and cervical alignment change, T1 slope and cervical alignment, cervical alignment, and neutral position flexion reserved ROM. A negative correlation was found between the C1/2 angle change and cervical alignment change. Laminoplasty with a reconstruction of SPLMC followed by appropriate postoperative muscle exercises may be an encouraging way to maintain or improve physiological alignment and prevent postoperation kyphosis deformity at 2 years follow-up.

A Feasibility Study of a New Muscle Sparing "C3 Dome-Hybrid Open-Door Laminoplasty": A Surgical Technique, Clinical Outcome, and Learning Curve Description

STUDY DESIGN

Retrospective case series to investigate the result of a new C3 dome-hybrid open-door laminoplasty technique.

OBJECTIVE

This study reports the design and feasibility of a new hybrid laminoplasty technique aimed to reduce the complications of the conventional laminoplasty, with the incorporation of C3 dome-osteotomy, an open-door C4-6 instrumented laminoplasty and C7 cephalad dome-osteotomy.

SUMMARY OF BACKGROUND DATA

Recent findings showed that the preservation of the dorsal muscles attached at either C2 or C7 cervical spine reduced the complications of C3-C7 open-door laminoplasty.

METHODS

A retrospective review of consecutive patients who underwent the C3 dome-hybrid laminoplasty technique by a single surgeon with at least 2 years follow-up was performed. The surgical technique was described in detail. Clinical and radiological outcome data were analyzed.

RESULTS

Twenty six patients with cervical cord compression who underwent C3 dome-hybrid laminoplasty were recruited. The mean postoperative follow-up was 45.6 ± 24.7 (24-101) months. Significant improvements were observed in the preoperative to postoperative mean Japanese Orthopaedic Association (JOA) score (13→15, P < 0.001), Nurick grade (2.3→1.2, P < 0.001), neck disability index (NDI) (23→11, P = 0.011), 36-item short form survey (SF-36) physical component score (40→46, P = 0.027), and neck visual analogue scale (VAS) (3.1→0.3, P < 0.001). There was no significant loss in cervical lordosis from 12° preoperatively to 8° at final follow-up. Postoperative cervical range of motion (ROM) was preserved at 85% and 78% of the preoperative ROM at 2 years and at final follow-up, respectively. When comparing the first 10 patients with the next 16 patients, there was a reduction in mean operation time from 252 ± 75 to 208 ± 7 minutes, mean blood loss from 359 ± 326 to 211 ± 177 mL, and median hospital stay from 7 days (interquartile range [IQR]: 34) to 5 days (IQR: 6).At final follow-up, no patients had revision surgery, spinal infection, C5 palsy, symptomatic cervical kyphosis, or axial neck pain.

CONCLUSION

The new C3 dome-hybrid laminoplasty technique is safe, feasible, and reproducible with good clinical outcomes. This technique may be considered as an alternative to traditional laminoplasty for patients with C3-C7 multi-level myelopathic disease.

LEVEL OF EVIDENCE

3.

Clinical application of large channel endoscopic decompression in posterior cervical spine disorders

Background

We investigated the clinical value of posterior percutaneous endoscopic decompression (PED) for single-segment cervical spondylotic myelopathy (CSM) and cervical spondylotic radiculopathy (CSR). Methods: Clinical data from February 2016 to March 2018 were collected for 32 patients with single-segment CSM or CSR who underwent posterior cervical percutaneous large channel endoscopic decompression and completed a regular follow-up exam at 12 months after surgery. Patient data included: age (range 30–81 years and mean of 49.5 years) and surgical information (operation time, bleeding volume, hospital stay, complications, etc.). The Japan Orthopedic Association (JOA) score and pain visual analog scale (VAS) were used to evaluate the surgical outcome for each patient. Cervical spine radiographs were used to evaluate cervical curvature (Cervical spondylotic angle (CSA), C2–7 Cobb angle) and CT and MRI were used to assess the extent of laminectomy and nerve root decompression. The JOA score, VAS score, cervical curvature were analyzed statistically, and the clinical outcome was evaluated using modified Macnab criteria at the last patient follow-up exam.

Results

The JOA and VAS scores were compared before and after surgery (1 day Pre-op; 3 days, 3 months and 12 months Post-op). The differences were statistically significant (P < 0.05). There were significant differences in cervical curvature (C2–7 Cobb angle) between the time points (1 day Pre-op; 3 days, 3 months and 12 months Post-op), but the differences were no statistically significant in CSA angle (P < 0.05) The operation time range was 45–110 min (mean 68.6 ± 23.8 min); the intraoperative blood loss range was 20–85 ml (mean28 ± 14.8 ml), and the hospital stay was 3–8 days (mean4.5 days). At the last follow-up, the clinical efficacy was evaluated using modified Macnab criteria. The results were excellent in 18 cases, good in 11 cases, and fair in 3 cases. The combined excellent and good rate was 93.75%. Postoperative CT and MRI showed that the compression of the spinal cord or nerve roots was completely relieved.

Conclusion

Endoscopic decompression of posterior cervical vertebral disorders is a safe, effective, and minimally invasive surgical procedure with rapid recovery times. This procedure warrants additional research and clinical application.

Comparison of clinical outcomes of expansive open-door laminoplasty with unilateral or bilateral fixation and fusion for treating cervical spondylotic myelopathy: a multi-center prospective study

Background

The present study evaluated the clinical outcomes and safety of expansive open-door laminoplasty, when securing with C4 – C6 lateral mass screw and fusion.

Methods

A total of 110 patients with cervical spondylotic myelopathy (CSM) were enrolled. There were 88 male and 22 female, with mean age at 60.55 ± 10.95 years. All of the patients underwent expansive open-door laminoplasty with unilateral or bilateral C4–6 lateral mass screws fixation and fusion. Clinical data, including age, gender, operation-related information, pre- and post-operation Japanese Orthopedic Association (JOA) scores, and cervical curvatures were collected.

Results

The mean follow-up time of the cohort was 13.61 ± 9.53 months. Among the 110 patients, 33 of them were allocated to Unilateral group, and 77 of them were in Bilateral group. The mean JOA score of the 110 patients before surgery was 10.07 ± 2.39, and the score was improved significantly to 12.85 ± 2.45 after surgery. There were no reported cases of neurological deterioration or symptom worsening. Patients in both the Unilateral group and Bilateral groups had significant improvement of JOA scores. Among all patients, the most frequently observed complications were axial symptoms (n = 7). The average preoperative cervical curvature among all patients was 15.17 ± 5.26, and the post-surgery curvature was 14.41 ± 4.29. Similar observations were found between Unilateral and Bilateral groups.

Conclusion

The modified surgical approach provided satisfactory clinical outcome in patients with CSM. The unilateral and bilateral fixation appeared to provide similar outcomes, in terms of cervical curvature maintenance and improvement of clinical symptoms. However, the examination of the exact differences between the two fixation methods await further biomechanical studies.

Clinical and radiological outcomes following open door laminoplasty: a single center evolution of the technique

BACKGROUND

A comparison of clinical and radiological outcomes after two different variants of open door laminoplasty for cervical spondylotic myelopathy (CSM) is described.

METHODS

Fifty-five patients underwent cervical laminoplasty for CSM. Between 2005 to 2009, 32 patients underwent open-door laminoplasty (Group A) performed with a monolateral exposure with contralateral "green stick" laminar fracture. A technical variant consisting in bilateral exposure, spinous process removal and symmetrical muscular closure was applied in the other 23 (Group B), from 2009 to 2016. A retrospective analysis of surgical results between the two groups was performed.

RESULTS

In group B, the mean operative time was longer and the mean volume of intraoperative blood loss was much higher than in group A. Both differences were not significant (p=0.1601 and p=0.0884, respectively). The average hospitalization was nonsignificantly longer in group B (7.3±1.8 vs. 6.5±1.6 d; p= 0.0947). Postoperatively, axial neck pain was more severe in group A at last follow-up than preoperatively (P>0.05). mJOA scores and Nurick grades improved significantly in both groups at last follow-up; in group A, the mean recovery rates were 41.5 % by mJOA scores and 29.4 % by Nurick grades, whereas in group B they were 52.7 % and 36.8 %, respectively.

CONCLUSIONS

Applying some few variations to a standard monolateral approach, although slightly more time and blood consuming, could reduce the incidence of long term axial symptoms and, in our experience, are not burdened by worsening of outcomes. A prospective, multicentric study with a longer follow-up should be conducted in order to confirm our findings.

WITHDRAWN: A Comparative Study Between Anterior Controllable Antedisplacement and Fusion Versus Laminoplasty in the Surgical Management of Multilevel Cervical Ossification of the Posterior Longitudinal Ligament

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Comparison between Radiological and Clinical Outcomes of Laminoplasties with Titanium Miniplates for Cervical Myelopathy

Background

Laminoplasty is a surgical procedure frequently performed for cervical myelopathy. We investigated correlations between changes in the anteroposterior diameter (APD) of the spinal canal, spinal canal area (SCA), and laminar angle (LA) and clinical outcomes of laminoplasty.

Methods

Of the 204 cervical myelopathy patients who underwent laminoplasty from July 2010 to May 2015, 49 patients who were evaluated with pre- and postoperative computed tomography of the cervical vertebrae were included. The average age of the patients was 60.4 years (range, 31 to 82 years), and the average duration of follow-up was 31.6 months (range, 9 to 68 months). Changes in the APD and SCA were measured at the middle of the vertebral body. Changes in LA were measured where both pedicles were clearly visible. Clinical outcomes were assessed using the Japanese Orthopaedic Association (JOA) score and visual analog scale score for pain preoperatively (1 day before surgery) and postoperatively (last outpatient visit) and examining postoperative complications.

Results

The APD showed an average of 54.7% increase from 11.5 to 17.8 mm. The SCA showed an average of 57.7% increase from 225.9 to 356.3 mm². The LA increased from 34.2° preoperatively to 71.9° postoperatively. The JOA score increased from an average of 9.1 preoperatively to 13.4 postoperatively. Three patients were found to have hinge fractures during surgery. Postoperative complications, including two cases of C5 palsy, were recorded. The correlation coefficient between the LA change and JOA score improvement was −0.449 (p < 0.05). Patients with a < 33° (25%) increase in the LA showed the most significant clinical improvement.

Conclusions

Patients with a < 33° (25%) change in the LA after laminoplasty with a titanium miniplate showed the most significant clinical improvement. Thus, LA changes can be useful in predicting the clinical outcome of laminoplasty.

Preoperative Factors Affecting Postoperative Axial Symptoms After Single-Door Cervical Laminoplasty for Cervical Spondylotic Myelopathy: A Prospective Comparative Study

Background

Postoperative axial symptoms (post-AS) after single-door cervical laminoplasty for cervical spondylotic myelopathy (CSM) are a common and severe complication that adversely affects normal daily activities. Their etiology remains unclear. It is important to know which preoperative factors are the most predictive of post-AS. Therefore, this study aimed to elucidate the preoperative factors affecting post-AS.

Material/Methods

A total of 102 patients with CSM who underwent single-door cervical laminoplasty between 2009 and 2015 were studied. According to operation date, patients were prospectively assigned to treatment with conventional laminoplasty (CL) or modified laminoplasty (ML). Preoperative clinical and radiological parameters were recorded. The incidence of post-AS with 2 procedures was compared prospectively. Multivariate analysis was used to determine the preoperative factors affecting post-AS.

Results

The incidence of post-AS after ML was significantly lower than after CL (P=0.010). ML and preoperative cervical C2–7 Cobb angle (CCA) were significant protective factors against post-AS (ML: P=0.011, odds ratio=0.302; CCA: P=0.042, odds ratio=0.947). Patients with post-AS had a lower preoperative CCA than patients without post-AS (P=0.043). The other preoperative factors were not significantly associated with post-AS.

Conclusions

The results of this study suggest that choosing ML procedure or selecting patients with high preoperative CCA can reduce the incidence of post-AS after single-door cervical laminoplasty for CSM, and that the other preoperative clinical or radiological parameters are less critical.

Optimal area of lateral mass mini-screws implanted in plated cervical laminoplasty: a radiography anatomy study

PURPOSE

Lateral mass mini-screws used in plated cervical laminoplasty might penetrate into facet joints. The objective is to observe this complication incidence and to identify the optimal areas for 5- and 7-mm-long mini-screws to implant on lateral mass.

METHODS

47 patients who underwent plated cervical laminoplasty were included. The optimal area for mini-screws implanting was set according to pre-operative 3D CT reconstruction data. Then, each posterior-lateral mass surface was divided into three regions: 7-mm region, 5-mm region, and dangerous area. The mini-screw implanted region was recorded. Post-operative CT images were used to identify whether the mini-screws penetrated into facet joints.

RESULTS

235 mini-plates and 470 lateral mass mini-screws were used in the study. 117 (24.9%) mini-screws penetrated 88 (37.4%) facet joints. The 5-mm-long mini-screw optimal area occupied the upper 72, 65, 65, 64, and 65 % area of the posterior-lateral mass surface for C3-7, while the 7-mm-long mini-screw optimal area encompassed the upper 54, 39, 40, 33, and 32 %. Only 7-mm-long mini-screws were used to fix the plate to the lateral mass. 4 of 240 mini-screws in 7-mm region, 67 of the 179 mini-screws in 5-mm region, and 46 of the 51 mini-screws in dangerous region penetrated into the facet joint. The differences in the rate of facet joint penetration related to region were statistically significant (P < 0.001).

CONCLUSIONS

The facet joint destruction by mini-screws was not a rare complication in plated cervical laminoplasty. The optimal areas we proposed may help guide the mini-screw implantation positions.

The Midterm Surgical Outcome of Modified Expansive Open-Door Laminoplasty

Laminoplasty is a standard technique for treating patients with multilevel cervical spondylotic myelopathy. Modified expansive open-door laminoplasty (MEOLP) preserves the unilateral paraspinal musculature and nuchal ligament and prevents facet joint violation. The purpose of this study was to elucidate the midterm surgical outcomes of this less invasive technique. We retrospectively recruited 65 consecutive patients who underwent MEOLP at our institution in 2011 with at least 4 years of follow-up. Clinical conditions were evaluated by examining neck disability index, Japanese Orthopaedic Association (JOA), Nurick scale, and axial neck pain visual analog scale scores. Sagittal alignment of the cervical spine was assessed using serial lateral static and dynamic radiographs. Clinical and radiographic outcomes revealed significant recovery at the first postoperative year and still exhibited gradual improvement 1–4 years after surgery. The mean JOA recovery rate was 82.3% and 85% range of motion was observed at the final follow-up. None of the patients experienced aggravated or severe neck pain 1 year after surgery or showed complications of temporary C5 nerve palsy and lamina reclosure by the final follow-up. As a less invasive method for reducing surgical dissection by using various modifications, MEOLP yielded satisfactory midterm outcomes.

En Bloc Cervical Laminoplasty Using Translaminar Screws (T-laminoplasty): Novel Procedure for Preserving Midline Ligamentous Structures

STUDY DESIGN

Prospectively maintained and retrospectively analyzed study.

OBJECTIVE

The authors have newly developed an en bloc cervical laminoplasty using translaminar screws (T-laminoplasty) to preserve the posterior midline structures so as to maintain spinal stability and prevent postoperative axial pain and deformity.

SUMMARY OF BACKGROUND DATA

Cervical laminoplasty is a popular surgical procedure for patients with multilevel compressive cervical lesions. However, several reports have noted its limitations and shortcomings.

METHODS

After exposure of the posterior cervical spine with preservation of the midline ligamentous structure, en bloc laminotomy was performed and made a laminectomized block. While the laminotomized block was being lifted, the translaminar trajectory from the lamina to the contralateral lateral mass was prepared. Then a translaminar screw was inserted with suspension of the laminotomized block to expand the spinal canal, passed through the laminar spacer, and finally fixed in the contralateral lateral mass. Next, another screw was inserted into the adjacent segment from the opposite side, and further screw fixations were made in this alternating manner.

RESULTS

Twenty patients underwent T-laminoplasty and 83 segments were operated upon. Clinical outcomes were statistically improved during the mean follow-up period of 19.7 months. Radiologic outcomes of cervical lordosis and range of motion were preserved with the expansion of the cross-sectional area of the spinal canal. In addition, no restenosis or laminar settlement was observed at the last follow-up.

CONCLUSIONS

T-laminoplasty can be one of the surgical options for multilevel compressive cervical lesions. With midline ligamentous structures preserving the procedure, it was possible to get enough canal decompression and foraminal decompression, while obtaining good clinical and radiologic outcomes.

Efficacy and Safety of One-Stage Selective Discectomy Combined with Expansive Hemilaminectomy in the Treatment of Cervical Spondylotic Myelopathy

OBJECTIVES

We designed a novel surgical strategy named one-stage selective discectomy combined with expansive hemilaminectomy, which might theoretically reduce the postoperative complications of cervical spondylotic myelopathy (CSM). The objective of this study is to evaluate its efficacy and safety.

METHODS

Sixty-two patients with CSM were enrolled in this study. The procedure includes selective discectomy with fusion at 1 or 2 segments of maximal cord compression and expansive hemilaminectomy on the symptomatic or severe side of the body. Neurologic function was evaluated using the Japanese Orthopedics Association Score before and after surgery. Midsagittal dural sac diameter, dural sac transverse area at segments of discetomy on magnetic resonance imaging, and lordosis of the cervical spine on lateral plain film were measured. All patients were followed up for more than 1 year.

RESULTS

A total of 88 discs and 272 hemilaminas were resected from 62 patients. The Japanese Orthopedics Association Score improved from 8.7 ± 1.76 preoperatively to 13.4 ± 1.61 at 1 year follow-up (P < 0.001). The mean midsagittal dural sac diameter, dural sac area, and lordotic angle also increased from 0.45 ± 0.10 cm, 0.83 ± 0.14 cm², and 7.9 ± 2.60° to 0.81 ± 0.08 cm, 0.96 ± 0.14 cm², and 11.7 ± 3.06°, respectively (P < 0.05). No case of postoperative axial pain, C5 palsy, nonunion, or kyphosis was reported.

CONCLUSIONS

One-stage selective discectomy combined with expansive hemilaminectomy is an effective surgical approach for the treatment of CSM in patients whose neurologic function, midsagittal dura sac diameter, and dura transverse area can be improved and has few postoperative complications.

Combined expansive open-door laminoplasty with short-segment lateral mass instrumented fusion for multilevel cervical spondylotic myelopathy with short segment instability

OBJECTIVES

Expansive open-door laminoplasty (EOLP) is an effective procedure for multilevel cervical spondylotic myelopathy (MCSM). It preserves a higher range of cervical motion than laminectomy with fusion and reserves more posterior elements than laminectomy alone. MCSM with short-segment instability or correctable local kyphosis often requires long-segment decompression and adequate segment fusion.

MATERIALS AND METHODS

We retrospectively reviewed 20 patients who received EOLP with short-segment posterior lateral mass instrumented fusion at our institution from 2008 to 2011. The follow-up period was at least 36 months. Postoperative functional and radiographic outcomes were collected and analyzed.

RESULTS

Japanese Orthopedic Association scores improved significantly 36 months after surgery and the average recovery ratio was 85.3 ± 14.7%. Nurick disability scores and neck pain visual analog scale scores considerably decreased 3 years after surgery. No patients had aggravated neck pain or C5 nerve palsy during follow-up. The preservation of range of motion was approximately 60% after 36 months. No implant loosening or laminar collapse was reported on radiographic follow-up.

CONCLUSION

EOLP with concomitant lateral mass instrumented fusion yields favorable short-term clinical results for MCSM with short segment instability.

Cervical laminoplasty developments and trends, 2003-2013: a systematic review

OBJECT

Despite extensive clinical experience with laminoplasty, the efficacy of the procedure and its advantages over laminectomy remain unclear. Specific clinical elements, such as incidence or progression of kyphosis, incidence of axial neck pain, postoperative cervical range of motion, and incidence of postoperative C-5 palsies, are of concern. The authors sought to comprehensively review the laminoplasty literature over the past 10 years while focusing on these clinical elements.

METHODS

The authors conducted a literature search of articles in the Medline database published between 2003 and 2013, in which the terms "laminoplasty," "laminectomy," and "posterior cervical spine procedures" were used as key words. Included was every single case series in which patient outcomes after a laminoplasty procedure were reported. Excluded were studies that did not report on at least one of the above-mentioned items.

RESULTS

A total of 103 studies, the results of which contained at least 1 of the prespecified outcome variables, were identified. These studies reported 130 patient groups comprising 8949 patients. There were 3 prospective randomized studies, 1 prospective nonrandomized alternating study, 15 prospective nonrandomized data collections, and 84 retrospective reviews. The review revealed a trend for the use of miniplates or hydroxyapatite spacers on the open side in Hirabayashi-type laminoplasty or on the open side in a Kurokawa-type laminoplasty. Japanese Orthopaedic Association (JOA) scoring was reported most commonly; in the 4949 patients for whom a JOA score was reported, there was improvement from a mean (± SD) score of 9.91 (± 1.65) to a score of 13.68 (± 1.05) after a mean follow-up of 44.18 months (± 35.1 months). The mean preoperative and postoperative C2-7 angles (available for 2470 patients) remained stable from 14.17° (± 0.19°) to 13.98° (± 0.19°) of lordosis (average follow-up 39 months). The authors found significantly decreased kyphosis when muscle/posterior element-sparing techniques were used (p = 0.02). The use of hardware in the form of hydroxyapatite spacers or miniplates did not influence the progression of deformity (p = 0.889). An overall mean (calculated from 2390 patients) of 47.3% loss of range of motion was reported. For the studies that used a visual analog scale score (totaling 986 patients), the mean (cohort size-adjusted) postoperative pain level at a mean follow-up of 29 months was 2.78. For the studies that used percentages of patients who complained of postoperative axial neck pain (totaling 1249 patients), the mean patient number-adjusted percentage was 30% at a mean follow-up of 51 months. The authors found that 16% of the studies that were published in the last 10 years reported a C-5 palsy rate of more than 10% (534 patients), 41% of the studies reported a rate of 5%-10% (n = 1006), 23% of the studies reported a rate of 1%-5% (n = 857), and 12.5% reported a rate of 0% (n = 168).

CONCLUSIONS

Laminoplasty remains a valid option for decompression of the spinal cord. An understanding of the importance of the muscle-ligament complex, plus the introduction of hardware, has led to progress in this type of surgery. Reporting of outcome metrics remains variable, which makes comparisons among the techniques difficult.

Neck Pain following Laminoplasty

Study Design Retrospective evaluation of prospectively collected data. Objective To compare preoperative and postoperative neck pain following laminoplasty using the Neck Disability Index (NDI). Methods Seventy-two patients undergoing laminoplasty from 2006 to 2009 at a single institution were identified. Thirty-four patients with a minimum 1-year follow-up who completed preoperative, 6-week, and 1-year postoperative NDI questionnaires were enrolled. Demographic data and surgical data including estimated blood loss (EBL), length of surgery, number of laminoplasty levels, complications, and length of hospitalization were collected. Results Mean age was 62 years (range: 34 to 88), mean follow-up was 17 months (range: 12 to 31), and there were 21 men and 13 women. Diagnoses were cervical spondylotic myelopathy (n = 26), ossification of the posterior longitudinal ligament (n = 6), and central cord syndrome (n = 2). Mean EBL was 120 mL (range: 50 to 200), and mean surgical time was 152 minutes (range: 70 to 240). Average number of laminoplasty levels was 3 (range: 1 to 5). The open door technique was used, and 24/34 (71%) did not have laminoplasty at C3 and C7. No intraoperative complications were noted, and average hospital stay was 1.6 days (range: 1 to 7). Significant improvement in NDI total score was noted at 1 year (p < 0.002) and in NDI pain score at 6 weeks (p < 0.028) and 1 year (p < 0.007) postoperatively. Conclusions Patients having laminoplasty experienced significant improvement in NDI pain subscore and NDI total scores at a minimum of 1 year postoperatively.

Modified expansive open-door laminoplasty technique improved postoperative neck pain and cervical range of motion

BACKGROUND/PURPOSE

Expansive open-door laminoplasty (EOLP) is a useful technique for multiple-level cervical spondylotic myelopathy. The common postoperative complications of EOLP include moderate to severe neck pain, loss of cervical lordosis, decrease of cervical range of motion, and C5 palsy. We modified the surgical technique to lessen these complications. This study is aimed to elucidate the efficacy of modified techniques to lessen the complications of traditional procedures.

METHODS

We collected data from 126 consecutive patients treated at our institution between August 2008 and December 2012. Of these, 66 patients underwent conventional EOLP (CEOLP) and the other 60 patients underwent modified EOLP (MEOLP). The demographic and preoperative data, axial pain visual analog scale scores at 2 weeks and 3 months postoperatively, clinical outcomes evaluated using Nurick score and Japanese Orthopedic Association recovery rate at 12 months postoperatively, and radiographic results assessed using plain films at 3 months and 12 months postoperatively for both groups were compared and analyzed.

RESULTS

There were no significant differences regarding the preoperative condition between the CEOLP and MEOLP groups (p > 0.05). The Japanese Orthopedic Association recovery rate of the MEOLP group was 70.3%, comparable to the result of the other group (70.2%). Postoperative axial neck pain, loss of range of motion, and loss of lordosis of cervical curvature decreased significantly in the MEOLP group (p < 0.05). The complications of temporary C5 nerve palsy found in the CEOLP group did not exist in the MEOLP group.

CONCLUSION

MEOLP is a minimally invasive surgical method to treat multiple-level cervical spondylotic myelopathy, which decreases postoperative complications effectively.

Expansive open-door laminoplasty secured with titanium miniplates is a good surgical method for multiple-level cervical stenosis

BACKGROUND

Laminoplasty is an effective procedure for treating cervical spondylotic myelopathy (CSM). Little information is available regarding the surgical outcomes of expansive open-door laminoplasty (EOLP) when securing with titanium miniplates without bone grafting. This study is aimed to elucidate the efficacy of and problems associated with EOLP secured with titanium miniplates without bone grafting, thereby enhancing future surgical outcomes.

METHODS

This is a retrospective study. The study participants comprised 104 patients who underwent cervical EOLP secured with titanium miniplates without bone graft for CSM treatment between August 2005 and March 2011. The clinical results were evaluated based on the Japanese Orthopedic Association (JOA) and Nurick scores. The radiographic outcomes were determined based on plain film and magnetic resonance imaging findings, which were assessed and compared.

RESULTS

Lateral cervical spine X-rays exhibited improvement in the Pavlov ratio of the spinal canal at 1 day postoperation, and this ratio did not change at 1 year postoperation. The mean cervical curvature from C2 to C7 decreased 0.21° ± 10.09° and the mean cervical range of motion was deteriorated by 35% at 12 months (P < 0.05). The Nurick score improved from 3.19 ± 1.06 to 0.92 ± 1.32 (P < 0.05). The mean JOA recovery rate was 75% ± 21.1% at 1 year. The mean level of postoperative neck pain at 3 months was 3.09 ± 2.31, as determined using the visual analogue scale (VAS). Increased age, concomitant thoracolumbar stenosis, depression disorder, and preexisting myelomalacia negatively affected the JOA recovery rate (P < 0.05). A decreased preoperative Nurick score and superior sensory function in the upper extremities were powerful predictors of an enhanced JOA recovery rate. The postoperative complications involved hematoma formation 0.9%, reversible C5 nerve palsy 2.8%, and moderate to severe neck pain (VAS ≥ 4) 42%. No cases of lamina closure or collapse were observed.

CONCLUSION

EOLP secured with titanium miniplates without bone grafting is a safe and effective surgical method for treating most patients with CSM.

Neck Pain Following Cervical Laminoplasty: Does Preservation of the C2 Muscle Attachments and/or C7 Matter?

Study Design Systematic review. Objective In patients aged 18 years or older, with cervical spondylotic myelopathy or ossification of the posterior longitudinal ligament (OPLL), does sparing the C2 muscle attachments and/or C7-preserving cervical laminoplasty lead to reduced postoperative axial pain compared with conventional C3 to C7 laminoplasty? Do these results vary based on early active postoperative cervical motion? Methods A systematic review of the English-language literature was undertaken for articles published between 1970 and August 17, 2012. Electronic databases and reference lists of key articles were searched to identify studies evaluating C2/C3- or C7-preserving cervical laminoplasty for the treatment of cervical spondylotic myelopathy (CSM) or OPLL in adults. Studies involving traumatic onset, cervical fracture, infection, deformity, or neoplasms were excluded, as were noncomparative studies. Two independent reviewers assessed the level of evidence quality using the grading of recommendations assessment, development and evaluation (GRADE) system, and disagreements were resolved by consensus. Results We identified 11 articles meeting our inclusion criteria. Only the randomized controlled trial (RCT) showed no significant difference in late axial pain (at 12 months) when C7 spinous muscle preservation was compared with no preservation. However, seven other retrospective cohort studies showed significant pain relief in the preserved group compared with the nonpreserved group. The preservation group included those with preservation of the C7 spinous process and/or attached muscles, the deep extensor muscles, or C2 muscle attachment and/or C3 laminectomy (as opposed to laminoplasty). One study that included preservation of either the C2 or C7 posterior paraspinal muscles found that only preservation of the muscles attached to C2 resulted in reduced postoperative pain. Another study that included preservation of either the C7 spinous process or the deep extensor muscles found that only preservation of C7 resulted in reduced postoperative pain. Conclusion Although there is conflicting data regarding the importance of preserving C7 and/or the semispinalis cervicis muscle attachments to C2, there is enough evidence to suggest that surgeons should make every attempt to preserve these structures whenever possible since there appears to be little downside to doing so, unless it compromises the neurologic decompression.

Modified plate-only open-door laminoplasty versus laminectomy and fusion for the treatment of cervical stenotic myelopathy

The purpose of this study was to compare modified plate-only laminoplasty and laminectomy and fusion to confirm which of the 2 surgical modalities could achieve a better decompression outcome and whether a significant difference was found in postoperative complications. Clinical data were retrospectively reviewed for 141 patients with cervical stenotic myelopathy who underwent plate-only laminoplasty and laminectomy and fusion between November 2007 and June 2010. The extent of decompression was assessed by measuring the cross-sectional area of the dural sac and the distance of spinal cord drift at the 3 most narrowed levels on T2-weighted magnetic resonance imaging. Clinical outcomes and complications were also recorded and compared. Significant enlargement of the dural sac area and spinal cord drift was achieved and well maintained in both groups, but the extent of decompression was greater in patients who underwent laminectomy and fusion; however, a greater decompression did not seem to produce a better clinical outcome. No significant difference was observed in Japanese Orthopaedic Association and Nurick scores between the 2 groups. Patients who underwent plate-only laminoplasty showed a better improvement in Neck Dysfunction Index and visual analog scale scores. In addition, limited decompression, rigid reconstruction of the spinal canal, and preservation of cervical mobility combined with preservation of the posterior structure resulted in a lower rate of postoperative C5 palsy and axial pain in the modified laminoplasty group. For this reason, modified laminoplasty may be a more viable option for patients with cervical stenotic myelopathy.

Ossification of the posterior longitudinal ligament: pathogenesis, management, and current surgical approaches. A review

Ossification of the posterior longitudinal ligament (OPLL) is an important cause of cervical myelopathy that results from bony ossification of the cervical or thoracic posterior longitudinal ligament (PLL). It has been estimated that nearly 25% of patients with cervical myelopathy will have features of OPLL. Patients commonly present in their mid-40s or 50s with clinical evidence of myelopathy. On MR and CT imaging, this can be seen as areas of ossification that commonly coalesce behind the cervical vertebral bodies, leading to direct ventral compression of the cord. While MR imaging will commonly demonstrate associated changes in the soft tissue, CT scanning will better define areas of ossification. This can also provide the clinician with evidence of possible dural ossification. The surgical management of OPLL remains a challenge to spine surgeons. Surgical alternatives include anterior, posterior, or circumferential decompression and/or stabilization. Anterior cervical stabilization options include cervical corpectomy or multilevel anterior cervical corpectomy and fusion, while posterior stabilization approaches include instrumented or noninstrumented fusion or laminoplasty. Each of these approaches has distinct advantages and disadvantages. While anterior approaches may provide more direct decompression and best improve myelopathy scores, there is soft-tissue morbidity associated with the anterior approach. Posterior approaches, including laminectomy and fusion and laminoplasty, may be well tolerated in older patients. However, there often is associated axial neck pain and less improvement in myelopathy scores. In this review, the authors discuss the epidemiology, imaging findings, and clinical presentation of OPLL. The authors additionally discuss the merits of the different surgical techniques in the management of this challenging disease.

Long-term results of tension-band laminoplasty for cervical stenotic myelopathy

We reviewed 75 patients (57 men and 18 women), who had undergone tension-band laminoplasty for cervical spondylotic myelopathy (42 patients) or compression myelopathy due to ossification of the posterior longitudinal ligament (33 patients) and had been followed for more than ten years. Clinical and functional results were estimated using the Japanese Orthopaedic Association score. The rate of recovery and the level of postoperative axial neck pain were also recorded. The pre- and post-operative alignment of the cervical spine (Ishihara curve index indicating lordosis of the cervical spine) and the range of movement (ROM) of the cervical spine were also measured.

The mean rate of recovery of the Japanese Orthopaedic Association score at final follow-up was 52.1% (sd 24.6) and significant axial pain was reported by 19 patients (25.3%). Axial pain was reported more frequently in patients with ossification of the posterior longitudinal ligament than in those with cervical spondylotic myelopathy (p = 0.027). A kyphotic deformity was not seen post-operatively in any patient. The mean ROM decreased post-operatively from 32.8° (sd 12.3) to 16.2° (sd 12.3) (p < 0.001). The mean ROM ratio was 46.9% (sd 28.1) for all the patients. The mean ROM ratio was lower in patients with ossification of the posterior longitudinal ligament than in those with cervical spondylotic myelopathy (p < 0.001). Compared to those with cervical spondylotic myelopathy, patients with ossification of the posterior longitudinal ligament had less ROM and more post-operative axial neck pain.