Phyo Kim, Hidetoshi Murata, Ryu Kurokawa, Yoshiyuki Takaishi, Keizo Asakuno and Toshiki Kawamoto
Laminoplasty has been used to expand the cervical spinal canal, based on the belief that reconstruction of the laminae preserves musculoskeletal function. The true efficacy of laminoplasty for maintaining spinal alignment, stability, and flexibility, however, remains to be proven. The authors have developed a new method, myoarchitectonic spinolaminoplasty (MSLP), which preserves all of the nuchal muscles and reconstitutes all of the musculoskeletal couplings to the posterior elements of the vertebrae. The details of this technique are described, and the efficacy of the technique in conserving muscle volume, alignment, and motion, as well as in preventing postoperative musculoskeletal discomfort, is assessed.
The authors' previous midline-splitting laminoplasty procedure, which utilized a hydroxyapatite (HA) implant as a substitute for the spinous process, was improved. Detachment of the muscles is avoided with this new technique by cutting inside the spinous process. The bone–muscle flaps are affixed to the HA spinous process. Radiographs, computed tomography scans, and neurological evaluations obtained at the 1-year follow-up in the groups of consecutive patients assessed immediately prior to and after the modification of the previous technique (the control and the MSLP groups, respectively) were analyzed and compared.
The HA bone constructs became integrated due to osteoconduction. The cross-sectional area of the semispinalis capitis, semispinalis cervicis, and multifidus muscles remained significantly larger in the MSLP group. Slight attenuation in lordosis was observed in the control group, but was prevented in the MSLP group. Range of motion was somewhat restricted in the MSLP group, but the incidence of neck pain and shoulder strain was significantly reduced.
The new MSLP method was effective in preserving the volume and functions of the nuchal musculature and helping to minimize postoperative musculoskeletal complaints.
Yuji Matsuoka, Hidekazu Suzuki, Kenji Endo, Yasunobu Sawaji, Kazuma Murata, Hirosuke Nishimura, Hidetoshi Tanaka and Kengo Yamamoto
Preoperative positive cervical sagittal imbalance and global sagittal imbalance are risk factors for postoperative cervical kyphosis after expansive open-door cervical laminoplasty (ELAP). The purpose of this study was to investigate the relationship between the incidence of postoperative cervical kyphosis after ELAP and the preoperative global sagittal spinal alignment in patients with cervical spondylotic myelopathy (CSM) without spinal sagittal imbalance.
Among 84 consecutive patients who underwent ELAP for CSM at the authors’ hospital, 43 patients without preoperative cervical kyphosis (C2–7 angle ≥ 0°) and spinal sagittal imbalance (C2–7 sagittal vertical axis [SVA] ≤ 80 mm and C-7 SVA ≤ 95 mm) were included in the study. The global spinal sagittal parameters were measured on lateral whole-spine standing radiographs preoperatively and at 1 year postoperatively. The difference in preoperative global sagittal spinal alignment between the postoperative cervical lordosis group and the cervical kyphosis group was analyzed.
The incidence of postoperative cervical kyphosis after ELAP was 25.6% (11 of 43 cases). Thirty-two patients (16 men and 16 women; mean age 67.7 ± 12.0 years) had lordosis, and 11 (7 men and 4 women; mean age 67.2 ± 9.6 years) had kyphosis. The preoperative C-7 SVA and pelvic incidence minus lumbar lordosis (PI−LL) in the kyphosis group were significantly smaller than those in the lordosis group (p < 0.05). The smaller C-7 SVA accompanied by a small PI−LL, the “truncal negative offset,” led to postoperative cervical kyphosis due to posterior structural weakening by ELAP.
In patients with CSM without preoperative cervical and global spinal sagittal imbalance, a small SVA accompanied by lumbar hyperlordosis is the characteristic alignment leading to postoperative cervical kyphosis after ELAP.
Keisuke Takai, Toshiki Endo, Takao Yasuhara, Toshitaka Seki, Kei Watanabe, Yuki Tanaka, Ryu Kurokawa, Hideaki Kanaya, Fumiaki Honda, Takashi Itabashi, Osamu Ishikawa, Hidetoshi Murata, Takahiro Tanaka, Yusuke Nishimura, Kaoru Eguchi, Toshihiro Takami, Yusuke Watanabe, Takeo Nishida, Masafumi Hiramatsu, Tatsuya Ohtonari, Satoshi Yamaguchi, Takafumi Mitsuhara, Seishi Matsui, Hisaaki Uchikado, Gohsuke Hattori, Nobutaka Horie, Hitoshi Yamahata and Makoto Taniguchi
Spinal arteriovenous shunts are rare vascular lesions and are classified into 4 types (types I–IV). Due to rapid advances in neuroimaging, spinal epidural AVFs (edAVFs), which are similar to type I spinal dural AVFs (dAVFs), have recently been increasingly reported. These 2 entities have several important differences that influence the treatment strategy selected. The purposes of the present study were to compare angiographic and clinical differences between edAVFs and dAVFs and to provide treatment strategies for edAVFs based on a multicenter cohort.
A total of 280 consecutive patients with thoracic and lumbosacral spinal dural arteriovenous fistulas (dAVFs) and edAVFs with intradural venous drainage were collected from 19 centers. After angiographic and clinical comparisons, the treatment failure rate by procedure, risk factors for treatment failure, and neurological outcomes were statistically analyzed in edAVF cases.
Final diagnoses after an angiographic review included 199 dAVFs and 81 edAVFs. At individual centers, 29 patients (36%) with edAVFs were misdiagnosed with dAVFs. Spinal edAVFs were commonly fed by multiple feeding arteries (54%) shunted into a single or multiple intradural vein(s) (91% and 9%) through a dilated epidural venous plexus. Preoperative modified Rankin Scale (mRS) and Aminoff-Logue gait and micturition grades were worse in patients with edAVFs than in those with dAVFs. Among the microsurgical (n = 42), endovascular (n = 36), and combined (n = 3) treatment groups of edAVFs, the treatment failure rate was significantly higher in the index endovascular treatment group (7.5%, 31%, and 0%, respectively). Endovascular treatment was found to be associated with significantly higher odds of initial treatment failure (OR 5.72, 95% CI 1.45–22.6). In edAVFs, the independent risk factor for treatment failure after microsurgery was the number of intradural draining veins (OR 17.9, 95% CI 1.56–207), while that for treatment failure after the endovascular treatment was the number of feeders (OR 4.11, 95% CI 1.23–13.8). Postoperatively, mRS score and Aminoff-Logue gait and micturition grades significantly improved in edAVFs with a median follow-up of 31 months.
Spinal epidural AVFs with intradural venous drainage are a distinct entity and may be classified as type V spinal vascular malformations. Based on the largest multicenter cohort, this study showed that primary microsurgery was superior to endovascular treatment for initial treatment success in patients with spinal edAVFs.