Abstract

Background: Degenerative cervical myelopathy (DCM) is a common cause of spinal cord dysfunction. The effectiveness of laminoplasty (LP) versus laminectomy with fusion (LF) for treating DCM is still debated. Here, we compared LP versus LF for treating DCM using propensity score matching (PSM) to minimize selection bias.

Methods: We identified DCM patients undergoing LP versus LF (2004–2022). Our analysis included demographics, preoperative/postoperative modified Japanese orthopedic association (mJOA) scoring, Visual Analog Scale (VAS) scores, assessment of postoperative cervical lordosis, operative time, blood loss, length of stay (LOS), and adverse events. PSM was performed to create balanced groups and minimize selection bias. Paired t-tests and Chi-square tests were used for statistical analysis.

Results: After PSM, 55 patients in each group were analyzed. LP patients had significantly shorter operative times and LOS, but VAS scores were significantly better for the LF group. Notably, both groups showed similar improvements in mJOA scores, frequency of intraoperative/postoperative adverse events, and reoperation rates. Although changes in cervical lordosis were significantly different between the groups, both groups showed comparable final lordotic curvatures.

Conclusion: LP procedures resulted in significantly shorter operative times and LOS, but VAS scores were correlated with significantly better outcomes in the LF group. Notably, both LP and LF patients demonstrated similar improvement in mJOA scores, frequencies of intraoperative/postoperative adverse events, and reoperation rates.

Keywords: Cervical lordosis, Laminectomy, Laminoplasty, Propensity score matching

INTRODUCTION

Laminoplasty (LP) and laminectomy with fusion (LF) are commonly employed posterior procedures for treating multilevel degenerative cervical myelopathy (DCM).[ 3 , 4 ] LF provides immediate rigid fixation, stability, and deformity correction.[ 3 ] LP, a motion-preserving technique, alternatively maintains the cervical range of motion and mitigates the risk of adjacent segment disease.[ 2 ] Several meta-analyses have previously compared the relative efficacies of performing LP versus LF in DCM patients.[ 3 - 5 , 7 , 8 ] Here, however, we offer a propensity-matched analysis comparing LP and LF specifically for DCM patients to minimize confounding variables and better analyze/compare the relative effectiveness of these two surgical techniques.

MATERIALS AND METHODS

This retrospective cohort study compares open-door LP (55 patients) versus LF (55 patients) for the treatment of DCM. It was approved by the Institutional Review Board (2004–2022). Following 1:1 propensity score matching (PSM) and using multiple inclusion and exclusion criteria, we analyzed multiple clinical and radiological variables to select patients for the LP and LF surgical groups [ Tables 1 and 2 ].[ 1 , 5 , 6 ] A notable major shortcoming of this study was the design that allows surgeon preference to determine the choice of surgical techniques (LP or LF) without any randomization or even cohort matching.

Table 1:

Comparison between LP and LF in terms of demographics and outcomes.

Table 2:

Inclusion and exclusion criteria.

PSM and statistical analysis

We utilized PSM to minimize selection bias and confounding variables inherent in retrospective studies. We employed a logistic regression model to estimate the propensity score for each LF versus LP patient by looking at the following variables/covariates: age, body mass index, American Society of Anesthesiologists grade, Charlson comorbidity index, smoking status, hypertension, diabetes mellitus, number of surgical levels, preoperative modified Japanese orthopedic association (mJOA), and preoperative lordosis. Patients in these two groups were then matched 1:1 using a nearest-neighbor matching algorithm with a fuzz factor of 1, resulting in two balanced groups of patients. Differences between the matched groups were assessed using paired t-tests for continuous variables and the Chi-square test for categorical variables. Changes in clinical and radiographic outcomes within each group were assessed using paired t-tests.

RESULTS

The LP group had a significantly shorter mean operative time and their mean length of stay (LOS) was significantly shorter versus the LF group. However, the LF patients demonstrated significantly greater improvement in Visual Analog Scale (VAS) scores versus LP patients and less loss of final lordosis. Notably, no significant differences were found between the two groups regarding estimated blood loss (EBL), number of levels operated on, final mJOA scores, changes in mJOA scores, frequencies of intraoperative/postoperative adverse events, or numbers of reoperations [ Table 1 ].

DISCUSSION

We compared the safety/efficacy of LP and LF for treating DCM utilizing PSM to minimize the impact of confounding variables. LP was associated with significantly shorter surgical duration and length of hospital stay (LOS) versus LF. Lee et al. voiced similar findings (i.e., they included both randomized and nonrandomized studies, introducing potential selection bias).[ 3 ] Yang et al., in their propensity-matched analysis of the Neuropoint Alliance Quality Outcomes Database, also found significantly decreased EBL and LOS with LP.[ 6 ] Ma et al., in their meta-analysis, reported better maintenance of lordosis with multilevel LF (i.e., stabilizing effect of fusion) versus LP.[ 4 ] We observed a nonsignificant greater loss of lordosis with LP versus LF. We found comparable clinical outcomes/improvement (mJOA and VAS scores) using either LP or LF procedures, findings also confirmed by Lee et al., Yang et al, and Yuan et al.[ 3 , 6 , 7 ] We did not document a higher incidence of C5 palsy for LF versus LP patients as had been found in Yuan et al. and Zhao et al. studies [ Table 3 ].[ 7 , 8 ]

Table 3:

Summary table.

CONCLUSION

This PSM analysis provides compelling evidence for the comparative effectiveness and safety of LP and LF for DCM.

Ethical approval:

The research/study was approved by the Institutional Review Board at University at Buffalo, approval number STUDY00005439 , dated August 6th, 2021.

Declaration of patient consent:

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship:

Nil.

Conflicts of interest:

Asham Khan received a research grant from the Scoliosis Research Society to study scoliosis in Chiari patients. Jeffrey P. Mullin serves as a consultant for SI Bone and Medtronic. John Pollina is involved with surgical training for Medtronic and serves as a consultant for and receives royalties from ATEC spine.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation:

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

Disclaimer

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.

References

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