- Orthopedic Spine Fellow, Department of Orthopedics and Neurosurgery, UCLA, Santa Monica, CA, USA
- Chief Orthopedic Spine Surgery, Department of Orthopedics and Neurosurgery, UCLA, Santa Monica, CA, USA
Correspondence Address:
Beck D. McAllister
Chief Orthopedic Spine Surgery, Department of Orthopedics and Neurosurgery, UCLA, Santa Monica, CA, USA
DOI:10.4103/2152-7806.98581
Copyright: © 2012 McAllister BD. 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 credited.How to cite this article: McAllister BD, Rebholz BJ, Wang JC. Is posterior fusion necessary with laminectomy in the cervical spine?. Surg Neurol Int 17-Jul-2012;3:
How to cite this URL: McAllister BD, Rebholz BJ, Wang JC. Is posterior fusion necessary with laminectomy in the cervical spine?. Surg Neurol Int 17-Jul-2012;3:. Available from: http://sni.wpengine.com/surgicalint_articles/is-posterior-fusion-necessary-with-laminectomy-in-the-cervical-spine/
Abstract
Background:Cervical decompressive laminectomy is a common procedure for addressing multilevel cervical spine pathology. The most common reasons for performing simultaneous posterior cervical fusion include the prevention of progressive postlaminectomy kyphotic deformity or other types of instability which can contribute to late neurological deterioration.
Methods:The medical literature (Pub Med with MeSH) concerning cervical laminectomy, posterior cervical fusion, and complications of laminectomy/fusion was reviewed. Additionally, references from the articles were queried to find additional literature.
Results:Multiple studies concluded that cervical laminectomy versus laminectomy and fusion produced similar short-term postoperative outcomes. Careful patient selection was warranted to minimize the complications associated with cervical laminectomy alone; these included postoperative kyphosis (6–46%) and late deterioration (10–37%). The addition of a posterior cervical fusion was associated with relatively low complication rates, and avoided the evolution of late deformity or delayed neurological deterioration.
Conclusion:Although the short-term results of cervical laminectomy versus laminectomy and fusion are similar, there appear to be more complications associated with performing laminectomy alone over the long term. Here, we reviewed the pros and cons of posterior cervical decompression alone versus decompression with fusion/instrumentation to treat cervical pathology, highlighting the complications associated with each surgical alternative.
Keywords: Cervical, complications, fusion, indications, laminectomy
INTRODUCTION
Frequently, the spine surgeon is faced with multilevel compressive cervical pathology that is appropriately treated by a posterior cervical approach. In general, the indications for cervical laminectomy include cervical stenosis (congenital and acquired), cervical spondylotic myelopathy, multilevel spondylotic radiculopathy, ossification of the posterior longitudinal ligament (OPLL), ossification of the yellow ligament (OYL), neoplasm, and infection.[
SUCCESS OF CERVICAL LAMINECTOMY DEPENDS ON AN ADEQUATE LORDOTIC CURVATURE AND PRESERVATION OF THE FACET JOINTS
The natural lordotic curvature of the cervical spine distributes the compressive load differently than in other spinal locations. The cervical spine transmits 36% of compressive loads through the anterior column, while 64% is borne through the posterior column facet joints.[
The success of cervical laminectomy is determined by several factors. First, the normal lordotic alignment of the cervical spine is 14°–20° from C2–C7.[
INDICATIONS FOR CERVICAL LAMINECTOMY
The indications for cervical laminectomy include cervical stenosis (congenital and acquired), cervical spondylotic myelopathy, multilevel spondylotic radiculopathy, OPLL, OYL, neoplasm, and infection.[
CERVICAL LAMINECTOMY OFFERS VENTRAL/DORSAL DECOMPRESSION AND INCREASED PERFUSION
Cervical laminectomy, by removing the posterior bony elements, allows the spinal cord to migrate dorsally away from anteriorly situated compressive pathology, while also affording direct relief from dorsal stenosis/spondyloarthrosis. Laminectomy, whether offering ventral or dorsal decompression, improves cervical cord perfusion.
Additional keys to achieving successful outcomes following cervical laminectomy include careful preoperative attention to the location of the compression (anterior/posterior), the preoperative sagittal alignment, and whether the cervical spine is stable.
EARLY SUCCESS OF CERVICAL LAMINECTOMY
The literature is replete with studies documenting the clinical success and utility of cervical laminectomy. Ryken et al. performed a detailed systematic review of the results of cervical laminectomy for cervical myelopathy.[
INCIDENCE OF POSTOPERATIVE KYPHOTIC DEFORMITY
The potential for the development of postoperative kyphotic deformity is a major concern when choosing to perform cervical laminectomy in adults or children. The incidence of postlaminectomy kyphosis ranges from 6 to 47% in adults, and can reach 100% in children [
PATHOGENESIS OF POSTLAMINECTOMY KYPHOSIS
The pathogenesis of postlaminectomy kyphosis is multifactorial, and varies between adults and children. Yasuko et al. found a 46% incidence of postlaminectomy kyphosis for those less than 15 years of age, while the rate was only 6% for those between the ages of 15 and 24. The rate of kyphosis also varied by spinal region, with 100% following cervical laminectomy, 36% following thoracic laminectomy, and 0% following lumbar laminectomy.[
LOSS OF THE POSTERIOR TENSION BAND IN ADULTS FOLLOWING LAMINECTOMY
Postlaminectomy kyphosis is multifactorial in adults, with the incidence ranging between 6% and 47%.[
POSTOPERATIVE CERVICAL LAMINECTOMY KYPHOSIS IN CHILDREN
In children, there are two types of postoperative cervical laminectomy kyphosis: wedging of the vertebral bodies and subluxation with excessive motion between vertebrae.[
NO IMPACT OF LAMINECTOMY AND POSTOPERATIVE CERVICAL KYPHOSIS ON OUTCOME IN ADULTS
What is the clinical significance of postlaminectomy kyphosis with respect to outcome?[
Although postoperative cervical kyphosis is a known sequelae of cervical laminectomy, the clinical impact on neurological deterioration is difficult to ascertain. When Kaptain et al. evaluated preoperative and postoperative sagittal alignment in 46 patients undergoing cervical laminectomy, the rate of postoperative kyphosis was twofold greater for patients with preoperative “straightened” cervical spinal alignment.[
DELAYED DETERIORATION FROM POSTLAMINECTOMY KYPHOSIS
The incidence of late deterioration following cervical laminectomy alone varies from 10 to 39% [
CERVICAL LAMINECTOMY AND FUSION
Cervical laminectomy and fusion may be performed to avoid the potential complications of instability and kyphosis associated with cervical laminectomy alone. For the latter, dissection and removal of the posterior elements disrupts the normal biomechanics of the cervical spine, leading to postlaminectomy deformity and instability.
POSTERIOR CERVICAL FUSION TECHNIQUES
Posterior cervical fusion techniques have evolved over the years. Currently, the most common method of fixation is lateral mass screw/rod constructs. The fusion rates with these technique are consistently over 90–95%, depending on the fusion criteria utilized.[
INCREASED COMPLICATION RATES OF POSTERIOR CERVICAL FUSION
The benefits of posterior cervical stabilization must be weighed against the added potential complications of fusions: increased operative time, blood loss, and instrument-related complications [
DISCUSSION
When to Perform Cervical Laminectomy with Fusion
Cervical laminectomy with or without fusion may be utilized to treat multilevel cervical cord compression. In several studies, the clinical outcomes documented in the immediate postoperative period are similar for laminectomy alone versus laminectomy with fusion. The key question is when to perform the fusion [
Factors Affecting the Success of Laminectomy
Factors affecting the success of cervical laminectomy alone were based upon evaluation of several critical preoperative and intraoperative parameters. Where preoperative radiographs documented 10° of cervical lordosis, without instability on flexion/extension views, laminectomy alone sufficed [Figures
Figure 1
One example of the dilemma on whether to perform a fusion in addition to a cervical laminectomy. A 27-year-old female presented with a several month history of gait imbalance and sensory disturbance attributed to an intradural-intramedullary ependymoma. Despite the patient's young age (27 years old) and loss of loridosis, the patient was very concerned about the ability to monitor for recurrent tumor utilizing MR Scans (with/ without Gadolinium-DTPA). After being informed about the risks of postlaminectomy kyphosis and instability, the patient chose a cervical laminectomy alone to resect the tumor. Currently, patient has had improvement in balance and gait with no change in preoperative sensory exam. One year follow up radiographs and MR show no recurrence of tumor or progression of kyphosis. (a) Preoperative T2 Sagittal, (b) preoperative T1 contrast sagittal, (c) postoperative T2 sagittal, (d) postoperative T1 contrast sagittal, (e) postoperative sagittal cervical X-ray, see text recommendations
Figure 2
A 67-year-old female presented with myeloradiculopathy from a single level (C6) posterior element mass compressing the spinal cord (a, b). The patient had no evidence of cervical instability on preoperative flexion/extension views, and exhibited normal lordosis. A cervical laminectomy of C6 allowed for direct decompression of the spinal cord and did not lead to instability as it involved minimal resection of the posterior elements (Figure 2c-e). The lesion was found to be calcium pyrophosphate deposition in the yellow ligament at C6. (a) Sagittal CT myelogram, (b) axial CT myelogram, (c) cervical lateral neutral X-ray, (d) cervical lateral extension X-ray, (e) cervical lateral flexion X-ray
Extent of Facet Resection Avoids Iatrogenic Instability
When performing cervical laminectomies, close attention to the extent of facetectomy performed over single or multiple levels helps to determine the development of instability. If it is necessary to perform multiple foraminotomies, or resect greater than 30–50% of the facet joint, we recommend the addition of a posterior cervical fusion to avoid iatrogenic instability.[
Posterior Fusion Avoids Postlaminectomy Kyphosis
Cervical laminectomy alone results in a 6–47% incidence of postlaminectomy kyphosis that contributes to varying rates of late neurological deterioration (10–39%).[
Posterior Cervical Fusion Rates and its Complications
In general, the authors advocate performing cervical laminectomy with fusion, as laminectomy alone can result in postoperative kyphosis and late deterioration [Figures
Figure 3
A 64 year-old male presented with progressive cervical myelopathy characterized by gait imbalance, loss of fine motor skills, and numbness in the fingertips. The patient had previously undergone an anterior cervical discectomy and fusion from C4 to C7 ten years ago. The prior anterior surgery had included discectomy/autograft/plating. New radiographs indicated spinal instability above (C3/4) and below (C7/T1) the previous fusion mass (C4-C7). Concerns for the added complications associated with repeated anterior surgery (esophageal injury, recurrent laryngeal nerve injury, access to T1) and creating further instability, led to a posterior cervical decompression/instrumentation/fusion from C3 to T1 being performed. (a) Sagittal T2 MRI, (b) cervical AP X-ray, (c) cervical lateral X-ray, (d) cervical swimmer's view X-ray
Figure 4
A 64-year-old female presented with symptoms of increased cervical spondylotic myelopathy, accompanied by loss of fine motor skills and gait imbalance, over one year duration. This patient had lost normal cervical lordosis, therefore a posterior C3 to C6 laminectomy and fusion with instrumentation was performed. (a) Sagittal T2 MRI, (b) cervical AP X-ray, (c) cervical lateral X-ray
Indications for Cervical Laminectomy Alone: Geriatric Patients
Those who are considered candidates for a cervical laminectomy alone are typically elderly patients with multiple comorbidities, who demonstrate adequate preservation of the cervical lordotic curvature (10° lordosis), without demonstrable instability.
Indications for Cervical Laminectomy with Posterior Fusion
Posterior cervical fusion is usually appropriate if the patient demonstrates the following factors: significant axial neck pain, minimal lordosis or straightening of the cervical spine, younger age, postoperative radiation, or the presence of instability [
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