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Laminoplasty Versus Laminectomy with Posterior Spinal Fusion For CLINICAL ARTICLE J Neurosurg Spine 27:508–517, 2017 Laminoplasty versus laminectomy with posterior spinal fusion for multilevel cervical spondylotic myelopathy: influence of cervical alignment on outcomes Darryl Lau, MD,1 Ethan A. Winkler, MD, PhD,1 Khoi D. Than, MD,2 Dean Chou, MD,1 and Praveen V. Mummaneni, MD1 1Department of Neurological Surgery, University of California, San Francisco; and 2Department of Neurosurgery, Oregon Health Science University, Portland, Oregon OBJECTIVE Cervical curvature is an important factor when deciding between laminoplasty and laminectomy with pos- terior spinal fusion (LPSF) for cervical spondylotic myelopathy (CSM). This study compares outcomes following lamino- plasty and LPSF in patients with matched postoperative cervical lordosis. METHODS Adults undergoing laminoplasty or LPSF for cervical CSM from 2011 to 2014 were identified. Matched cohorts were obtained by excluding LPSF patients with postoperative cervical Cobb angles outside the range of lami- noplasty patients. Clinical outcomes and radiographic results were compared. A subgroup analysis of patients with and without preoperative pain was performed, and the effects of cervical curvature on pain outcomes were examined. RESULTS A total of 145 patients were included: 101 who underwent laminoplasty and 44 who underwent LPSF. Pre- operative Nurick scale score, pain incidence, and visual analog scale (VAS) neck pain scores were similar between the two groups. Patients who underwent LPSF had significantly less preoperative cervical lordosis (5.8° vs 10.9°, p = 0.018). Preoperative and postoperative C2–7 sagittal vertical axis (SVA) and T-1 slope were similar between the two groups. Laminoplasty cases were associated with less blood loss (196.6 vs 325.0 ml, p < 0.001) and trended toward shorter hospital stays (3.5 vs 4.3 days, p = 0.054). The perioperative complication rate was 8.3%; there was no significant differ- ence between the groups. LPSF was associated with a higher long-term complication rate (11.6% vs 2.2%, p = 0.036), with pseudarthrosis accounting for 3 of 5 complications in the LPSF group. Follow-up cervical Cobb angle was similar between the groups (8.8° vs 7.1°, p = 0.454). At final follow-up, LPSF had a significantly lower mean Nurick score (0.9 vs 1.4, p = 0.014). Among patients with preoperative neck pain, pain incidence (36.4% vs 31.3%, p = 0.629) and VAS neck pain (2.1 vs 1.8, p = 0.731) were similar between the groups. Similarly, in patients without preoperative pain, there was no significant difference in pain incidence (19.4% vs 18.2%, p = 0.926) and VAS neck pain (1.0 vs 1.1, p = 0.908). For lami- noplasty, there was a significant trend for lower pain incidence (p = 0.010) and VAS neck pain (p = 0.004) with greater cervical lordosis, especially when greater than 20° (p = 0.011 and p = 0.018). Mean follow-up was 17.3 months. CONCLUSIONS For patients with CSM, LPSF was associated with slightly greater blood loss and a higher long-term complication rate, but offered greater neurological improvement than laminoplasty. In cohorts of matched follow-up cervical sagittal alignment, pain outcomes were similar between laminoplasty and LPSF patients. However, among laminoplasty patients, greater cervical lordosis was associated with better pain outcomes, especially for lordosis greater than 20°. Cervical curvature (lordosis) should be considered as an important factor in pain outcomes following posterior decompression for multilevel CSM. https://thejns.org/doi/abs/10.3171/2017.4.SPINE16831 KEY WORDS alignment; cervical spondylotic myelopathy; laminoplasty; laminectomy; posterior spinal fusion EGENERATIVE cervical spondylosis can result in spi- that 20%–60% of patients will deteriorate neurologically.8 nal cord compression and injury, which can lead CSM can be treated through an anterior and/or posterior to myelopathy.14 Cervical spondylotic myelopa- approach to the spine, and both approaches have been Dthy (CSM) often involves multiple vertebral levels, and proven to be effective for multilevel disease.12 The two evidence regarding the natural history of CSM suggests posterior approaches traditionally used are laminoplasty, ABBREVIATIONS CSM = cervical spondylotic myelopathy; EBL = estimated blood loss; JOA = Japanese Orthopaedic Association; LOS = length of stay; LPSF = laminec- tomy with posterior spinal fusion; SVA = sagittal vertical axis; VAS = visual analog scale. SUBMITTED July 12, 2016. ACCEPTED April 10, 2017. INCLUDE WHEN CITING Published online September 1, 2017; DOI: 10.3171/2017.4.SPINE16831. 508 J Neurosurg Spine Volume 27 • November 2017 ©AANS, 2017 Unauthenticated | Downloaded 10/05/21 07:03 AM UTC Laminoplasty versus laminectomy with fusion for CSM and laminectomy with posterior spinal fusion (LPSF). Laminectomy alone is generally avoided given the signifi- cant risk for delayed postlaminectomy kyphosis.2 The indications for using either laminoplasty or LPSF for multilevel CSM depend on a variety of demographic, social, and clinical factors. There are several clinical and radiological factors that are often taken into account when deciding between the two surgical techniques: presence of neck pain, degree of movement with flexion-extension, and cervical curvature. Generally, LPSF is preferred in pa- tients with neck pain, significant translational movement, and/or cervical kyphosis. The rationale is that LPSF is able to stabilize the spinal column, thus offering superior pain relief compared with laminoplasty. The decision to use either procedure is based on each individual case and surgeon familiarity.5,13,27 Over the past 5–10 years, there has been a greater un- derstanding of the relation of regional and global spinal alignment with functional and pain outcomes. In particu- lar, cervical alignment has been suggested as an impor- tant factor associated with neck pain.9,15,20,23 We sought to assess whether LPSF allows for greater neck pain relief when compared with laminoplasty for multilevel CSM in cohorts of patients with similar postoperative cervical lordosis. This study compared perioperative and follow- up outcomes of patients with matched cervical sagittal alignment who had undergone either laminoplasty or LPSF. The analysis of neck pain outcomes takes into con- sideration the presence of preoperative pain via subgroup analysis. Additionally, we attempted to define the relation- ship between cervical sagittal curvatures and neck pain FIG. 1. Postoperative neutral lateral cervical radiograph showing C3–7 outcomes. Hirabayashi (single-hinge door) laminoplasty. Methods tend to be patients who have a neutral or lordotic cervical Study Cohort spine, absence of listhesis (slip), and/or have a unilateral This study was formally approved by the Committee foraminal compression causing radiculopathy. In general, of Human Research at the University of California, San the decision to pursue either LPSF or laminoplasty was Francisco. A consecutive cohort of patients diagnosed case based and patient wishes were taken into account if with multilevel CSM based on physical examination and they fit indications for both procedures. radiographic imaging was identified from the time period January 2011 to December 2014. Patients who underwent Data Collection posterior decompression of the cervical spine via lamino- A comprehensive retrospective review of medical re- plasty or LPSF were identified and included in the study. cords was performed to gather data concerning patient Patients who underwent prior cervical spine surgery were demographics, clinical outcomes, and radiographic mea- excluded (the majority of whom were in the LPSF group). sures. Patient age and sex were recorded. Pain and neu- Matched cohorts of cervical lordosis were obtained by rological outcomes were reported based on the presence excluding patients with LPSF who had postoperative or absence of neck pain, visual analog scale (VAS) neck cervical sagittal Cobb angle measurements outside the pain score, and Nurick myelopathy score.17 The VAS was range of the patients in the laminoplasty group. Patients measured from 0 to 10, with 0 representing no pain and 10 underwent surgery by either 1 of 2 senior spine surgeons representing the worst pain. The radiographic outcomes (P.V.M. and D.C). All laminoplasties were performed with of interest were cervical lordosis, cervical sagittal vertical the Hirabayashi technique (single-hinge door; Fig. 1) with axis (SVA), and T-1 slope, which were all measured on plating and LPSF was performed with screw-rod fixation neutral upright lateral cervical spine radiographs. Cervi- (Fig. 2).6 The selection of which surgical technique to use cal lordosis was measured by the C2–7 Cobb angle (infe- was considered on an individual case-by-case basis. The rior endplate of C-2 to inferior endplate of C-7). Cervical indications to proceed with either LPSF or laminoplasty SVA was measured as the distance between a plumb line for patients with multilevel CSM depended on clinical from the C-2 centroid to a plumb line from the C-7 supe- symptoms and radiological findings. LPSF was offered rior posterior endplate. The T-1 slope was defined as the to patients who had significant neck pain and/or needed angle between a horizontal line and the superior end plate bilateral foraminotomies. Candidates for laminoplasties of T-1. The methodology of these measurements can be J Neurosurg Spine Volume 27 • November 2017 509 Unauthenticated | Downloaded 10/05/21 07:03 AM UTC D. Lau et al. who underwent LPSF. An additional analysis was per- formed to determine the relationship between degree of cervical lordosis and neck pain outcomes. For this analy- sis, patients were categorized into 5 groups based on post- operative cervical lordosis (<5°, 5°–10°, 11°–15°, 16°–20°, and > 20°). Pain outcomes were then compared in the total cohort, in laminoplasty patients, and in LPSF patients. A bivariate analysis was then performed to identify a cervi- cal lordosis threshold. Bivariate analyses were performed using either a chi-square test for categorical outcomes or a 2-tailed Student t-test for continuous outcomes. A p value < 0.050 was the threshold for statistical significance.
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