CERVICAL MYELOPATHY East Meets West

OSET Meeting 2017 Las Vegas, Nevada

John G. Heller, MD Professor of Orthopaedic Surgery Fellowship Director The Emory Spine Center Emory University School of Medicine Atlanta, Georgia Disclosures: Royalties, Stock & Consultant - Medtronic Cervical Myelopathy Surgical Treatment Options Anterior Posterior • Multiple Discectomies • Laminectomy: • Corpectomies • ‘Skip Laminectomy’ • Hybrid • Laminoplasty • Disc Replacement • Laminectomy & Fusion

Combined Anterior & Posterior Important Questions to Note

• Do either of the surgical strategies yield a better/worse neurologic outcome? • No • Except laminectomy: (Kyphosis, recurrent myelopathy) • Do the complication rates differ between these procedures? • Yes. • They may differ when attempting multi-level fusions. • What about comparative value? • Stay tuned… (CSM-S: Ghogawala, et al.) How did we get here?

• North America: Birth place • Asia: Innovation in posterior of anterior cervical surgery. decompression. • Robinson • Hirabayashi • Cloward • Kurokawa • Bohlman • International contributions • Europe: Internal fixation. to a cognitive framework for • Roy-Camille designing treatment. • Magerl • CSRS • Caspar The Evolution of Laminoplasty

Professor Kiyoshi Hirabayashi The Evolution of Laminoplasty

Professor Kiyoshi Hirabayashi Problems Associated with Laminectomy

• Postoperative malalignment:

• Importance of preserving posterior elements

• Laminectomy membrane compressing the spinal cord

• Risk of spinal cord injury by segmental removal of lamina:

• Simultaneous multilevel decompression Problems Associated with Laminectomy

• Postoperative malalignment:

• Importance of preserving posterior elements

• Laminectomy membrane compressing the spinal cord

• Risk of spinal cord injury by segmental removal of lamina:

• Simultaneous multilevel decompression Development of Laminoplasty 1906 1968 Kirita Y - en bloc laminectomy using a burr Chubu Seisai 13：241－242

1950

2006 The linked image cannot be displayed. The file may have been moved, renamed, or deleted. Verify that the link points to the correct file and location. Development of Laminoplasty 1906

1973 Oyama M、Hattori S： Z-shaped laminoplasty Chubu Seisai 16：792-793

1950

Development of Laminoplasty 2006 The linked image cannot be displayed. The file may have been moved, renamed, or deleted. Verify that the link points to the correct file and location. 1906 1978 Hirabayashi - Open door laminoplasty Shujyutsu 32：1159-1163

1950

The linked image cannot be displayed. The file may have been moved, renamed, or deleted. Verify that the link points to the correct file and location. 2006 Conventional Laminectomy vs Laminoplasty Herkowitz HN et al: Spine 1988

• Comparison of ACDF, Laminectomy and laminoplasty in 45 patients with multilevel spondylotic radiculopathy. • Laminoplasty was an effective alternative to ACDF and laminectomy with less complications Laminoplasty Technique The Troughs Delayed adoption in the West: Technique dependent – No experienced teachers

Excessive bone removal Trough too medial & on hinge side into lamina Ito et al. Spine, 1984

O'Brien MF et al. Spine 1996 Use of titanium miniplates for stabilization of laminae

Wang JM et al. J Bone Joint Surg Br. 1998 Use of anchoring system for stabilization of laminae Laminoplasty & Mini-Plate Fixation: Mr. Alan Crockard Laminoplasty Technique Keeping the ‘Open Door’ Open

• Suture to paraspinal m. (Hirabayashi) • Prop open: • Notched spinous processes • Allograft rib, etc. • Prosthetics (Japan) • Mini-plates & screws Laminoplasty Technique Keeping the ‘Open Door’ Open

• Suture to paraspinal m. (Hirabayashi) • Prop open: • Notched spinous processes • Allograft rib, etc. • Prosthetics (Japan) • Mini-plates & screws What about ‘French Door’ Laminoplasty? 1906 1982 Kurokawa T -Double door laminoplasty Seikeigeka S2:234-240

Double door laminoplasty

1950

2006 The linked image cannot be displayed. The file may have been moved, renamed, or deleted. Verify that the link points to the correct file and location. Spinous process-splitting laminoplasty using hydroxyapatite spinous process spacer Nakano et al, Spine 1992 T-saw laminoplasty Tomita K et al Spine 1998 Laminoplasty Technique Keeping the ‘French’ Door Open

• Suture to paraspinal m. • Re-closure rate? • Prop open: sutured in place • Prosthetics (Japan) • Split spinous processes • Allograft rib, etc. • New implants? Laminoplasty Technique Keeping the ‘French’ Door Open

• Suture to paraspinal m. • Re-closure rate? • Prop open: sutured in place • Prosthetics (Japan) • Split spinous processes • Allograft rib, etc. • New implants? Postop AROM Anterior Surgery – North America

• Smith & Robinson: • Direct removal of anterior pathology • Cloward • Bohlman • Many technical refinements Anterior Surgery - Europe

• Orozco • Caspar: • Re-shaped our thinking with innovative instruments & implant concepts • Iterative changes in implant design. Anterior Surgery - Europe

• Orozco • Caspar: • Re-shaped our thinking with innovative instruments & implant concepts • Iterative changes in implant design. Posterior Cervical Fixation: Europe’s Genius

-Simple -Effective: - Ugly but fairly effective? -Cheap Posterior Cervical Fixation: Europe’s Genius

-Simple -Effective: - Ugly but fairly effective? -Cheap POSTERIOR CERVICAL STABILIZATION

1. Arthrodesis 2. Internal fixation a) Wire/Cable - Interspinous - Facet - Sublaminar POSTERIOR CERVICAL STABILIZATION

1. Arthrodesis 2. Internal fixation a) Wire/Cable - Interspinous - Facet - Sublaminar Raymond Roy-Camille, MD Roy-Camille v. Magerl They were practical anatomists with a dose of creative genius Lateral Mass Screws Insertion Techniques

- Roy-Camille - Starting Point - Magerl - Trajectory - Louis • axial - Sonntag • sagittal - Anderson - An

Eastern Contribution to Posterior Screw Fixation - Abumi

• 59 patients • Breach of pedicle cortex: –5.3-6.7%

• No neurovascular compl. • No pseudarthrosis Abumi et al., Spine., 1999 Cervical Pedicle Screws

Indications: •Select circumstances •Clear indications •Suitable pedicle morphology Cervical Pedicle Screws

Indications: •Select circumstances •Clear indications •Suitable pedicle morphology Posterior Cervical Fixation Points

Anatomical Purchase Level “Midline” below Occiput EOP C-1 Articular Mass C-2 Pedicle/Pars C3-6 Lat. Mass C-7 LM v. Ped? Thoracic Pedicle Multi-Level Cervical Myelopathy

•Laminoplasty • ≥3 motion segs. • ≤130 kyphosis • Non-union risk • Congenital stenosis • Previous ant. surg. • Inadequate decompression • Adj. segment deg. Multi-Level Cervical Myelopathy

•Laminoplasty • ≥3 motion segs. • ≤130 kyphosis • Non-union risk • Congenital stenosis • Previous ant. surg. • Inadequate decompression • Adj. segment deg. Laminoplasty Contra-Indications

• Significant axial pain • >130 kyphosis • “Hill Shaped” OPLL • Segmental instability • Previous post. Surg. • Epidural fibrosis Laminoplasty Contra-Indications

• Significant axial pain • >130 kyphosis • “Hill Shaped” OPLL • Segmental instability • Previous post. Surg. • Epidural fibrosis Multi-Level Cervical Myelopathy

Lam./Fuse

 ≥ 3 motion segs.

 Kyphosis (Flexible)

 Seg. instability

 Axial pain

 Prev. anterior surgery

 Inadeq. decompr.

 Dysphagia Multi-Level Cervical Myelopathy

Lam./Fuse

 ≥ 3 motion segs.

 Kyphosis (Flexible)

 Seg. instability

 Axial pain

 Prev. anterior surgery

 Inadeq. decompr.

 Dysphagia Multi-Level Cervical Myelopathy

Lam./Fuse

 ≥ 3 motion segs.

 Kyphosis (Flexible)

 Seg. instability

 Axial pain

 Prev. anterior surgery

 Inadeq. decompr.

 Dysphagia Multi-Level Cervical Myelopathy

Anterior/Posterior •Fixed malalignment •High risk non-union •Osteoporosis •Dystonia or C.P. •Postlam. Kyphosis •Neuromuscular kyphosis − Parkinson’s − Musc. Dystrophy − Post XRT •Halo contraindicated Multi-Level Cervical Myelopathy

• We are deeply indebted to surgeons from around the world for our current insights. • Each patient is unique. • Surgeons differ in their training & experience. • We should strive to be familiar/comfortable with all of the relevant treatment options. • We should know what differentiates one technique from another. • Design the solution to fit the problem. • Optimal result for the patient. East & West have jointly shaped the world of cervical spine surgery

Thank You