Enlarged laminectomy and lateral mass screw fixation for multilevel cervical degenerative myelopathy associated with kyphosis

Background contextEither an anterior approach or a posterior approach, which aims to decompress the spinal cord and restore the sagittal alignment, has been adopted to treat multilevel cervical degenerative myelopathy (CDM) associated with kyphosis. However, there is controversy on the optimal surgical strategy for the treatment of multilevel CDM with kyphotic deformity because of the complications of each surgical approach.PurposeThe purpose of this study was to investigate the surgical efficacy of enlarged laminectomy (removing the inside edge of facet joints and decompressing the nerve foramina) and lateral mass screw fixation for the treatment of multilevel CDM associated with kyphosis.Study designA retrospective radiographic and clinical study to access the efficacy of enlarged laminectomy with lateral mass screw fixation in the treatment of multilevel CDM related to kyphosis.Patient sampleA total of 43 patients (28 men and 15 women; average age, 59.6 years) with multilevel CDM correlated to kyphosis were obtained in the study.Outcome measuresAll radiological data were recorded on computer-based measurement from preoperative or postoperative X-ray, magnetic resonance imaging (MRI), and computed tomography. All neurological parameters were accessed in each patient.MethodsAnalysis consisted of: Japanese Orthopedic Association (JOA) score, recovery rate, curvature index (CI), the expansion degree and drift-back distance of the spinal cord, axial symptom severity, and C5 root palsy. The recovery rate based on the JOA score was calculated for each patient. Cervical CI as well as the expansion degree and drift-back distance of the spinal cord was measured using MRI. Axial symptom severity was quantified by a visual analog scale (VAS). Statistical analysis was performed using paired t test with significance set at p<.05.ResultsEnlarged laminectomy was performed over a mean of 3.97 levels (range, 3–5 levels). Follow-up information was obtained at a mean of 2.8 years (range, 1.5–5 years) after surgery. Analysis of the final follow-up data showed significant differences before and after surgery in the JOA score (t=24.17, p<.001), CI improvement (t=21.89, p<.001), the anteroposterior diameter at the level of maximum compression of the spinal cord (t=9.54, p<.001), and VAS score (t=13.30, p<.001). The mean spinal cord posterior shift was 4.72±1.10 mm (range, 0–6.71 mm). X-rays confirmed that bone grafts were completely fused at a mean of 3 months after surgery. During the follow-up period, only two patients (4.7%) did not obtain complete recovery, four patients (9.3%) experienced axial symptoms; there were no C5 root palsy and instrument failures noted in this series.ConclusionEnlarged laminectomy with fixation for the management of multilevel CDM is demonstrated to be an effective strategy for improving neurological function, restoring the normal cervical lordosis, and decreasing the incidence of axial symptoms and C5 root palsy, but there is a need for randomized controlled studies with long-term follow-up to confirm and clarify these results.     

Effectiveness of multiple-level decompression in laminoplasty and simultaneous C1 laminectomy for patients with cervical myelopathy

A retrospective study to investigate the relationship between the surgical levels and decompression effects was performed in patients with cervical myelopathy who had undergone Tension-band laminoplasty (TBL) with/without simultaneous C1 laminectomy. One hundred and sixty-eight patients (115 males, 53 females; age: 31–80 years, average 58.9 years; follow-up period: 12–120 months, average 20 months) were divided into three groups according to the range of the surgical levels: seventy-two patients in group A underwent TBL at the C2–C7 levels with C1 laminectomy; 60 patients in group B underwent TBL at the C2–C7 levels; 36 patients in group C underwent TBL at the C3–C7 levels. Neurological evaluation was performed by using the Japanese Orthopedic Association (JOA) scoring system. The alignment changes of the spinal column and the spinal cord were analyzed using pre- and post-operative roentgenograms and MRIs. The differences in the pre- and post-operative anterior subarachnoid spaces (D-ASAS), the spinal cord diameters (D-CORD), and the dural sleeve diameters (D-DURA) at the C1–C7 levels were also analyzed by using MRIs. The JOA scores improved in all groups. As for the spinal alignment, neither significant changes between pre- and post-operation in any group nor significant differences among the three groups were found. The lordosis of the cervical spinal cord was decreased in all groups. D-ASAS of group A was larger than that of group B at the C1–C5 levels (P<0.05), as were those of D-CORD and D-DURA at the C1–C2 and C4–C5 levels (P<0.05). D-ASAS of group A was larger than that of group C at the C1–C4 levels (P<0.05), as were those of D-CORD and D-DURA at the C1–C5 levels (P<0.05). In conclusion, laminoplasty including the C2–C7 levels with simultaneous C1 laminectomy was proven to allow the most posterior shift of the spinal cord within the widened dural sleeve at C5 or higher levels without significantly changing the spinal alignment.     

Laminoplasty versus laminectomy and fusion for cervical spondylotic myelopathy: a cost analysis

Background ContextLaminectomy with fusion (LF) and laminoplasty (LP) are commonly used to treat cervical spondylotic myelopathy (CSM). The decision regarding which procedure to perform is largely a matter of surgeon's preference, while financial implications are rarely considered.PurposeWe aimed to better understand the financial considerations of LF compared to LP in the treatment of CSM.Study DesignRetrospective comparative study.Patient SampleAdult patients, 18 years of age or older, who had undergone LF or LP for CSM from 2017 to 2019 at 2 large academic centers were included. Patients who had undergone previous cervical spine surgery or procedures that extended above C2 or below T2 were excluded.Outcome MeasuresThe primary outcome was defined as the total cost of the procedure, which was calculated as the sum of the implant and non-implant supply costs.MethodsPatient demographics, surgical parameters, including estimated blood loss and operative time, and length of stay were collected. Operating room material – both implant and non-implant – cost data was also obtained. Variables were analyzed individually as well as after adjustment based on the number of operative levels involved. Statistical analysis was performed using either Student t test with unequal variance or Wilcoxon rank sum test for continuous variables and chi-squared analysis for categorical variables.ResultsTwo hundred fifty patients were identified who met inclusion criteria. There was no statistical difference in the mean age at time of surgery (p=.25), gender distribution (p=.33), or re-operation rate between the LF and LP groups (p=.39). Overall, operative time was similar between the LF (165.7 ± 61.9 min) and LP (173.8 ± 58.2 min) groups (p=.29), but the LP cohort had a shorter length of stay at 3.8 ± 2.7 days compared to the LF cohort at 4.8 ± 3.7 days. Implant costs in the LF group were significantly more at $6,204.94 ± $1426.41 compared to LP implant costs at $1994.39 ± $643.09. Mean total costs of LP were significantly less at $2,859.08 ± $784.19 compared to LF total costs of $6,983.16 ± $1,589.17. Furthermore, when adjusted for the number of operative levels, LP remained significantly less costly at $766.12 ± $213.64 per level while LF cost $1,789.05 ± $486.66 per operative level. Additional subgroup analysis limiting the cohorts to patients with either three or four involved vertebral levels demonstrated nearly identical cost savings with LP as compared to LF.ConclusionsThis study demonstrates that LF is on average at least 2.4 times the total operative supply cost of LP and at least 2.3 times the operative supply cost of LP when adjusted for the number of operative levels. In patients deemed appropriate for either LP or LF, these data may be incorporated into decision-making for the treatment of CSM.     

Centerpiece单开门椎板成形术和椎板切除融合术治疗多节段颈脊髓病的临床疗效对比分析

目的：比较多节段颈脊髓病2种后路手术方式的临床疗效。方法回顾分析80例因多节段颈脊髓病行椎板成形术（A组）和椎板切除融合术（B组）的患者的资料,对2组患者术前、术后及随访时影像学资料和临床评价指标进行比较。结果术后1周2组日本骨科学会（ Japanese Orthopaedic Association , JOA）评分平均改善率差异无统计学意义（P＞0．05）,A组疼痛视觉模拟量表（visual analogue scale, VAS）评分、颈椎曲度与术前相比差异无统计学（P＜0．05）,B组则显著改善（P＜0．05）。术后1年B组JOA评分较术后1周显著降低（P＜0．05）,B组与术前颈椎活动度的差值显著大于A组（P＜0．01）。随访期间,A组C5神经麻痹的发生率为2．8％（1/36）,B组为12．5％（3/24）,差异有统计学意义（χ2＝3．35,P＜0．05）。结论2种方法早期都可取得良好的神经功能改善,在颈椎曲度、颈痛和活动度的影响上,两者各有优劣。     

超声骨刀在脊髓型颈椎病全椎板切除术中的应用

目的 :对比研究超声骨刀与高速磨钻应用于脊髓型颈椎病全椎板切除术的有效性与安全性。方法 :回顾性分析2014年1月~2015年12月我科收治的36例脊髓型颈椎病行全椎板切除术的患者临床资料,其中超声骨刀组16例(A组,男9例,女7例,年龄58.4±11.7岁)、高速磨钻组20例(B组,男11例,女9例,年龄61.6±12.4岁)。比较两组间手术节段、手术时间、术中出血量、术后引流量、术前及术后1周日本骨科学会(Japanese orthopedics association,JOA)评分、JOA评分改善率、围手术期并发症等指标。结果 :两组间手术节段、术前JOA无统计学差异(P0.05),A组和B组术中出血量分别为141.7±76.5ml和196.5±93.2ml,无统计学差异(P0.05);A组手术时间120.6±32.7min明显少于B组159.2±35.5min(P0.05);术后引流量为164.5±84.2ml明显低于B组的236.2±93.4ml(P0.05)。两组患者术后JOA评分(A组14.6±1.1分,B组14.5±1.6分)均优于术前(A组10.1±1.4分,B组10.8±2.1分,P0.05),但两组间术前、术后JOA评分及JOA评分改善率[A组(75.1±12.3)% VS B组(70.4±16.2)%]比较,无统计学差异(P0.05)。两组各发生硬膜囊撕裂1例,均无持续脑脊液漏及伤口感染病例。结论:脊髓型颈椎病全椎板切除术中应用超声骨刀可缩短手术时间及减少术后引流量,其安全性和有效性与高速磨钻相似。     

Anterior fusion alone compared with combined anterior and posterior fusion for the treatment of degenerative cervical kyphosis

We evaluated the efficacy of anterior fusion alone compared with combined anterior and posterior fusion for the treatment of degenerative cervical kyphosis. Anterior fusion alone was undertaken in 15 patients (group A) and combined anterior and posterior fusion was carried out in a further 15 (group B). The degree and maintenance of the angle of correction, the incidence of graft subsidence, degeneration at adjacent levels and the rate of fusion were assessed radiologically and clinically and the rate of complications recorded. The mean angle of correction in group B was significantly higher than in group A (p = 0.0009). The mean visual analogue scale and the neck disability index in group B was better than in group A (p = 0.043, 0.0006). The mean operation time and the blood loss in B were greater than in group A (p < 0.0001, 0.037). Pseudarthrosis, subsidence of the cage, and problems related to the hardware were more prevalent in group A than in group B (p = 0.034, 0.025, 0.013). Although the combined procedure resulted in a longer operating time and greater blood loss than with anterior fusion alone, our results suggest that for the treatment of degenerative cervical kyphosis the combined approach leads to better maintenance of sagittal alignment, a higher rate of fusion, a lower incidence of complications and a better clinical outcome.     

Cervical laminoplasty vs cervical laminectomy with fusion

Cervical spinal stenosis is a commonly encountered condition. Symptoms of radiculopathy are ameliorable to conservative measures. However, central canal stenosis in the setting of myelopathy is a disease warranting surgical intervention. To decompress the spinal cord, the canal needs to be expanded. Traditionally this can be accomplished via a laminectomy. The occurrence of postoperative deformity has led to the advent of other surgical techniques to address spinal stenosis. Both cervical laminoplasty and laminectomy with posterior fusion are available options that may prevent the progression of cervical instability or deformity or both. This article discusses the treatments available and outlines the benefits of each.     

Laminoplasty versus laminectomy and fusion for multilevel cervical myelopathy: an independent matched cohort analysis.

STUDY DESIGN: A matched cohort clinical and radiographic retrospective analysis of laminoplasty and laminectomy with fusion for the treatment of multilevel cervical myelopathy. OBJECTIVES: To compare the clinical and radiographic outcomes of two procedures increasingly used to treat multilevel cervical myelopathy. SUMMARY OF BACKGROUND DATA: Traditional methods of treating multilevel cervical myelopathy (laminectomy and corpectomy) are reported to have a notable frequency of complications. Laminoplasty and laminectomy with fusion have been advocated as superior procedures. A comparative study of these two techniques has not been reported. METHODS: Medical records of all patients treated for multilevel cervical myelopathy with either laminoplasty or laminectomy with fusion between 1994 and 1999 at our institution were reviewed. Thirteen patients that underwent laminectomy with fusion were matched with 13 patients that underwent laminoplasty. All patients and radiographs were independently evaluated at latest follow-up by a single physician. RESULTS: Cohorts were well matched based on patient age, duration of symptoms, and severity of myelopathy (Nurick grade) before surgery. Mean independent follow-up was similar (25.5 and 26.2 months). Both objective improvement in patient function (Nurick score) and the number of patients reporting subjective improvement in strength, dexterity, sensation, pain, and gait tended to be greater in the laminoplasty cohort. Whereas no complications occurred in the laminoplasty cohort, there were 14 complications in 9 patients that underwent laminectomy with fusion patients. Complications included progression of myelopathy, nonunion, instrumentation failure, development of a significant kyphotic alignment, persistent bone graft harvest site pain, subjacent degeneration requiring reoperation, and deep infection. CONCLUSIONS: The marked difference in complications and functional improvement between these matched cohorts suggests that laminoplasty may be preferable to laminectomy with fusion as a posterior procedure for multilevel cervical myelopathy.     

Comparison of ventral corpectomy and plate-screw-instrumented fusion with dorsal laminectomy and rod-screw-instrumented fusion for treatment of at least two vertebral-level spondylotic cervical myelopathy

The objective of the article is to verify the hypothesis that the dorsal multilevel laminectomy and rod-screw-instrumented fusion (DLF) for multilevel spondylotic cervical myelopathy (MSCM) is less strenuous for patients, and less prone to perioperative complications, than ventral multilevel corpectomy and plate-screw-instrumented fusion (VCF), while clinical outcome is comparable. One hundred and three successive patients were treated for at least two vertebral-level MSCM, 42 of them by VCF and 61 by DLF. The two patients groups were retrospectively compared. VCF patients were slightly younger than DLF patients (62.5 ± 10.61 years versus 66 ± 12.4 years, P = 0.012). In VCF patients, a median of 2 (2–3) corpectomies and in DLF patients a median of 3 (2–5) laminectomies were performed. In VCF patients, surgery lasted longer than in DLF patients (229 ± 60 min versus 183 ± 46 min, P ≤ 0.001). Between the VCF and the DLF patients groups, no significant difference was found in perioperative complications (e.g. hardware failure rates of 16.7% in VCF and of 6.6% in the DLF patients) and mortality rates. The postoperative outcome, as assessed by the postoperative change of the Nurick scores, the change of neck pain, the patients’ satisfaction, and the change of the subaxial Cobb angle of the spine did not differ between the two patients groups. However, when comparing the postoperative Nurick scores directly, VCF patients fared somewhat better than DLF patients [median of 2 (0–5) versus 3 (1–5), P = 0.003]. The hypothesized advantages of DLF over VCF in the surgical treatment of at least two vertebral-level MSCM could not be confirmed in this retrospective study. A prospective randomized study is warranted to clarify this issue.     

Influence of laminectomy on the course of cervical myelopathy

Summary The pathogenesis of cervical myelopathy resulting from cervical spondylarthrosis seems to be the result of intermittent compression of the cervical cord and its feeding arteries. In the literature proof is given that both factors play an important role. By laminectomy or ventral fusion a regression of the neurological disability can be obtained. In our series of 75 patients there was no significant difference in the results obtained by either partial or total laminectomy.In all our cases there was a narrowing of the sagittal spinal diameter.     

颈前路减压融合术治疗多节段颈椎病

目的报告颈前路减压融合术治疗多节段颈椎病的手术方法及临床疗效。方法回顾性分析自2003年8月-2008年1月期间,采用前路减压融合术治疗并获随访的28例多节段颈椎病患者,具体方法为间隙减压+椎体次全切除减压,取三面皮质自体髂骨或钛质网及椎间融合器(cage)填充切除病椎之松质骨置入,钢板固定。手术前后对患者进行JOA评分并计算改善率,并记录患者并发症。结果本组患者术中无并发症,随访18月～72个月。术后18月JOA评分平均改善率为75.2%,其中优11例,占39.3%;良9例,占32.1%;中8例,占28.6%;结论采用该术式的颈前路融合术治疗多节段颈椎病,减压直接彻底,恢复和重建颈椎生理曲度和病变节段椎间高度,坚强固定达到即刻稳定,疗效比较满意。     

Efficacy of combined anteroposterior fusion with no plate versus anterior fusion alone with cage and plate for multilevel degenerative cervical disease

Background contextMany studies have reported that anterior fusion alone has high rates of complications, such as pseudoarthrosis, graft subsidence, and graft dislodgement, with multisegmental constructs. No previous studies have compared the outcomes of combined anteroposterior fusion with no plate and anterior fusion alone with a cage and plate.PurposeTo compare the efficacy of combined anteroposterior fusion with that of anterior fusion alone for the treatment of multisegmental degenerative cervical disorder.Study designRetrospective study.Patient sampleSixty-two consecutive patients who underwent anterior fusion alone with a cage and plate or combined anteroposterior fusion with no plate for multisegmental (three or more segments) degenerative cervical disease.Outcome measureRadiological and clinical outcome measures.MethodsPatients in group A (n=36) underwent anterior fusion with a cage and plate construct (AFA); patients in group B (n=26) underwent combined anterior fusion with a cage and posterior fusion with a rod/screw construct (CAPF). The degree and maintenance of the correction angle, fusion rates, and adjacent level degeneration were assessed with radiographs. Clinical outcomes were assessed with a visual analog scale (VAS) and Neck Disability Index (NDI) scores, operative time, blood loss, and rates of complications.ResultsThe mean correction angle did not differ significantly between groups, but the loss of correction at final follow-up was greater in group A than group B (p=.001). Compared with group B, group A had a higher incidence of pseudarthrosis (p=.035), cage subsidence (p=.005), hardware-related complications (p=.032), and dysphagia (p=.012). The mean VAS score for arm pain and the mean NDI score were better for group B than group A (p=.0461, .0360), but the mean VAS score for posterior neck pain was better for group A than group B (p=.0352). Group B had greater blood loss and a longer operative time than group A (blood loss: p=.037; operative time: p=.0001).ConclusionsAlthough combined anterior/posterior fusion is associated with a longer operative time and greater blood loss than anterior fusion alone, the combined approach provides better maintenance of sagittal alignment, a higher rate of fusion, a lower incidence of cage subsidence and adjacent level disease, and better VAS and NDI scores.     

颈椎病前路减压融合后相邻节段退变原因分析

目的 :探讨颈椎病前路减压融合后相邻节段退变的因素。方法 :回顾分析行前路减压融合治疗的 34例脊髓型颈椎病患者的临床资料及影像学改变。结果 :随访 1～ 1 2年 ,平均 5年。 34例中 1 2例出现不同程度的相邻节段退变 ,其中 3例再次手术治疗。结论 :颈椎病前路减压融合后相邻节段退变的因素除与应力集中有关外 ,还与患者年龄、术前相邻节段退变情况、融合节段长度、重建的颈椎椎间高度及生理曲度等有关     

颈椎病患者退变颈椎骨基质代谢的变化

目的:分析颈椎病患者退变颈椎基质骨代谢变化,并探讨其退变的生物学机制。方法:收集16例手术治疗的脊髓型颈椎病患者的退变椎体,并随机取其中6例的外周血;另取5例急性脑死亡者正常椎体作为对照。放射免疫法测定透明质酸(HA)、层粘连蛋白(LN)、Ⅲ型前胶原、Ⅳ型胶原含量;全自动生化分析仪测定钙、磷和总蛋白质含量。结果:颈椎病患者的退变椎体中HA、LN、Ⅲ型前胶原、Ⅳ型胶原均较正常对照骨显著降低(P<0.01),并且排除了血液因素引起退变椎体骨基质成分的变化;退变椎体骨组织中钙、磷含量较正常骨中的含量也显著降低(P<0.01)。结论:颈椎在退变过程中骨基质成分明显减少,从而引起颈椎骨韧性、硬度的减低,可能是导致颈椎生物力学的改变和退变逐渐加重的生物学机制之一。     

有限椎板减压内固定治疗退行性腰椎管狭窄症的疗效分析

目的:探讨有限椎板切除减压内固定治疗退行性腰椎管狭窄症的疗效.方法:2002年9月～2007年3月共收治45例退行性腰椎管狭窄症患者,男16例,女29例,年龄36～80岁,平均61.3岁,病程5个月～20年,平均16个月.依据Hansraj等的经典与复杂型腰椎管狭窄症分型标准及引起症状的"责任"部位,经典的腰椎管狭窄症患者采用有限椎板切除椎管减压术(A组,14例):复杂型腰椎管狭窄症患者行有限椎板切除椎管减压并脊柱融合内固定术(B组,10例)或行全椎板切除减压并脊柱融合内固定术(C组,21例).采用日本骨科学会(JOA)15分法及Eule法对术前和末次随访时的神经功能与自觉症状进行评估,计算改善率,并对结果进行统计学分析.结果:随访9个月～5年,平均3.4年,末次随访时JOA评分改善率A组58.2%±34.0%,B组61.7%±23.6%,C组56.4%±26.8%,优良率A组78%,B组80%,C组76%,三组间无统计学差异.Eule法评估除A组与C组分别有1例术后疼痛加重外,其余病例腰腿痛症状均改善.结论:有限椎板切除减压是治疗退行性腰椎管狭窄症的一种可靠术式,只要把握好手术适应证与减压范围,无论单纯有限减压还是减压并植骨融合内固定均可获得良好的疗效.     

Cervical laminectomy and dentate ligament section for cervical spondylotic myelopathy.

Seventy-five patients who underwent surgical treatment for cervical spondylotic myelopathy were evaluated with respect to the operative procedure performed and their outcome. Forty patients underwent a laminectomy plus dentate ligament section (DLS), 18 underwent laminectomy alone, and 17 underwent an anterior cervical decompression and fusion (ACDF). The patients were evaluated postoperatively for both stability and for neurologic outcome using a modification of the Japanese Orthopaedic Association Assessment Scale. Functional improvement occurred in all but one patient in the laminectomy plus DLS group. The average improvement was 3.1 +/- 1.5 points in this group; whereas the average improvement in the laminectomy and the ACDF groups was 2.7 +/- 2.0 and 3.0 +/- 2.0 points respectively. All of the patients who improved substantially (greater than or equal to 6 points) in the laminectomy plus DLS and the laminectomy alone groups had normal cervical spine contours (lordosis). The remainder had either a normal lordosis or no curve (no kyphosis or lordosis). All patients in the ACDF group had either a straight spine or a cervical kyphosis. These factors implicate spine curvature, in addition to choice of operation, as factors which are important in outcome determination. No problems with instability occurred in either the laminectomy or the laminectomy plus DLS group. Two patients incurred problems with stability in the ACDF group. Both required reoperation. In addition, four patients in this group who initially improved, subsequently deteriorated. Six patients in the laminectomy plus DLS group had a several day febrile episode related to an aseptic meningitis process. Laminectomy plus DLS is a safe and efficacious alternative to laminectomy for the treatment of cervical spondylotic myelopathy. The data presented here suggests that myelopathic patients with a cervical kyphosis are best treated with an ACDF and that patients with a normal cervical lordosis are best treated with a posterior approach. Although some selected patients may benefit from DLS, no criteria are available which differentiate this small subset of patients.