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Spinal Posterior Movement After Posterior Cervical Decompression Surgery: Clinical Findings and Factors Affecting Postoperative Functional Recovery

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Spinal Posterior Movement After Posterior Cervical Decompression Surgery: Clinical Findings and Factors Affecting Postoperative Functional Recovery ■ Feature Article Spinal Posterior Movement After Posterior Cervical Decompression Surgery: Clinical Findings and Factors Affecting Postoperative Functional Recovery GANG XIA, MD; RONG TIAN, MD; TIANTONG XU, MD; HUIMING LI, MD; XUELI ZHANG, MD abstract Full article available online at ORTHOSuperSite.com. Search: 0000020111021-03 This study investigated the posterior movement of the spinal cord after posterior de- compression surgery and evaluated factors affecting postoperative functional recovery in patients with cervical spondylotic myelopathy (CSM). Thirty-two patients with CSM underwent posterior decompression from C3 to C7 through laminectomy (nϭ12) and single, open-door laminoplasty (nϭ20). There were no signifi cant differences between laminectomy and laminoplasty in degree of spinal posterior movement, recovery rate, A and curvature index. Japanese Orthopedic Association (JOA) scores improved from pre- operative (10.63Ϯ1.77; range, 7-14) to 3-months postoperative (13.57Ϯ1.50; range, 11-16) (nϭ32, PϽ.05) and from preoperative (10.24Ϯ1.87; range, 7-14) to 6-months postoperative (14.16Ϯ1.54; range, 12-16) (nϭ21) (PϽ.05). C5 palsy was observed in 1 (3.1%) patient. The vertebral body-to-spinal cord distances signifi cantly increased after operations, with the greatest posterior movement at C5 and the least posterior move- ment at C3 and C7. However, the difference in the degree of the spinal movement of C3 to C7 was not statistically signifi cant (PϾ.05). Furthermore, no correlation was found between the magnitude of spinal posterior movement and the curvature index. In addition, the magnitude of posterior movement and age were not correlated with the postoperative JOA improvement, but the preoperative JOA scores were. B Our study shows that both laminectomy and laminoplasty can produce a similar de- Figure: Pre- (A) and postoperative (B) radiographs gree of posterior movement of the spinal cord. Cervical lordosis is not associated with of the cervical spine of patients who underwent laminectomy. the posterior movement of the cord. The preoperative JOA scores, but not posterior movement of the cord and age, are important determinants for postoperative outcome. Drs Xia, Tian, Xu, Li, and Zhang are from the Department of Orthopedics, Tianjin Union Medical Center, Tianjin, China. Drs Xia, Tian, Xu, Li, and Zhang have no relevant fi nancial relationships to disclose. The authors thank Dr. Xinlong Ma for helpful discussion, and Dr. Jun Yang from Department of Radiology for technical assistance with radiological measurement. Correspondence should be addressed to: Gang Xia, MD, Department of Orthopedics, Tianjin Union Medical Center, 190 Jieyuan Rd, Tianjin 300121, China ([email protected]). doi: 10.3928/01477447-20111021-03 DECEMBER 2011 | Volume 34 • Number 12 e911 ■ Feature Article ervical spondylotic myelopathy (CSM) is a common degenerative Cdisease that affects the elderly. Narrowing of the spinal canal with age leads to compression of the spinal cord, which can cause a variety of symptoms, including pain, numbness, and weakness. Surgery is often required to widen the spi- nal canal to release the compression of the spinal cord, especially when the clinical symptoms are severe and progressive and 1A 1B when the conservative treatment, such as acupuncture, physical therapy, and vari- ous traction methods, as well as analge- sic medications and neuromodulating medications, is not effective in relieving the pain and other symptoms.1-3 Posterior decompression surgery, including lami- nectomy and laminoplasty, has been used in clinics to allow the spinal cord to move backward to keep it clear of anterior com- 3,4 pression. 1C 1D However, the mechanism of the pos- Figure 1: Plain radiographs of the cervical spine of patients who underwent laminectomy (A, B) and lami- terior movement of the spinal cord post- noplsty (C, D) preoperatively (A, C) and 3 months postoperatively (B, D). operatively remains unclear. The posterior movement of spinal cord is hypothesized to result from the bowstring effect with an MATERIALS AND METHODS SURGICAL TECHNIQUE increased tension in the spinal cord after Thirty-two patients (22 men and 10 We performed a laminectomy or single, the posterior decompression surgery wid- women) who underwent laminectomy open-door laminoplasty. Laminoplasty ens the spinal canal.5-7 The spinal cord (n=12) and single, open-door laminoplas- was preferred by the surgeons, but lami- (bowstring) moves backward by itself in ty (n=20) at C3-C7 were included in this nectomy was performed in patients with response to the change of cervical lordosis study. The average age at operation was severe spinal stenosis, a broken hinge (bow) after the posterior decompression 51 years (range, 29-73 years). All patients during laminoplasty, or a thin and frag- surgery. However, the feasibility of the presented with symptoms of neural com- ile lamina that is diffi cult to use to form bowstring effect of the spinal cord has not pression, and magnetic resonance imag- a hinge. been clearly demonstrated. ing (MRI) fi ndings were consistent with The patient was placed in a prone posi- In addition, the clinical signifi cance CSM. tion on an operating table. A midline ap- of posterior movement of the spinal This study selected patients with CSM proach was made to expose the spinous cord after posterior decompression who had progressive neurological symp- process. For laminectomies, lateral gutters surgery remains controversial. Some toms, alterations of bladder function, and were created at the medial margin of bilat- studies have reported that the degree of multilevel cervical involvement. Patients eral intervertebral joints, and the C3-C7 posterior movement is associated with with spinal cord injuries due to acute trau- lamina were then taken out by removing the postoperative outcome,8,9 whereas matic injuries, ossifi cation of the posterior the outer cortex, cancellous bone, and in- others have reported that the degree longitudinal ligament, and tumors were ner cortex. The posterior wall of the spinal of movement is not.4 We performed excluded. All patients underwent plain canal was completely removed by this sur- laminectomy and laminoplasty on 32 radiographs and MRIs preoperatively and gery (Figure 1A, B). For single, open-door patients with cervical spondylotic my- were followed-up 3 months postoperative- laminoplasty, lateral gutters were created elopathy to investigate the posterior ly. The MRIs and plain radiographs for all at the medial margin of the bilateral inter- movement of the spinal cord and its as- patients were also performed at 3 months vertebral joints. The gutter on the lateral sociated postoperative outcome. postoperatviely during the follow-up. margin of the lamina was completed fi rst e912 ORTHOPEDICS | ORTHOSuperSite.com SPINAL MOVEMENT AFTER POSTERIOR CERVICAL DECOMPRESSION| XIA ET AL 2A 3A 4A 2B Figure 2: The enlargement and expansion of the spinal cord during laminectomy (A) after the lami- na was removed, and during laminoplasty (B) after the lamina door was opened. on the open side to remove the outer cor- 4B tex, cancellous bone, and inner cortex. On Figure 4: The measurement of cervical curvature the hinge side, the inner cortex and part of index in a diagram (A) and in a sagittal MRI (B). the cancellous bone remained. The lamina door was opened by carefully moving the 3B lamina on the open side laterally toward the the TE was 112 ms and the TR was 4500 Figure 3: The measurement of the distance from hinge side. The lamina was fi xed to the sur- the posterior surface of the vertebral body to the ms. In the sagittal plane, the fi eld of view rounding ligament and muscle, and bones anterior surface of the spinal cord on sagittal mag- was 28 cm, and the slice thickness was trimmed from spinous processes were netic resonance images preoperatively (A) and 3 set at 3 mm with a spacing of 0.5 mm. grafted into the hinges to secure the expan- months postoperatively (B). To estimate the magnitude of posterior sion of the spinal canal (Figure 1C, D). movement of the spinal cord, the distance During the posterior decompression preoperative score)/(17–preoperative from the posterior surface of the vertebral surgery, the enlargement and expansion score)ϫ100%. The patients were catego- body to the anterior surface of the spinal of the spinal cord was observed after the rized into 2 groups according to the recov- cord (vertebral body-to-spinal cord dis- lamina was removed for laminectomy ery rate: an excellent group with recovery tance) was measured using T1-weighted (Figure 2A) and after the lamina door was rate у33% and a fair group with recovery sagittal MRIs (Figure 3). The degree of opened for laminoplasty (Figure 2B). rate р33%. postoperative posterior movement of the The MRI study was produced by a spinal cord was calculated by the differ- Evaluation 1.5-T MRI device (Philips, Best, The ence between the pre- and postoperative For each patient, neurologic functions Netherlands). T1-weighted images were vertebral body-to-spinal cord distances. were evaluated pre- and postoperatively captured by the spin-echo method in To quantify postoperative cervical lordo- according to the Japanese Orthopedic which the echo time (TE) was 12 ms, and sis, a cervical curvature index was cal- Association (JOA). The recovery rate the repetition time (TR) was 500 ms. T2- culated using postoperative MRI (Figure was calculated according to the equation: weighted images were captured by the 4) according to the equation: curvature recovery rate=(postoperative score– fast spin echo sequence method in which index=100ϫ(a1ϩa2ϩa3ϩa4)/A. DECEMBER 2011 | Volume 34 • Number 12 e913 ■ Feature Article Statistical Analysis The values were presented as means Table 1 and standard deviations. Student’s t test Surgical Outcome of Laminectomy and Laminoplasty and analysis of variance (ANOVA) were at 3 Months Postoperatively used for comparison of the difference in the means. A paired t test was used (MeanϮSD) to assess the statistical signifi cance be- Preoperative Curvature Posterior tween pre- and postoperative JOA scores.
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