Comparison of Laminoplasty vs. Laminectomy for Cervical Spondylotic Myelopathy: A Systematic Review and Meta-Analysis

Long-Term Outcomes of Modified Expansive Open-Door Laminoplasty Combined with Short-Level Anterior Cervical Fusion in Multilevel Cervical Spondylotic Myelopathy

Background and Objectives: Multilevel cervical spondylotic myelopathy (MCSM) presents complex challenges for surgical management, particularly in patients with kyphosis or significant anterior pathology. This study aimed to assess the long-term efficacy of modified expansive open-door laminoplasty (MEOLP) combined with short-level anterior cervical fusion (ACF) in providing decompression, preserving alignment, and maintaining range of motion (ROM) over a nine-year follow-up. Materials and Methods: A retrospective analysis was conducted on 124 MCSM patients treated with MEOLP combined with ACF between 2011 and 2015. MEOLP, a muscle-sparing posterior approach, was combined with ACF to correct sagittal misalignment and address anterior compression. Key outcome measures included the Pavlov ratio, C2-C7 angle, Japanese Orthopedic Association (JOA) score, and Visual Analog Scale (VAS) for neck pain. Patients were monitored for adjacent segment degeneration (ASD) and other postoperative changes over the long-term follow-up. Results: At nine years post-surgery, patients demonstrated significant improvements in decompression and cervical alignment. The mean C2-C7 angle increased, reflecting enhanced lordotic curvature, while the Pavlov ratio showed maintained canal expansion. JOA scores improved significantly, indicating reduced myelopathy symptoms, and VAS scores for neck pain decreased, reflecting symptom relief. Despite these positive outcomes, ASD was noted, especially in patients with reduced preoperative disk height, highlighting the need for strategies to mitigate degeneration at adjacent segments. Conclusions: MEOLP combined with short-level ACF is a viable and durable option for managing complex MCSM cases, offering effective decompression, alignment correction, and ROM preservation. The limitations of this study, including its retrospective, single-center design and the lack of quality-of-life assessments, underscore the need for future multi-center studies with broader outcome measures. These findings support MEOLP with ACF as an alternative approach in cases where traditional laminoplasty may be insufficient.

The Effect of C2 Muscular Exposure Technique on Radiographic and Clinical Outcomes After C2-T2 Posterior Cervical Fusion

STUDY DESIGN

Retrospective cohort analysis.

OBJECTIVE

To determine whether the C2 exposure technique was a predictor of change in cervical alignment and patient-reported outcomes measures (PROMs) after posterior cervical decompression and fusion (PCDF) for degenerative indications.

BACKGROUND

In PCDF handling of the C2 posterior paraspinal musculature during the operative approach varies by surgeon technique. To date, no studies have investigated whether maintenance of the upper cervical semispinalis cervicis attachments as compared with complete reflection of upper cervical paraspinal musculature from the posterior bony elements is associated with superior radiographic and clinical outcomes after PCDF.

PATIENTS AND METHODS

All adult patients who underwent C2-T2 PCDF for myelopathy or myeloradiculopathy at multi-institutional academic centers between 2013 and 2020 were retrospectively identified. Patients were dichotomized by the C2 exposure technique into semispinalis preservation or midline muscular reflection groups. Preoperative and short and long-term postoperative radiographic outcomes (upper cervical alignment, global alignment, and fusion status) and PROMs (Visual Analog Scale-Neck, Neck Disability Index, and Short Form-12) were collected. Univariate analysis compared patient factors, radiographic measures, and PROMs across C2 exposure groups.

RESULTS

A total of 129 patients met the inclusion/exclusion criteria (73 muscle preservation and 56 muscle reflection). Patients in the muscular preservation group were on average younger ( P = 0.005) and more likely to have bone morphogenic protein ( P < 0.001) and C2 pars screws ( P = 0.006) used during surgery. Preoperative to postoperative changes in C2 slope, C2 tilt, C2-C3 segmental lordosis, C2-C3 listhesis, C0-C2 Cobb angle, proximal junctional kyphosis, ADI, C1 lamina-occiput distance, C2 sagittal vertical axis, C2-C7 lordosis, and PROMs at all follow-up intervals did not vary significantly by C2 exposure technique. Likewise, there were no significant differences in fusion status, C2-C3 pseudoarthrosis, C2 screw loosening, and complication and revision rates between C2 exposure groups.

CONCLUSIONS

Preservation of C2 semispinalis attachments versus muscular reflection did not significantly impact cervical alignment, clinical outcomes, or proximal junction complications in long-segment PCDF.

LEVEL OF EVIDENCE

Level III.

Evaluation of Postoperative Kyphotic Changes in Patients Who Underwent Cervical Laminectomy

BACKGROUND

The stenosis of the cervical canal due to spondylotic changes is one of the common causes of spinal cord compression. Without adequate treatment, it results in progressive neurological deterioration. However, despite the wide acceptance of newer techniques, such as laminoplasty and laminectomy with fusion, in most situations, especially in resource-constraint situations, the role of laminectomy alone is pertinent. The following study reviews the effectiveness and safety of laminectomy alone in patients with cervical spondylotic myelopathy.

METHODS

A retrospective cohort study was conducted at Par Private Hospital, Erbil, including 46 patients diagnosed with cervical canal stenosis. All patients underwent laminectomy without fusion or laminoplasty, and postoperative outcomes were assessed using the modified Japanese Orthopaedic Association (mJOA) score, Neck Disability Index (NDI), and radiographic evaluations of cervical alignment. The relationship between preoperative and postoperative cervical alignment, kyphosis progression, and clinical outcomes was analyzed.

RESULTS

Most patients showed significant neurological improvement in accordance with the improvement of scores of both mJOA and NDI. Among them, radiographic kyphosis progression occurred in 40% of patients, which was not associated with clinical deterioration. This showed a remarkable correlation between preoperative cervical alignment and postoperative outcomes, with R² = 0.733 and p < 0.001. No major complications like C5 palsy or wound infection were recorded throughout the follow-up period.

CONCLUSION

Laminectomy alone constitutes a proper and safe surgical alternative for cervical canal stenosis, especially in resource-poor countries. Although kyphosis progression occurred in some cases, there was no clinical impairment. Careful selection of patients by preoperative alignment is important for favorable outcomes. Comparing laminectomy alone with other techniques in longer follow-up will provide the final result in larger, multi-institutional groups.

Laminoplasty Versus Laminectomy and Posterior Fusion for Cervical Myelopathy : A Meta-Analysis of Radiographic and Clinical Outcomes

STUDY DESIGN

Meta-analysis.

OBJECTIVE

This meta-analysis investigates the outcomes of laminoplasty (LP) and laminectomy with fusion (LF) to guide effective patient selection for these 2 procedures.

BACKGROUND

Although LF traditionally offers the ability for excellent posterior decompression, it may alter cervical spine biomechanics and increase the risk of adjacent segment degeneration. LP aims to preserve the natural kinematics of the spine but has not been universally accepted, and may be associated with inadequate decompression, neck pain, and recurrent stenosis.

MATERIALS AND METHODS

PubMed, Cochrane, and Google Scholar (pages 1-20) were searched up until March 2024. The outcomes studied were surgery-related outcomes [operative time (OR) time, estimated blood loss (EBL), and length of stay], adverse events (overall complications, C5 palsy, and reoperations), radiographic outcomes (cervical lordosis, cervical sagittal vertical axis, and T1 slope angle), and patient-reported outcome measures (Neck Disability Index, Visual Analog Scale for neck pain, and Japanese Orthopaedic Association).

RESULTS

Twenty-two studies were included in this meta-analysis, of which 19 were retrospective studies, 2 were prospective nonrandomized studies, and 1 was a randomized controlled trial. A total of 2128 patients were included, with 1025 undergoing LP and 1103 undergoing LF. Patients undergoing LP experienced significantly shorter operative time ( P = 0.009), less EBL ( P = 0.02), a lower rate of overall complications ( P < 0.00001) and C5 palsy ( P = 0.003), a lower T1 slope angle ( P = 0.02), and a lower Neck Disability Index ( P = 0.0004). No significant difference was observed in the remaining outcomes.

CONCLUSION

This meta-analysis demonstrates that for cervical myelopathy, LP has the benefits of shorter operative time time, less EBL, and reduced incidence of C5 palsy as well as overall complication rate. Given these findings, LP remains an important surgical option with a favorable complication profile in patients with cervical myelopathy, although careful patient selection is still paramount in choosing the right procedure for individual patients.

LEVEL OF EVIDENCE

4.

Radiographic characterization of OPLL progression in patients receiving laminoplasty with a minimum of two-years follow-up

Ossification of the posterior longitudinal ligament (OPLL) is a common cause of degenerative cervical myelopathy (DCM) in Asian populations. Characterization of OPLL progression following laminoplasty remains limited in the literature. 29 patients with OPLL received cervical laminoplasty and a minimum of 2-years follow-up. Clinical and radiological surveillance occurred at 3-months, 6-months, 12-months post-op and then at yearly intervals. Transverse (anteroposterior) diameter and sagittal length of OPLL in relation to their cervical vertebral level of localisation was assessed upon immediate post-op radiographs compared to those obtained at subsequent follow-up. OPLL progression was defined as an increase in transverse dimensions and/or length by ≥ 2 mm. The average period of clinical follow-up was 6.7 ± 3.3 years. Upon latest follow-up, 79% of patients demonstrated at least 2 mm of transverse or longitudinal progression of OPLL. This corresponded to 2-years and 5-year progression rates of 54% and 71% respectively. OPLL located over C5 demonstrated the greatest transverse progression rate at (0.24 ± 0.34 mm / year). The mean overall longitudinal progression rate was 1.61 ± 2.06 mm / year. No patients experienced neurological decline resulting from OPLL progression requiring revision decompression during the period of post-operative observation. Characterizing transverse and longitudinal progression by cervical level via radiographs has implications in surgical planning for OPLL and should be consolidated upon post-operative CT/MRI scans as well as larger sample sizes.

Cervical kyphosis after posterior cervical laminectomy with and without fusion

BACKGROUND

Cervical posterior instrumentation and fusion is often performed to avoid post-laminectomy kyphosis. However, larger comparative analyses of cervical laminectomy with or without fusion are sparse.

METHODS

A retrospective, two-center, comparative cohort study included patients after stand-alone dorsal laminectomy with (n = 91) or without (n = 46) additional fusion for degenerative cervical myelopathy with a median follow-up of 59 (interquartile range (IQR) 52) months. The primary outcome was the C2-7 Cobb angle and secondary outcomes were Neck Disability Index (NDI), modified Japanese Orthopaedic Association (mJOA) scale, revision rates, T1 slope and C2-7 sagittal vertical axis (C2-7 SVA) at final follow-up. Logistic regression analysis adjusted for potential confounders (i.e. age, operated levels, and follow-up).

RESULTS

Preoperative C2-7 Cobb angle and T1 slope were higher in the laminectomy group, while the C2-7 SVA was similar. The decrease in C2-7 Cobb angle from pre- to postoperatively was more pronounced in the laminectomy group (- 6° (IQR 20) versus -1° (IQR 7), p = 0.002). When adjusting for confounders, the decrease in C2-7 Cobb angle remained higher in the laminectomy group (coefficient - 12 (95% confidence interval (CI) -18 to -5), p = 0.001). However, there were no adjusted differences for postoperative NDI (- 11 (- 23 to 2), p = 0.10), mJOA, revision rates, T1 slope and C2-7 SVA.

CONCLUSION

Posterior cervical laminectomy without fusion is associated with mild loss of cervical lordosis of around 6° in the mid-term after approximately five years, however without any clinical relevance regarding NDI or mJOA in well-selected patients (particularly in shorter segment laminectomies of < 3 levels).

Racial and Socioeconomic Disparities in Laminoplasty Versus Laminectomy With Fusion in Patients With Cervical Spondylosis

STUDY DESIGN

A retrospective cohort study using prospectively collected data.

OBJECTIVE

The aim of this study was to investigate preoperative differences in racial and socioeconomic factors in patients undergoing laminoplasty (LP) versus laminectomy and fusion (LF) for degenerative cervical myelopathy (DCM).

SUMMARY OF BACKGROUND DATA

DCM is prevalent in the United States, requiring surgical intervention to prevent neurological degeneration. While LF is utilized more frequently, LP is an emerging alternative. Previous studies have demonstrated similar neurological outcomes for both procedures. However, treatment selection is primarily at the discretion of the surgeon and may be influenced by social determinants of health that impact surgical outcomes.

MATERIALS AND METHODS

The Quality Outcome Database (QOD), a national spine registry, was queried for adult patients who underwent either LP or LF for the management of DCM. Covariates associated with socioeconomic status, pain and disability, and demographic and medical history were collected. Multivariate logistic regression was performed to assess patient factors associated with undergoing LP versus LF.

RESULTS

Of 1673 DCM patients, 157 (9.4%) underwent LP and 1516 (90.6%) underwent LF. A significantly greater proportion of LP patients had private insurance (P<0.001), a greater than high school level education (P<0.001), were employed (P<0.001), and underwent primary surgery (P<0.001). LP patients reported significantly lower baseline neck/arm pain and Neck Disability Index (P<0.001). In the multivariate regression model, lower baseline neck pain [odds ratio (OR)=0.915, P=0.001], identifying as non-Caucasian (OR=2.082, P<0.032), being employed (OR=1.592, P=0.023), and having a greater than high school level education (OR=1.845, P<0.001) were associated with undergoing LP rather than LF.

CONCLUSIONS

In DCM patients undergoing surgery, factors associated with patients undergoing LP versus LF included lower baseline neck pain, non-Caucasian race, higher education, and employment. While symptomatology may influence the decision to choose LP over LF, there may also be socioeconomic factors at play. The trend of more educated and employed patients undergoing LP warrants further investigation.

Emerging Technologies within Spine Surgery

New innovations within spine surgery continue to propel the field forward. These technologies improve surgeons' understanding of their patients and allow them to optimize treatment planning both in the operating room and clinic. Additionally, changes in the implants and surgeon practice habits continue to evolve secondary to emerging biomaterials and device design. With ongoing advancements, patients can expect enhanced preoperative decision-making, improved patient outcomes, and better intraoperative execution. Additionally, these changes may decrease many of the most common complications following spine surgery in order to reduce morbidity, mortality, and the need for reoperation. This article reviews some of these technological advancements and how they are projected to impact the field. As the field continues to advance, it is vital that practitioners remain knowledgeable of these changes in order to provide the most effective treatment possible.

Nationwide sample data analysis of additional surgery rate after anterior or posterior cervical spinal surgery

Surgical outcomes of degenerative cervical spinal disease are dependent on the selection of surgical techniques. Although a standardized decision cannot be made in an actual clinical setting, continued education is provided to standardize the medical practice among surgeons. Therefore, it is necessary to supervise and regularly update overall surgical outcomes. This study aimed to compare the rate of additional surgery between anterior and posterior surgeries for degenerative cervical spinal disease using the National Health Insurance Service-National Sample Cohort (NHIS-NSC) nationwide patient database. The NHIS-NSC is a population-based cohort with about a million participants. This retrospective cohort study included 741 adult patients (> 18 years) who underwent their first cervical spinal surgery for degenerative cervical spinal disease. The median follow-up period was 7.3 years. An event was defined as the registration of any type of cervical spinal surgery during the follow-up period. Event-free survival analysis was used for outcome analysis, and the following factors were used as covariates for adjustment: location of disease, sex, age, type of insurance, disability, type of hospital, Charles comorbidity Index, and osteoporosis. Anterior cervical surgery was selected for 75.0% of the patients, and posterior cervical surgery for the remaining 25.0%. Cervical radiculopathy due to foraminal stenosis, hard disc, or soft disc was the primary diagnosis in 78.0% of the patients, and central spinal stenosis was the primary diagnosis in 22.0% of them. Additional surgery was performed for 5.0% of the patients after anterior cervical surgery and 6.5% of the patients after posterior cervical surgery (adjusted subhazard ratio, 0.83; 95% confidence interval, 0.40-1.74). The rates of additional surgery were not different between anterior and posterior cervical surgeries. The results would be helpful in evaluating current practice as a whole and adjusting the health insurance policy.

Predictors for cervical kyphotic deformity following laminoplasty: a systematic review and meta-analysis

OBJECTIVE

Laminoplasty is a common treatment for cervical spondylotic myelopathy (CSM) and for ossification of the posterior longitudinal ligament (OPLL). However, approximately 21% of patients undergoing laminoplasty develop cervical kyphotic deformity (KD). Because of the high prevalence rate of KD, several studies have sought to identify predictors for this complication, but the findings remain highly inconsistent. Therefore, the authors performed a systematic review and meta-analysis to establish reliable preoperative predictors of KD.

METHODS

PubMed, Scopus, and Web of Science databases were used to systematically extract potential references. The first phase of screening required the studies to be written in the English language, involve patients treated for CSM and/or OPLL via laminoplasty, and report postoperative cervical KD. The second phase required the studies to provide more than 10 patients and include a control group. The mean difference (MD) and odds ratio (OR) were calculated for continuous and dichotomous parameters. Study quality was evaluated using the Newcastle-Ottawa Scale. CSM and OPLL patients were further assessed by performing subgroup analyses.

RESULTS

Thirteen studies comprising patients who developed cervical KD (n = 296) and no KD (n = 1254) after receiving cervical laminoplasty for CSM or OPLL were included in the meta-analysis. All studies were retrospective cohorts and were rated as high quality. In the combined univariate analysis of CSM and OPLL patients undergoing laminoplasty, statistically significant predictors for postoperative KD included age (MD 2.22, 95% CI 0.16-4.27, p = 0.03), preoperative BMI (MD 0.85, 95% CI 0.06-1.63, p = 0.04), preoperative C2-7 range of flexion (MD 10.42, 95% Cl 4.24-16.59, p = 0.0009), preoperative C2-7 range of extension (MD -4.59, 95% CI -6.34 to -2.83, p < 0.00001), and preoperative center of gravity of the head to the C7 sagittal vertical axis (MD 26.83, 95% CI 9.13-44.52, p = 0.003). Additionally, among CSM patients, males were identified as having a greater risk for postoperative KD (OR 1.73, 95% CI 1.02-2.93, p = 0.04).

CONCLUSIONS

The findings from this study currently provide the largest and most reliable review on preoperative predictors for cervical KD after laminoplasty. Given that several of the included studies identified optimal cutoff points for the variables that are significantly associated with KD, further investigation into the development of a preoperative risk scoring system that can accurately predict KD in the clinical setting is encouraged. PROSPERO registration no.: CRD42022299795 (https://www.crd.york.ac.uk/PROSPERO/).