Results of laminoplasty versus laminectomy and posterior fusion for multilevel cervical spondylotic myelopathy

Background

The authors compared the clinical, MR, and clinical outcomes for patients with multilevel cervical spondylotic myelopathy (MCSM) who underwent laminoplasty (LP) versus laminectomy with fusion (LPSF).

Materials and methods

The authors evaluated 65 patients with MCSM (2019-2021) with 31 undergoing LP versus 34 having LPSF. Variables studied included JOA scores, T2W MR hyperintense cord signals, preoperative lordosis, number of stenotic levels, and neurological outcomes.

Results

Both groups showed similar preoperative JOA scores, number of stenotic levels, T2-weighted MR hyperintense cord signals, and nearly identifcal 12-month postoperative outcomes (good for 83.9 in the LP group vs. 85.3% in the LPSF group). Differences included: higher preoperative visual analog scale in the LPSF versus LP group, plus the LPSF patients significantly less preoperative cervical lordosis versus LP patients.

Conclusion

LP and LPSF used to treat MCSM resulted in similar clinical improvement and 1-year postoperative outcomes. However, our recommendation would be for patients with neck pain, instability, and/or cervical kyphosis to undergo LPSF.

A randomized controlled study of two different fixations in anterior cervical discectomy of multilevel cervical spondylotic myelopathy

Background: To compare the efficacy of anterior cervical discectomy and hybrid fusion (ACDHF) with short-segment plate plus self-locking, stand-alone intervertebral cages versus traditional anterior cervical discectomy and fusion (ACDF) with long-segment plate for multilevel cervical spondylotic myelopathy (MCSM). Methods: All the patients were randomly divided into two groups. 30 cases underwent ACDHF with short-segment plate and self-locking stand-alone cages (hybrid group), while the other 30 cases received ACDF with long-segment plate (control group). In patients meeting the inclusion and exclusion criteria, operation time, blood loss, postoperative drainage volume, length of stay (LOS), visual analogue scale for neck pain (VASNP) scores, Japanese Orthopaedic Association (JOA) score, and the cervical lordosis before and after the operation (5 days, 3, 6, 12 months after operation and final follow-up) were evaluated. The postoperative complications were analyzed as well. Results: All operations were performed uneventfully with followed-up. Compared with ACDF, ACDHF showed a shorter operation time, less intraoperative blood loss and postoperative drainage (p < 0.05). There were no significant difference in LOS between two groups (p ˃ 0.05). Both approaches significantly improved the JOA scores, VASNP scores and the cervical lordosis (p < 0.05). Based on Bazaz grading system, hybrid group had a lower incidence of dysphagia than control group in follow-up periods of 5 days, 3 and 6 months (p < 0.05). Conclusion: ACDF and ACDHF are both effective methods of restoring cervical lordosis following MCSM, but hybrid surgery minimizes intraoperative injury and postoperative dysphagia, making it a viable treatment option for the disorder.

[Effectiveness of three-dimensional printing artificial vertebral body and interbody fusion Cage in anterior cervical surgery]

Objective

To evaluate the effectiveness of three-dimensional (3D) printing artificial vertebral body and interbody fusion Cage in anterior cervical disectomy and fusion (ACCF) combined with anterior cervical corpectomy and fusion (ACDF).

Methods

The clinical data of 29 patients with multilevel cervical spondylotic myelopathy who underwent ACCF combined with ACDF between May 2018 and December 2019 were retrospectively analyzed. Among them, 13 patients were treated with 3D printing artificial vertebral body and 3D printing Cage as 3D printing group and 16 patients with ordinary titanium mesh Cage (TMC) and Cage as TMC group. There was no significant difference in gender, age, surgical segment, Nurick grade, disease duration, and preoperative Japanese Orthopaedic Association (JOA) score, visual analogue scale (VAS) score, and Cobb angle of fusion segment between the two groups ( P>0.05). The operation time, intraoperative blood loss, hospitalization stay, complications, and implant fusion at last follow-up were recorded and compared between the two groups; JOA score was used to evaluate neurological function before operation, immediately after operation, at 6 months after operation, and at last follow-up; VAS score was used to evaluate upper limb and neck pain. Cobb angle of fusion segment was measured and the difference between the last follow-up and the immediate after operation was calculated. The height of the anterior border (HAB) and the height of the posterior border (HPB) were measured immediately after operation, at 6 months after operation, and at last follow-up, and the subsidence of implant was calculated.

Results

The operation time of 3D printing group was significantly less than that of TMC group ( t=3.336, P=0.002); there was no significant difference in hospitalization stay and intraoperative blood loss between the two groups ( P>0.05). All patients were followed up 12-19 months (mean, 16 months). There was no obvious complication in both groups. There were significant differences in JOA score, VAS score, and Cobb angle at each time point between the two groups ( P<0.05). There was an interaction between time and group in the JOA score ( F=3.705, P=0.025). With time, the increase in JOA score was different between the 3D printing group and the TMC group, and the increase in the 3D printing group was greater. There was no interaction between time and group in the VAS score ( F=3.038, P=0.065), and there was no significant difference in the score at each time point between the two groups ( F=0.173, P=0.681). The time of the Cobb angle interacted with the group ( F=15.581, P=0.000). With time, the Cobb angle of the 3D printing group and the TMC group changed differently. Among them, the 3D printing group increased more and the TMC group decreased more. At last follow-up, there was no significant difference in the improvement rate of JOA score between the two groups ( t=0.681, P=0.502), but the Cobb angle difference of the 3D printing group was significantly smaller than that of the TMC group ( t=5.754, P=0.000). At last follow-up, the implant fusion rate of the 3D printing group and TMC group were 92.3% (12/13) and 87.5% (14/16), respectively, and the difference was not significant ( P=1.000). The incidence of implant settlement in the 3D printing group and TMC group at 6 months after operation was 15.4% (2/13) and 18.8% (3/16), respectively, and at last follow-up were 30.8% (4/13) and 56.3% (9/16), respectively, the differences were not significant ( P=1.000; P=0.264). The difference of HAB and the difference of HPB in the 3D printing group at 6 months after operation and last follow-up were significantly lower than those in the TMC group ( P<0.05).

Conclusion

For patients with multilevel cervical spondylotic myelopathy undergoing ACCF combined with ACDF, compared with TMC and Cage, 3D printing artificial vertebrae body and 3D printing Cage have the advantages of shorter operation time, better reduction of height loss of fusion vertebral body, and maintenance of cervical physiological curvature, the early effectiveness is better.

Comparison of the anterior and posterior approach in treating four-level cervical spondylotic myelopathy

BACKGROUND

The optimal surgical approach for four-level cervical spondylotic myelopathy remains controversial. The purpose of this study was to compare clinical and radiological outcomes and complications between the anterior and posterior approaches for four-level cervical spondylotic myelopathy.

METHODS

A total of 19 patients underwent anterior decompression and fusion and 25 patients underwent posterior laminoplasty and instrumentation in this study. Perioperative information, intraoperative blood loss, clinical and radiological outcomes, and complications were recorded. Japanese Orthopedic Association (JOA) score, 36-item short form survey (SF-36) score and cervical alignment were assessed.

RESULTS

There were no significant differences in JOA scores between the anterior and posterior group preoperatively (11.6 ± 1.6 vs. 12.1 ± 1.5), immediately postoperatively (14.4 ± 1.1 vs. 13.8 ± 1.3), or at the last follow-up (14.6 ± 1.0 vs. 14.2 ± 1.1) (P > 0.05). The JOA scores significantly improved immediately postoperatively and at the last follow-up in both groups compared with their preoperative values. The recovery rate was significantly higher in the anterior group both immediately postoperatively and at the last follow-up. The SF-36 score was significantly higher in the anterior group at the last follow-up compared with the preoperative value (69.4 vs. 61.7). Imaging revealed that there was no significant difference in the Cobb angle at C2-C7 between the two groups preoperatively (-2.0° ± 7.3° vs. -1.4° ± 7.5°). The Cobb angle significantly improved immediately postoperatively (12.3° ± 4.2° vs. 9.2° ± 3.6°) and at the last follow-up (12.4° ± 3.5° vs. 9.0° ± 2.6°) in both groups compared with their preoperative values (P = 0.00). Three patients had temporary dysphagia in the anterior group and four patients had persistent axial symptoms in the posterior group.

CONCLUSIONS

Both the anterior and posterior approaches were effective in treating four-level cervical spondylotic myelopathy in terms of neurological clinical outcomes and radiological features. However, the JOA score recovery rate and SF-36 score in the anterior group were significantly higher. Persistent axial pain could be a major concern when undertaking the posterior approach.

Multivariate analysis of poor outcome after anterior surgery in multilevel cervical spondylotic myelopathy patients with heterotopic ossification and preoperative kyphotic alignment

Objective

The aim of this study was to evaluate the risk factors for poor outcome in patients who underwent multi-segmental anterior surgery, and analyze postoperative complications.

Methods

We retrospectively reviewed 158 patients after anterior surgery due to multilevel cervical spondylotic myelopathy (m-CSM) between June 2008 and June 2016. Adjusted ORs and 95% CIs were determined by multivariate logistic regression analysis. Cutoff values and the area under the curve for continuous risk factors were calculated through receiver operating characteristic curve analysis. The chi-squared test was performed for the comparison of complications among the three surgical groups.

Results

By analyzing 105 patients with good outcome and 53 patients with poor outcome, we established that the risk factors for poor outcome were advanced age (OR =1.12, P=0.003), longer duration of symptoms (OR =1.07, P=0.028), and bigger kyphotic angle at final follow-up (OR =1.29, P< 0.001). The optimal cutoff values for age, duration of symptoms, and kyphotic angle at final follow-up were 63.1 years, 15.5 months, and 5.3 angle. Postoperative complications occurred in 21 patients (13.3%). The incidence of dysphagia and cerebrospinal fluid leakage were higher in multilevel anterior cervical discectomy and fusion (m-ACDF) group than in other groups (P< 0.05).

Conclusion

Advanced age, longer duration of symptoms, and bigger kyphotic angle at final follow-up were the risk factors for poor postoperative outcome in patients with m-CSM. The complications after hybrid approach and m-ACDF approach were less than after anterior cervical corpectomy and fusion approach.

Comparison of clinical outcomes and safety between laminectomy with instrumented fusion versus laminoplasty for the treatment of multilevel cervical spondylotic myelopathy

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVES

Posterior laminectomy with instrumented fusion and laminoplasty are widely used for the treatment of multilevel cervical spondylotic myelopathy (MCSM). There is great controversy over the preferred surgical method. The purpose of this study is to evaluate the clinical outcomes and safety between laminectomy with instrumented fusion and laminoplasty for the treatment of MCSM.

METHODS

Related studies that compared the effectiveness of laminectomy with instrumented fusion and laminoplasty for the treatment of MCSM were acquired by a comprehensive search in PubMed, Embase, the Cochrane library, CNKI, VIP, and WANFANG up to April 2018. Included studies were evaluated according to eligibility criteria. The main endpoints included: preoperative and postoperative Japanese Orthopedic Association (JOA) scores, preoperative and postoperative visual analog scale (VAS), preoperative and postoperative cervical range of motion (ROM), preoperative and postoperative cervical curvature index (CCI), overall complication rate, C5 nerve palsy rate, axial symptoms rate, operation time and blood loss.

RESULTS

A total of 15 studies were included in this meta-analysis. All of the selected studies were of high quality as indicated by the Newcastle-Ottawa scale (NOS). Among 1131 patients, 555 underwent laminectomy with instrumented fusion and 576 underwent laminoplasty. The results of this meta-analysis indicated no significant difference in preoperative and postoperative JOA scores, preoperative and postoperative VAS, preoperative and postoperative CCI, preoperative ROM and axial symptoms rate. However, compared with laminoplasty, laminectomy with instrumented fusion exhibited a higher overall complication rate [RR = 1.99, 95% confidence intervals (CI) (1.24, 3.21), P <.05], a higher C5 palsy rate [RR = 2.22, 95% CI (1.30, 3.80), P <.05], a decreased postoperative ROM [SMD = -1.51, 95% CI (-2.14, -0.88), P <.05], a longer operation time [SMD = 0.51, 95% CI (0.12, 0.90), P <.05] and increased blood loss [SMD = 0.47, 95% CI (0.30, 0.65), P <.05].

CONCLUSION

These results suggested that both posterior laminectomy with instrumented fusion and laminoplasty were determined to be effective for MCSM. However, laminoplasty appeared to allow for a greater ROM, lower overall complication and C5 palsy rates, shorter operation time and lower blood loss. Future well-designed, randomized controlled trials are still needed to further confirm our results.

Anterior cervical discectomy and fusion versus hybrid surgery in multilevel cervical spondylotic myelopathy: A meta-analysis

OBJECTIVE

A meta-analysis was performed to compare the radiographic and surgical outcomes between anterior cervical discectomy and fusion (ACDF) and hybrid surgery (HS, corpectomy combined with discectomy) in the treatment for multilevel cervical spondylotic myelopathy (mCSM).

SUMMARY OF BACKGROUND DATA

Both ACDF and HS are used to treat mCSM, however, which one is better treatment for mCSM remains considerable controversy.

METHODS

An extensive search of literature was searched in PubMed/Medline, Embase, the Cochrane library, CNKI, and WANFANG databases on ACDF versus HS treating mCSM from January 2011 to December 2017. The following variables were extracted: blood loss, operation time, fusion rate, Cobb angles of C2-C7, total complications, dysphagia, hoarseness, C5 palsy, infection, cerebral fluid leakage, epidural hematoma, and graft subsidence. Data analysis was conducted with RevMan 5.3 and STATA 12.0.

RESULTS

A total of 4 studies including 669 patients were included in our study. The pooled analysis showed that there were no significant difference in the operation time, fusion rate, Cobb angles of C2-C7, dysphagia, hoarseness, C5 palsy, infection, cerebral fluid leakage, epidural hematoma, and graft subsidence. However, there were significant difference between 2 groups in blood loss [P < .00001, SMD = -30.29 (-45.06, -15.52); heterogeneity: P = .38, I = 0%= and total complications [P = .04, OR = 0.66 95%CI (0.44, 0.98); heterogeneity: P = .37, I = 4%].

CONCLUSIONS

Based on our meta-analysis, except for blood loss and total complications, both ACDF and hybrid surgery are effective options for the treatment of multilevel cervical spondylotic myelopathy.

Can tranexamic acid reduce blood loss in cervical laminectomy with lateral mass screw fixation and bone grafting: a retrospective observational study

To assess the safety and efficacy of tranexamic acid (TXA) for decreasing perioperative blood loss in cervical laminectomy with lateral mass screw fixation and bone grafting (CLF), in which all surgical procedures are identical.From November 2014 to April 2016, we performed a retrospective comparative analysis of 119 patients with multilevel cervical spondylotic myelopathy who had undergone a CLF from C3 to C6 in our center. All surgeries were performed on the patients using a consistent, standard procedure. Patients were divided into control (46) and TXA (73) groups according to whether or not they had received TXA treatment before and during surgery. Demographic profiles of patients such as gender, age, body weight, height, and body mass index were collated and differences between the 2 groups compared. Preoperative and postoperative hematological data in addition to intraoperative and postoperative blood loss were compared between the 2 groups. Additionally, any complications of TXA were also evaluated to assess safety.There was no statistically significant difference in demographic traits between the 2 groups. Intraoperative blood loss in the TXA group (179.66 ± 81.45 mL) was significantly lower than that of the control group (269.13 ± 94.68 mL, P < 0.001), as was postoperative blood loss (108.08 ± 44.31 and 132.83 ± 49.39 mL, respectively; P = 0.005). Total blood loss in the TXA group (287.74 ± 115.40 mL) was also significantly lower than that of the control group (401.96 ± 127.88, P < 0.01). No major intraoperative complications occurred in any of the cases.TXA significantly reduced perioperative blood loss in CLF with no major side effects.

Anterior cervical discectomy and fusion versus anterior cervical corpectomy and fusion in multilevel cervical spondylotic myelopathy: A meta-analysis

BACKGROUND

Both anterior cervical discectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF) are used to treat multilevel cervical spondylotic myelopathy (mCSM); however, which one is better treatment for mCSM remains considerable controversy. A meta-analysis was performed to compare clinical outcomes, radiographic outcomes, and surgical outcomes between ACDF and ACCF in treatment for mCSM.

METHODS

An extensive search of literature was performed in Pubmed/MEDLINE, Embase, the Cochrane library, CNKI, and WANFANG databases on ACDF versus ACCF treatment for mCSM from January 2011 to August 2016. The following variables were extracted: length of hospital stay, blood loss, operation time, Japanese Orthopedic Association (JOA) scores, Neck Disability Index (NDI) score, fusion rate, Cobb angles of C2 to C7, dysphagia, hoarseness, C5 palsy, infection, cerebral fluid leakage, donor site pain, epidural hematoma, graft subsidence, graft dislodgment, pseudoarthrosis, and total complications. Data analysis was conducted with RevMan 5.3 and STATA 12.0.

RESULTS

A total of 8 studies containing 878 patients were included in our study. The results showed that ACDF is better than ACCF in the angle of C2 to C7 at the final follow-up (P < 0.00001, standardized mean difference = 4.76 [3.48, 6.03]; heterogeneity: P = 0.17, I = 43%), C5 plasy (P = 0.02, odds ratio [OR] 0.42, 95% confidence interval [CI] 0.21, 0.86; heterogeneity: P = 0.52, I = 0%), blood loss (P < 0.00001, standardized mean difference = -53.12, 95% CI -64.61, -41.64; heterogeneity: P = 0.29, I = 20%), fusion rate (P = 0.04, OR 2.54, 95% CI 1.05, 6.11; heterogeneity: P = 0.29, I = 20%), graft subsidence (P = 0.004, OR 0.11, 95% CI 0.02, 0.48; heterogeneity: P = 0.94, I = 0%), and total complications (P = 0.0009, OR 0.56, 95% CI 0.40, 0.79; heterogeneity: P = 0.29, I = 18%).However, there are no significant differences in length of hospital stay, operation time, JOA scores, NDI scores, preoperative angle of C2 to C7, dysphagia, hoarseness, infection, cerebral fluid leakage, donor site pain, epidural hematoma, graft dislodgment, and pseudoarthrosis (all P > 0.05).

CONCLUSIONS

Based on our meta-analysis, our results suggest that both ACDF and ACCF are good plans in clinical outcomes; however, ACDF is a better choice in radiographic outcomes and total complications for the treatment of multilevel CSM.

Laminoplasty with adjunct anterior short segment fusion for multilevel cervical myelopathy associated with local kyphosis

BACKGROUND

When treating patients who have multilevel cervical spondylotic myelopathy (MCSM) with short-segment kyphosis, instability, or major anterior foci, long-level anterior decompression with fusion is often a standard method but can cause obvious loss of range of motion and usually needs further posterior stabilization. For MCSM with correctable kyphosis or simple instability, laminectomy with lateral-mass instrumented fusion is also a treatment of choice, but all the involved segments are immobilized. Combining expansive open-door laminoplasty (EOLP) and anterior short-segment fusion may be an alternative treatment to save more motion segments.

METHODS

This study included 109 patients who exhibited MCSM with combined local kyphosis, instability, and anterior pathology, and received EOLP and concomitant anterior short-segment fusion. The patients were enrolled from August 2005 to July 2012. Nurick scores and Japanese Orthopedics Association cervical myelopathy scores were used to evaluate the functional outcomes. Follow-up plain films were collected and magnetic resonance imaging was conducted to assess the radiographic outcomes.

RESULTS

One year after the operation, the Japanese Orthopedics Association recovery rate was 83.4 ± 16.6%. The improvement in the functional scores and decrease in neck pain were significant. The canal width improved without further collapse at 12 months. The preservation of range of motion was approximately 57% at 1 year.

CONCLUSION

EOLP with adjunct anterior short-segment decompression fusion yields an excellent outcome for MCSM patients who exhibit concomitant short-segment kyphosis, instability or major anterior pathology. Performing laminoplasty first is safer for the spinal cord due to its posterior shifting while anterior procedures are being done.