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Modified Plate-Only Open-Door Laminoplasty Versus Laminectomy and Fusion for the Treatment of Cervical Stenotic Myelopathy

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Modified Plate-Only Open-Door Laminoplasty Versus Laminectomy and Fusion for the Treatment of Cervical Stenotic Myelopathy n Feature Article Modified Plate-only Open-door Laminoplasty Versus Laminectomy and Fusion for the Treatment of Cervical Stenotic Myelopathy LILI YANG, MD; YIFEI GU, MD; JUEQIAN SHI, MD; RUI GAO, MD; YANG LIU, MD; JUN LI, MD; WEN YUAN, MD, PHD abstract Full article available online at Healio.com/Orthopedics. Search: 20121217-23 The purpose of this study was to compare modified plate-only laminoplasty and lami- nectomy and fusion to confirm which of the 2 surgical modalities could achieve a better decompression outcome and whether a significant difference was found in postopera- tive 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 en- largement 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 Figure: T2-weighted magnetic resonance image laminectomy and fusion; however, a greater decompression did not seem to produce a showing the extent of decompression assessed by better clinical outcome. No significant difference was observed in Japanese Orthopaedic measuring the cross-sectional area of the dural sac Association and Nurick scores between the 2 groups. Patients who underwent plate-only (arrow). laminoplasty showed a better improvement in Neck Dysfunction Index and visual ana- log 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. The authors are from the Department of Orthopedics (LY, YG, RG, YL, JL, WY) and the Department of Imageology (JS), Changzheng Hospital, Second Military Medical University, Shanghai, China. Drs Yang and Gu equally contributed to this work. The authors have no relevant financial relationships to disclose. This research was supported by the Natural Science Foundation of Shanghai Science and Technology Committee (11ZR1448400) and Innovation Program of Shanghai Municipal Education Commission (12ZZ079). Correspondence should be addressed to: Wen Yuan, MD, PhD, Department of Orthopedics, Changzheng Hospital, Second Military Medical University, No.415 Fengyang Rd, Shanghai 200003, China ([email protected]). doi: 10.3928/01477447-20121217-23 JANUARY 2013 | Volume 36 • Number 1 e79 n Feature Article osterior cervical decompression, including laminectomy and lami- Pnoplasty, has been widely used in the treatment of progressive myelopa- thy caused by stenotic conditions such as multilevel spondylosis, ossification of the posterior longitudinal ligament, and developmental spinal stenosis. Laminectomy has been a classic and standard treatment for cervical stenotic myelopathy for decades, whereas lami- noplasty was developed in the late 1970s in Japan as an alternative to laminecto- my, with satisfactory clinical outcomes reported by many studies.1-5 Despite 1A 1B presumed advantages, open-door lami- Figure 1: Transverse T2-weighed magnetic resonance image showing the extent of decompression assessed noplasty is not uniformly accepted com- by measuring the cross-sectional area of the dural sac (arrow) (A). The distance of spinal cord drift was as- pared with laminectomy and fusion due sessed from the posterior margin of the posterior longitudinal ligament to the anterior margin of the spinal cord (B). to several drawbacks, including reclosure problems, hinge fracture, and potential injuries to the nerve roots or the spinal compression at 3 or more cervical levels sia. A standard posterior exposure was cord by bone grafts at the open side.6-9 confirmed by radiography. Exclusion cri- performed for both procedures. In the Controversy over laminoplasty still ex- teria were patients with severe cervical laminoplasty group, the interspinous liga- ists. Some recent studies reported good kyphosis, fracture, segmental cervical in- ments were cut at the superior and inferior outcomes with plate-only open-door lami- stability, tumors, metabolic disorders, and ends of the target levels, with the supra- noplasty in patients with cervical spinal history of cervical spine surgery or com- spinous ligaments entirely preserved. At canal stenosis in which mini-plates were bined with anterior cervical spine proce- the open side, a full-thickness trough was used to reconstruct the spinal canal.10-13 dures. Twenty-two patients were lost to drilled at the junction of the lateral mass To the current authors’ knowledge, few follow-up. A total of 141 patients (106 and the lamina with a high-speed burr, studies compare this modified lamino- men and 35 women) with a mean age of and a partial-thickness trough was drilled plasty with laminectomy.14 The purpose 57.9768.17 years (range, 41-75 years) at at the hinge side. Because the ligamentum of the current study was to confirm which surgery were included in this study. This flavum was hypertrophic, causing double- of the 2 surgical modalities could achieve study was approved by the Committee on sided compression in most patients, it was a better decompression outcome and Ethics of Biomedical Research. removed with part of the cortical bone at whether a significant difference existed in The specific procedure was decided the open-side of the expanded levels. The postoperative complications between the by the surgeons. Patients with large ante- lamina was elevated from the open side 2 techniques. rior osteophytes, facet degeneration, and toward the hinge side for approximately the continuous type of ossification of the 8 to 10 mm and stabilized with 8 or 10 MATERIALS AND METHODS posterior longitudinal ligament typically mm mini-plates and screws. Autologous Clinical data for patients who under- underwent laminectomy and fusion. The bone debris was embedded into the hinge went laminectomy with instrumented 141 patients were divided into 2 groups trough as a bone graft to stimulate fusion. fusion and modified open-door lamino- according to procedure: the plate-only No bone graft was used as a strut at the plasty at the authors’ institution between open-door laminoplasty group (75 pa- open side. November 2007 and June 2010 were tients) and the laminectomy and fusion In the laminectomy and fusion group, retrospectively reviewed. Inclusion crite- group (66 patients). All patients had a the supraspinous and interspinous liga- ria were patients whose clinical findings minimum 24-month follow-up. ments and the total lamina with the liga- were consistent with the diagnosis of mentum flavum of the target levels were progressive cervical stenotic myelopa- SURGICAL TECHNIQUE removed completely with a high-speed thy that failed to respond to nonsurgi- The patients were placed in the prone drill and rongeur. Lateral mass screws and cal treatment and patients who had cord position while under general anesthe- rods were then fixed at the decompression e80 ORTHOPEDICS | Healio.com/Orthopedics CERVICAL STENOTIC MYELOPATHY | YANG ET AL scribed by Ishihara.15 Range of motion (ROM) was determined using the Cobb method for C2-C7 in flexion and exten- sion (Figure 2). To evaluate the clinical outcome, the Japanese Orthopaedic Association and the Nurick scoring systems were used to as- sess the neurological status, and the Neck Dysfunction Index (NDI) scoring system was used to assess neck function. Axial symptoms were evaluated by the 10-point visual analog scale (VAS). Complications 2A 2B 2C including infection, hardware failure, ce- Figure 2: Lateral radiograph showing evaluation of the cervical curvature index (CCI) with the Ishihara rebrospinal fluid leakage, C5 palsy, ky- method: CCI5(a11a21a31a4)/A (A). Lateral flexion-extension radiographs showing evalutation of range of motion (ROM) as the sum of the C2-C7 Cobb angle: ROM5a1b (B, C). phosis (kyphosis angle was measured), and axial pain (defined as a VAS score of 3 or more at 6-month follow-up) were re- Table 1 corded for both groups. Demographics and Surgical Parameters RESULTS Demographics and Surgical Parameters Mean6SD Seventy-five patients (56 men and 19 Laminoplasty Laminectomy and Demographic/Parameter Group Fusion Group Test Value P women) with a mean age of 57.19 years (range, 42-72 years) underwent modified Age at operation, y 57.1967.33 56.9868.34 Z520.161 .872 plate-only laminoplasty. Sixty-six patients Age range, y 42-72 41-75 (49 men and 17 women) with a mean age No. of M/F 56/19 49/17 x25 .954 0.003 of 56.98 years (range, 41-75 years) under- No. of operative levels 4.3360.622 4.5360.728 Z521.769 .901 went laminectomy and fusion. A mean of Blood loss, mL 284.53649.52 310.91650.92 Z522.985 .003 4.33 and 4.53 vertebral levels were operated Operation time, min 145.07627.13 173.79629.18 Z525.426 .000 on in the laminoplasty group and the lami- nectomy and fusion group, respectively. No statistical difference in sex, age, or operative levels was found between the 2 groups. levels. Autologous laminectomy bone was sac at the 3 most narrowed levels on T2- Mean operative time was 145.076 used as a bone graft. weighted magnetic resonance imaging 27.13 minutes in the laminoplasty group Patient data, including age, sex, op- preoperatively, 6 months postoperatively, vs 173.79629.18 minutes in the laminec- erative levels, intraoperative blood loss, and at last follow-up. The improve- tomy and fusion group. Mean intraop- and operative time, were recorded. ment ratio of the cross-sectional area erative blood loss was 284.53649.52 mL Anteroposterior and lateral flexion and was [(postoperative area2preoperative in the laminoplasty group and 310.916 extension plain radiographs and magnetic area)4preoperative area]3100%.
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