- Department of Neurosurgery, David Geffen UCLA School of Medicine, Los Angeles, USA
- Department of Orthopaedics, David Geffen UCLA School of Medicine, Los Angeles, USA
Correspondence Address:
Langston T. Holly
Department of Neurosurgery, David Geffen UCLA School of Medicine, Los Angeles, USA
Department of Orthopaedics, David Geffen UCLA School of Medicine, Los Angeles, USA
DOI:10.4103/2152-7806.130670
Copyright: © 2014 Chang V This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are creditedHow to cite this article: Chang V, Lu DC, Hoffman H, Buchanan C, Holly LT. Clinical results of cervical laminectomy and fusion for the treatment of cervical spondylotic myelopathy in 58 consecutive patients. Surg Neurol Int 16-Apr-2014;5:
How to cite this URL: Chang V, Lu DC, Hoffman H, Buchanan C, Holly LT. Clinical results of cervical laminectomy and fusion for the treatment of cervical spondylotic myelopathy in 58 consecutive patients. Surg Neurol Int 16-Apr-2014;5:. Available from: http://sni.wpengine.com/surgicalint_articles/clinical-results-of-cervical-laminectomy-and-fusion-for-the-treatment-of-cervical-spondylotic-myelopathy-in-58-consecutive-patients/
Abstract
Background:There are a number of surgical treatment options for cervical spondylotic myelopathy (CSM). In this study, the authors present their clinical results with cervical laminectomy and fusion for the treatment of patients with CSM.
Methods:This retrospective study included 58 consecutive patients who underwent cervical laminectomy and fusion for CSM. There were 38 males and 20 females, with a mean age of 64 (range 42-92) years. The Japanese orthopedic association score (mJOA) scale was used as the functional outcome measurement. Both the absolute increase in mJOA and the neurological recovery rate of mJOA were analyzed. The mean clinical follow-up was 17 months (range 5-52 months).
Results:There was a statistically significant improvement between mean preoperative (13.2, range 7-17) and postoperative (16.1, range 11-18) mJOA scores following surgery. The average improvement in mJOA score was 2.9 points. The mean neurological recovery rate was 56.6%. Overall 85.5% of patients improved with surgery (n = 51) and the remaining 14.5% of patients had no change in their mJOA score after surgery (n = 7). Fusion was documented in all 58 patients. There was a 10.3% overall complication rate (n = 6). The most common complications were C5 nerve palsies which occurred in 6.9% of the cohort (n = 4); all completely resolved.
Conclusion:Cervical laminectomy and fusion is a safe and efficacious procedure for the treatment of CSM. The clinical outcomes appear to be quite reproducible, and this technique is an important part of a spine surgeon's armamentarium.
Keywords: Cervical, fusion, laminectomy, myelopathy
INTRODUCTION
Cervical spondylotic myelopathy (CSM) is a degenerative disorder of the cervical spine that can potentially cause devastating and irreversible impairment of neurological function.[
The most optimal surgical technique for CSM is frequently debated among surgeons, and is a source of controversy in our field. As such, investigations into the efficacy of surgical approaches for CSM are a worthwhile undertaking. Surgical treatment options for CSM include: Anterior cervical discectomy or corpectomy and fusion, laminoplasty, laminectomy, and cervical laminectomy with fusion. All four methods have been shown to be efficacious in the treatment of CSM,[
MATERIALS AND METHODS
In this retrospective analysis, 58 patients underwent cervical laminectomy and fusion by authors DL and LTH (2008-2012) for CSM attributed to spinal cord compression at the C2 level and below. A summary of patient demographics is illustrated in
Clinical presentation
A total of 44 patients had multiple complaints of 3 months to 2 years duration at the time of presentation (76%). Gait disturbance, encountered in 40 patients (69%), was the most common presenting complaint [
Figure 1
(a) T2-weighted sagittal MRI of a 47-year-old male with a history of CSM and severe gait dysfunction. He has spinal cord compression and significant spinal cord edema at the C6-7 level. He underwent C5-7 laminectomy and fusion to treat his condition. Postoperative lateral (b) and AP (c) plain radiographs demonstrate satisfactory placement of hardware and maintenance of his spinal alignment. He achieved significant gait improvement after surgery, and postoperative MRI demonstrated excellent spinal cord decompression and resolution of the edema
Hyperreflexia, the most common preoperative neurological sign, was encountered in 29 patients (50%); this was followed in descending order by Hoffman's signs (22 patients), positive Babinski's signs (15 patients), and lower extremity clonus (14 patients). Of interest, 17 patients had no evidence of long tract signs.
Radiographical evaluation
Preoperatively, cervical sagittal alignment was assessed utilizing lateral standing radiographs and documented; straightening of the cervical lordosis (27 patients) (47%), a lordotic cervical spine (17 patients), and kyphosis (14 patients). Notably, preoperative T2 weighted MR studies documented hyperintense signal in the spinal cords of 39 patients (57%).
Functional assessment
The modified Japanese orthopedic association score (mJOA) was used as the primary clinical outcome measure.[
Statistical analysis for this study involved using the unpaired t-test to compare preoperative to postoperative mJOA. A sampling error of less than 5% was assumed in these calculations.
Surgical selection
The patients in this series with CSM attributed to multilevel spinal cord compression were optimally treated utilizing a posterior approach consisting of laminectomy with fusion to address significant dorsal compression and/or in select cases to avoid postoperative kyphosis (e.g, related to preoperative alignment or segmental instability).
Description of surgical technique
For the 58 patients in this study, an average of 4.5 levels was decompressed utilizing laminectomy, and an average of 4.4 levels was fused. Local autograft (morselized lamina and spinous processes) was used in 100% of cases (n = 58), additionally supplemented with allograft 19.0% of the time (n = 11).
Intubation and intraoperative monitoring
As all patients had cord compression responsible for their underlying CSM, endotracheal intubation was performed utilizing either the fiber optic bronchoscope or GlideScope (video laryngoscopy; Verathon Inc, Bothell, WA).
Somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) were both monitored intraoperatively (IOM). Baseline MEPs and SSEPs were obtained after intubation, and prior to positioning. A 3-pin Mayfield head holder was used in all cases, with the patient positioned prone on chest bolsters. The patient's shoulders were secured with tape toward the feet to facilitate intraoperative fluoroscopy of the cervical spine. MEPs and SSEPs were repeated after the final position was obtained.
Cervical laminectomy and posterior fusion
A standard posterior midline incision was used with subperiosteal dissection and exposure of the spinous processes, lamina, and lateral mass facet complexes. Laminectomy was performed in en bloc fashion utilizing a high speed matchstick burr to drill troughs in the bone at the lateral edge of the lamina. The ligamentum flavum was incised using Kerrison rongeurs and the lamina were lifted off the spinal cord in one piece. The lamina and spinous processes were cleaned of soft tissue and morselized to be used as autograft. For fixation, a top loading lateral mass screw-rod system was utilized using the Margerl technique.[
RESULTS
mJOA Outcomes
The mean preoperative mJOA score was 13.2 (range 10-17, Std Dev 2.51) and the mean postoperative mJOA was 16.1 (range 11-18, Std Dev 1.77), with an average improvement of 2.9 (range 0-8, Std Dev 2.17) [
Complications
There was a 10.3% overall complication rate (n = 6) that included minor complications. The most common complication, seen in four patients (6.9%), was a C5 nerve root palsy; all palsies completely resolved over a mean postoperative interval of 4 months (range 2 and 7 months). Other complications included one readmission for a fever of unknown origin, and one wound dehiscence of unknown etiology (e.g. no infection or seroma) that healed without further sequelae.
DISCUSSION
Background and rational for cervical laminectomy and fusion
There is a lack of consensus regarding the optimal surgical technique for the management of moderate to severe CSM. A number of factors impact the choice of surgical procedure for CSM: Location of compressive pathology, spinal alignment, number of levels involved, clinical variables (e.g, age), surgeon preference, and even patient preference. For many years, cervical laminectomy alone was utilized to manage CSM. However, a recent survey of spine surgeons demonstrated that cervical laminectomy and fusion is now most commonly used (70%), followed by laminoplasty (23%), and laminectomy alone (7%).[
Cervical laminectomy alone largely fell out of favor, due to the increased risk of postlaminectomy kyphosis attributed to the loss of the posterior musculoskeletal tension band (14-47%).[
Concern regarding motion
Another reason to choose laminectomy and fusion over laminectomy is the limitation of motion thought to contribute to CSM. Although direct spinal cord compression is the most commonly encountered mechanism of spinal cord injury in CSM, dynamic forces (e.g, shear, distraction, and stretch injury) also play an important role.[
Cervical laminectomy and fusion in the medical literature
Gonzalez-Feria and Epstein initially described the utility of cervical laminectomy and fusion to treat CSM authors utilizing facet wiring for arthrodesis.[
Present study
The present study is one of the largest single center reports of consecutive patients undergoing cervical laminectomy and fusion for CSM. The mean mJOA score significantly improved 2.9 points (preoperative 13.2 to 16.1 postoperative), with a neurological recovery rate of 56.6%. These results were similar to those seen in other studies. Despite the older average age for this cohort of 64, the complication rate was fairly low (10.6%); there were no major complications requiring reoperation, and the 6.9% incidence of C5 palsies all fully recovered.
Our results compare favorably with the AOSpine North America multicenter prospective study that included 302 patients undergoing CSM surgery wherein 82 of 107 posterior cervical procedures consisted of laminectomy/fusion.[
CONCLUSION
Cervical laminectomy and fusion is a safe and efficacious procedure for the treatment of CSM. The clinical outcomes appear to be quite reproducible, and this technique is an important part of a spine surgeon's armamentarium.
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