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Clinical Application of a New Plate Fixation System in Open-Door Laminoplasty

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Clinical Application of a New Plate Fixation System in Open-Door Laminoplasty ■ Feature Article Clinical Application of a New Plate Fixation System in Open-door Laminoplasty LIANGJUN JIANG, MD; WEISHAN CHEN, MD; QIXIN CHEN, MD; KAN XU, MD; QIONGHUA WU, MD; FANGCAI LI, MD abstract Full article available online at ORTHOSuperSite.com. Search: 20120123-07 The purpose of this retrospective clinical series was to evaluate the benefi ts and complications of plate fi xation for open-door laminoplasty in cervical spondylotic myelopathy with multilevel spinal stenosis compared with open-door laminoplasty without fi xation. Forty-nine patients underwent open-door laminoplasty for cervical myelopathy with multilevel spinal stenosis with at least 13 months of follow-up. A A B plate was used as the sole method of fi xation between the lateral mass and lamina Figure: One-week postoperative anteroposterior with 3 screws. Computed tomography scans obtained pre- and postoperatively were (A) and lateral (B) radiographs of a patient with assessed for plate complications and spinal canal enlargement. Pre- and postoperative cervical spondylotic myelopathy with multilevel neurological condition was assessed by the Japanese Orthopedic Association (JOA) spinal stenosis who received plate open-door lami- noplasty. We performed C3-C7 segment open-door myelopathy score. Overall cervical spine range of motion (ROM) was measured in full laminoplasty with 5 centerpiece plates. Each plate fl exion and extension radiographs pre- and postoperatively. was fi xed to the spinous lamina and the lateral mass by 3 mini-screws. No restenosis due to door reclosure was noted, and no plates failed. No screws were backed out or broken. Almost all patients showed neurological improvement. The JOA score increased by 3.9Ϯ0.7 points in the suture group and 4.3Ϯ0.8 points in the plate group (PϾ.05). The postoperative increase in mean anteroposterior diameter of the spinal canal from C3 to C7 was 4.5Ϯ0.6 mm in the suture group and 5.1Ϯ0.5 mm in the plate group. The greater mean anteroposterior diameter increase in the plate group was statistically signifi cant (PϽ.01). The mean cervical ROM decreased in the plate and suture groups postoperatively (PϽ.001). No signifi cant difference was found in mean cervical ROM reduction between the groups (PϾ.05). No difference in axial symptoms was found between the 2 groups. Drs Jiang, Chen (Weishan), Chen (Qixin), Xu, Wu, and Li are from the Department of Orthopaedics, The 2nd Affi liated Hospital of Zhejiang University, Hangzhou, Zhejiang, China. Drs Jiang, Chen (Weishan), Chen (Qixin), Xu, Wu, and Li have no relevant fi nancial relationships to disclose. Correspondence should be addressed to: Liangjun Jiang, MD, Department of Orthopaedics, The 2nd Affi liated Hospital of Zhejiang University, Jiefang Rd #88, Hangzhou, Zhejiang, China (abacus0610@ yahoo.com.cn). doi: 10.3928/01477447-20120123-07 FEBRUARY 2012 | Volume 35 • Number 2 e225 ■ Feature Article ultisegmental cervical spon- dylotic myelopathy remains a Table 1 Mpathophysiological and thera- Patient Demographics peutic challenge. Expansive laminoplasty has gradually become a preferred proce- Average age 58 (41-81) dure for almost all patients with cervical (range), y spondylotic myelopathy with multilevel No. of 40:21 spinal stenosis. Hirabayashi et al1 intro- men:women duced unilateral open-door laminoplasty, No. of patients in 38 the plate group 1A 1B which has been widely used worldwide. In the classic open-door laminoplasty tech- No. of patients in 23 Figure 1: One-week postoperative anteroposterior the suture group (A) and lateral (B) radiographs of a patient with nique, the lamina door is tethered open Levels of decompression, no. cervical spondylotic myelopathy with multilevel via sutures through the spinous process spinal stenosis who received plate open-door lami- 3 9 (C3-C5) and facet capsule or paravertebral muscle, noplasty. We performed C3-C7 segment open-door ϭ which are then tied to prevent reclosure of 4 14 (C4-C7 7; laminoplasty with 5 centerpiece plates. Each plate C3-C6ϭ7) was fi xed to the spinous lamina and the lateral the lifted lamina. 5 38 (C3-C7) mass by 3 mini-screws. Although this technique has proven to be successful, its limitations include inad- Plates used, no. equate decompression on the hinge side, 26group, 6 patients used 2 plates, 27 patients the potential for reclosing of the door, 327used 3 plates, 3 patients used 4 plates, and 2 range of motion (ROM) restriction, and 43patients used 5 plates (Table 1). lack of a truly stable fusion.2-4 Therefore, 52 a few fi xations, such as sutures, bone SURGICAL TECHNIQUE struts, ceramic blocks, and suture anchors, Modifi cations were made to the origi- were used in the open-door laminoplasty, MATERIALS AND METHODS nal Hirabayashi et al1 laminoplasty in our but all of them were defi cient in some Between January 2008 and January surgical technique. A standard posterior way. Sutures may cut out, break, or stretch 2011, a total of 61 consecutive patients exposure of the cervical spine was per- over time. Bone struts and ceramic blocks with cervical spondylotic myelopathy with formed. The number of segments operated have the potential for graft kickout. Suture multilevel spinal stenosis were assessed in on depended on the pattern of spinal cord anchors may displace, and the suture may our study. All patients met the following en- compression. Two hinges at bilateral junc- cut out or break. rollment criteria: (1) a clear history of pro- tions of the bilateral lateral mass and bone Recently, a new plate fi xation sys- gressive neurological defi cit; and (2) com- lamina were created by completely remov- tem was developed for open-door lami- parable radiography, magnetic resonance ing the dorsal cortex and thinning the ven- noplasty that fi xes the free lamina and imaging (MRI), and computed tomography tral cortex with an electric drill. The ventral lateral mass. Rhee et al5 reported that a (CT) fi ndings verifying multilevel cervical cortex in the open side was removed. In the plate in open-door laminoplasty could stenosis with or without ossifi cation of the plate group, the open side was stabilized maintain stable spinal canal expansion posterior longitudinal ligaments. Patients with plates and mini-screws (Centerpiece; with high rates of hinge union. However, with serious systemic disease, such as acute Medtronic Sofamor Danek, Memphis, information is lacking about the benefi ts cardiac accident or cerebral infarction, were Tennessee). Commonly, we chose the left and complications of the plate. Since excluded. Mean patient age at surgery was side as the open-door side and the right 2008, we have used the plate system in 58 years (range, 41-81 years). Thirty-eight side as the hinge side. The plate was mea- the open-door laminoplasty in patients patients (24 men, 14 women) underwent sured to suit the space between the lateral with multisegmental cervical spondy- open-door laminoplasty with plate fi xa- mass and lamina, and a suffi cient size (usu- lotic myelopathy in our institution. The tion, and 23 patients (16 men, 7 women) ally model #10-#12) was chosen to allow purpose of this study was to evaluate the underwent open-door laminoplasty with adequate expansion of the spinal canal. benefi ts and complications of plate fi xa- suture. The choice of internal fi xation used Two mini-screws were placed into the lat- tion in open-door laminoplasty for cer- was randomized. Nine patients had 3 lev- eral mass through the plate, and another vical spondylotic myelopathy compared els of decompression (C3-C5), 14 patients mini-screw was placed into the cut lamina with open-door laminoplasty without had 4 levels (C4-C7ϭ7; C3-C6ϭ7), and 38 through the plate to create stable fi xation fi xation. patients had 5 levels (C3-C7). In the plate (Figure 1). In the suture group, the lamina e226 ORTHOPEDICS | ORTHOSuperSite.com NEW PLATE FIXATION SYSTEM IN OPEN-DOOR LAMINOPLASTY | JIANG ET AL Table 2 Follow-up Data Characteristic Plate Group Suture Group No. of patients at follow-up 32 17 Mean patient age (range), y 56 (41-67) 59 (44-73) No. of men:women 20:12 13:4 Average operative time, min 145 132 Average blood loss, mL 350 345 Average follow-up (range), mo 19 (13-36) 20.5 (14-39) 2 Figure 2: Postoperative sagittal computed tomog- raphy scan. We measured the anteroposterior di- ameters of the C3-C7 segments and used the mean anteroposterior diameter ([aϩbϩcϩdϩe]/5) to evaluate the spinal canal expansion of open-door laminoplasty. In this patient, we performed an open-door laminoplasty with C3-C6 segment de- compression, and the plates were fi xed in the C4 and C5 segments. 3A 3B Figure 3: The mean Japanese Orthopedic Association (JOA) score increased postoperatively in the plate group (PϽ.05) and the suture group (PϽ.05) (A). The Japanese Orthopedic Association score increase Ͼ door was tethered open via #1 nonabsorb- was not signifi cant between the groups (P .05) (B). able sutures through the spinous process and facet capsule or paravertebral muscle. All patients were allowed to sit up or It was measured in full fl exion and full eratively. The follow-up rate was 80.3%. walk between 3 and 5 days postoperatively. extension radiographs.7 The ROM was Mean patient age in the plate group was 56 A cervical brace was worn for 3 months. measured preoperatively and 6 months years (range, 41-67 years) and in the suture Pre- and postoperative neurological postoperatively to evaluate the change in group was 59 years (range, 44-73 years). condition was assessed by the Japanese the cervical spine. The plate group comprised 20 men and 12 Orthopaedic Association (JOA) myelopa- Results were analyzed statistically women, and the suture group comprised thy score.
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