Gap between flexion and extension ranges of motion: a novel indicator to predict the loss of cervical lordosis after laminoplasty in patients with cervical spondylotic myelopathy

Takashi Fujishiro MD, PhD1,2, Sachio Hayama MD, PhD1, Takuya Obo MD1,2, Yoshiharu Nakaya MD, PhD1, Atsushi Nakano MD, PhD1, Yoshitada Usami MD1, Satoshi Nozawa MD, PhD1, Ichiro Baba MD, PhD1, and Masashi Neo MD, PhD1
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  • 1 Department of Orthopedic Surgery, Osaka Medical College, Takatsuki; and
  • | 2 Department of Orthopedic Surgery, First Towakai Hospital, Takatsuki, Osaka, Japan
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OBJECTIVE

Kyphotic deformity resulting from the loss of cervical lordosis (CL) is a rare but serious complication after cervical laminoplasty (CLP), and it is essential to recognize the risk factors. Previous studies have demonstrated that a greater flexion range of motion (fROM) and smaller extension ROM (eROM) in the cervical spine are associated with the loss of CL after CLP. Considering these facts together, one can hypothesize that an indicator representing the gap between fROM and eROM (gROM) is highly useful in predicting postoperative CL loss. In the present study, the authors aimed to investigate the risk factors of marked CL loss after CLP for cervical spondylotic myelopathy (CSM), including the gROM as a potential predictor.

METHODS

Patients who had undergone CLP for CSM were divided into those with and those without a loss of more than 10° in the sagittal Cobb angle between C2 and C7 at the final follow-up period compared to preoperative measurements (CL loss [CLL] group and no CLL [NCLL] group, respectively). Demographic characteristics, surgical information, preoperative radiographic measurements, and posterior paraspinal muscle morphology evaluated with MRI were compared between the two groups. fROM and eROM were examined on neutral and flexion-extension views of lateral radiography, and gROM was calculated using the following formula: gROM (°) = fROM − eROM. The performance of variables in discriminating between the CLL and NCLL groups was assessed using the receiver operating characteristic (ROC) curve.

RESULTS

This study included 111 patients (mean age at surgery 68.3 years, 61.3% male), with 10 and 101 patients in the CLL and NCLL groups, respectively. Univariate analyses showed that fROM and gROM were significantly greater in the CLL group than in the NCLL group (40.2° vs 26.6°, p < 0.001; 31.6° vs 14.3°, p < 0.001, respectively). ROC curve analyses revealed that both fROM and gROM had excellent discriminating capacities; gROM was likely to have a higher area under the ROC curve than fROM (0.906 vs 0.860, p = 0.094), with an optimal cutoff value of 27°.

CONCLUSIONS

The gROM is a highly useful indicator for predicting a marked loss of CL after CLP. For CSM patients with a preoperative gROM exceeding 30°, CLP should be carefully considered, since kyphotic changes can develop postoperatively.

ABBREVIATIONS

AUC = area under the ROC curve; CL = cervical lordosis; CLP = cervical laminoplasty; CSA = cross-sectional area; CSM = cervical spondylotic myelopathy; cSVA = cervical sagittal vertical axis; eROM = extension ROM; fROM = flexion ROM; gROM = gap between fROM and eROM; ICC = intraclass correlation coefficient; JOA = Japanese Orthopaedic Association; MF = multifidus; MF-SSC = MF-SSC muscle complex; OPLL = ossification of the posterior longitudinal ligament; PMLC = posterior neck muscular-ligament complex; ROC = receiver operating characteristic; ROM = range of motion; SSC = semispinalis cervicis.
Illustrations from Walker et al. (pp 80–90). © Barrow Neurological Institute, Phoenix, Arizona.

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Contributor Notes

Correspondence Takashi Fujishiro: Osaka Medical College, Takatsuki, Osaka, Japan. ort167@osaka-med.ac.jp.

INCLUDE WHEN CITING Published online April 30, 2021; DOI: 10.3171/2020.10.SPINE201723.

Disclosures The authors report no conflicts of interest concerning the materials or methods used in this study or the findings specified in this paper.

  • 1

    Hirabayashi K. Expansive open-door laminoplasty for cervical spondylotic myelopathy. Article in Japanese. Shujutsu. 1978;32(11):11591163.

    • Search Google Scholar
    • Export Citation
  • 2

    Oyama M, Hattori S, Morikawa N, et al. . A new method of cervical laminectomy. Article in Japanese. Cent Jpn J Orthop Traumatol. 1973;16(3):792794.

    • Search Google Scholar
    • Export Citation
  • 3

    Hirabayashi K, Watanabe K, Wakano K, et al. . Expansive open-door laminoplasty for cervical spinal stenotic myelopathy. Spine (Phila Pa 1976).1983;8(7):693699.

    • Search Google Scholar
    • Export Citation
  • 4

    Matsunaga S, Sakou T, Nakanisi K. Analysis of the cervical spine alignment following laminoplasty and laminectomy. Spinal Cord. 1999;37(1):2024.

    • Search Google Scholar
    • Export Citation
  • 5

    Michael KW, Neustein TM, Rhee JM. Where should a laminoplasty start? The effect of the proximal level on post-laminoplasty loss of lordosis. Spine J. 2016;16(6):737741.

    • Search Google Scholar
    • Export Citation
  • 6

    Cheung JPY, Cheung PWH, Law K, et al. . Postoperative rigid cervical collar leads to less axial neck pain in the early stage after open-door laminoplasty—a single-blinded randomized controlled trial. Neurosurgery. 2019;85(3):325334.

    • Search Google Scholar
    • Export Citation
  • 7

    Hida T, Sakai Y, Ito K, et al. . Collar fixation is not mandatory after cervical laminoplasty: a randomized controlled trial. Spine (Phila Pa 1976).2017;42(5):E253E259.

    • Search Google Scholar
    • Export Citation
  • 8

    Takeuchi K, Yokoyama T, Aburakawa S, et al. . Axial symptoms after cervical laminoplasty with C3 laminectomy compared with conventional C3-C7 laminoplasty: a modified laminoplasty preserving the semispinalis cervicis inserted into axis. Spine (Phila Pa 1976).2005;30(22):25442549.

    • Search Google Scholar
    • Export Citation
  • 9

    Kimura I, Shingu H, Nasu Y. Long-term follow-up of cervical spondylotic myelopathy treated by canal-expansive laminoplasty. J Bone Joint Surg Br. 1995;77(6):956961.

    • Search Google Scholar
    • Export Citation
  • 10

    Suda K, Abumi K, Ito M, et al. . Local kyphosis reduces surgical outcomes of expansive open-door laminoplasty for cervical spondylotic myelopathy. Spine (Phila Pa 1976).2003;28(12):12581262.

    • Search Google Scholar
    • Export Citation
  • 11

    Lafage R, Challier V, Liabaud B, et al. . Natural head posture in the setting of sagittal spinal deformity: validation of chin-brow vertical angle, slope of line of sight, and McGregor’s slope with health-related quality of life. Neurosurgery. 2016;79(1):108115.

    • Search Google Scholar
    • Export Citation
  • 12

    Tang JA, Scheer JK, Smith JS, et al. . The impact of standing regional cervical sagittal alignment on outcomes in posterior cervical fusion surgery. Neurosurgery. 2012;71(3):662669.

    • Search Google Scholar
    • Export Citation
  • 13

    Koda M, Furuya T, Kinoshita T, et al. . Dropped head syndrome after cervical laminoplasty: a case control study. J Clin Neurosci. 2016;32:8890.

    • Search Google Scholar
    • Export Citation
  • 14

    Odate S, Shikata J, Soeda T. Catastrophic dropped head syndrome requiring multiple reconstruction surgeries after cervical laminoplasty. Spine Surg Relat Res. 2018;2(3):243247.

    • Search Google Scholar
    • Export Citation
  • 15

    Choi I, Roh SW, Rhim SC, Jeon SR. The time course of cervical alignment after cervical expansive laminoplasty: determining optimal cut-off preoperative angle for predicting postoperative kyphosis. Medicine (Baltimore). 2018;97(47):e13335.

    • Search Google Scholar
    • Export Citation
  • 16

    Cao J, Zhang J, Yang D, et al. . Multivariate analysis of factors associated with kyphotic deformity after laminoplasty in cervical spondylotic myelopathy patients without preoperative kyphotic alignment. Sci Rep. 2017;7(1):43443.

    • Search Google Scholar
    • Export Citation
  • 17

    Lee BJ, Park JH, Jeon SR, et al. . Importance of the preoperative cross-sectional area of the semispinalis cervicis as a risk factor for loss of lordosis after laminoplasty in patients with cervical spondylotic myelopathy. Eur Spine J. 2018;27(11):27202728.

    • Search Google Scholar
    • Export Citation
  • 18

    Sakai K, Yoshii T, Hirai T, et al. . Cervical sagittal imbalance is a predictor of kyphotic deformity after laminoplasty in cervical spondylotic myelopathy patients without preoperative kyphotic alignment. Spine (Phila Pa 1976).2016;41(4):299305.

    • Search Google Scholar
    • Export Citation
  • 19

    Fujishiro T, Nakano A, Yano T, et al. . Significance of flexion range of motion as a risk factor for kyphotic change after cervical laminoplasty. J Clin Neurosci. 2020;76:100106.

    • Search Google Scholar
    • Export Citation
  • 20

    Lee SH, Son DW, Lee JS, et al. . Does extension dysfunction affect postoperative loss of cervical lordosis in patients who undergo laminoplasty? Spine (Phila Pa 1976).2019;44(8):E456E464.

    • Search Google Scholar
    • Export Citation
  • 21

    Usami Y, Nakaya Y, Hayama S, et al. . Impact of multifidus muscle swelling on C5 palsy after cervical laminoplasty. Spine (Phila Pa 1976).2020;45(1):E10E17.

    • Search Google Scholar
    • Export Citation
  • 22

    Fujishiro T, Nakano A, Baba I, et al. . Double-door cervical laminoplasty with suture anchors: evaluation of the clinical performance of the constructs. Eur Spine J. 2017;26(4):11211128.

    • Search Google Scholar
    • Export Citation
  • 23

    Nakaya Y, Nakano A, Fujiwara K, et al. . Percutaneous ultrasonographic evaluation of the spinal cord after cervical laminoplasty: time-dependent changes. Eur Spine J. 2018;27(11):27632771.

    • Search Google Scholar
    • Export Citation
  • 24

    Oichi T, Oshima Y, Taniguchi Y, et al. . Cervical anterolisthesis: a predictor of poor neurological outcomes in cervical spondylotic myelopathy patients after cervical laminoplasty. Spine (Phila Pa 1976).2016;41(8):E467E473.

    • Search Google Scholar
    • Export Citation
  • 25

    Suzuki A, Daubs MD, Inoue H, et al. . Prevalence and motion characteristics of degenerative cervical spondylolisthesis in the symptomatic adult. Spine (Phila Pa 1976).2013;38(17):E1115E1120.

    • Search Google Scholar
    • Export Citation
  • 26

    Lafage R, Ferrero E, Henry JK, et al. . Validation of a new computer-assisted tool to measure spino-pelvic parameters. Spine J. 2015;15(12):24932502.

    • Search Google Scholar
    • Export Citation
  • 27

    Iyer S, Lenke LG, Nemani VM, et al. . Variations in occipitocervical and cervicothoracic alignment parameters based on age: a prospective study of asymptomatic volunteers using full-body radiographs. Spine (Phila Pa 1976).2016;41(23):18371844.

    • Search Google Scholar
    • Export Citation
  • 28

    Fortin M, Dobrescu O, Jarzem P, et al. . Quantitative magnetic resonance imaging analysis of the cervical spine extensor muscles: intrarater and interrater reliability of a novice and an experienced rater. Asian Spine J. 2018;12(1):94102.

    • Search Google Scholar
    • Export Citation
  • 29

    Vasavada A, Ward S, Delp AL, Lieber RL. Architectural design and function of human back muscles. In: Pepper D, LoGiudice B, eds.The Spine. 6th ed. Elsevier;2011:5469.

    • Search Google Scholar
    • Export Citation
  • 30

    Nolan JP Jr, Sherk HH. Biomechanical evaluation of the extensor musculature of the cervical spine. Spine (Phila Pa 1976).1988;13(1):911.

    • Search Google Scholar
    • Export Citation
  • 31

    Hou X, Lu S, Wang B, et al. . Morphologic characteristics of the deep cervical paraspinal muscles in patients with single-level cervical spondylotic myelopathy. World Neurosurg. 2020;134:e166e171.

    • Search Google Scholar
    • Export Citation
  • 32

    Guildford JP. Fundamental Statistics in Psychology and Education. McGraw-Hill;1956.

  • 33

    Weir JP. Quantifying test-retest reliability using the intraclass correlation coefficient and the SEM. J Strength Cond Res. 2005;19(1):231240.

    • Search Google Scholar
    • Export Citation
  • 34

    Swets JA. Measuring the accuracy of diagnostic systems. Science. 1988;240(4857):12851293.

  • 35

    DeLong ER, DeLong DM, Clarke-Pearson DL. Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics. 1988;44(3):837845.

    • Search Google Scholar
    • Export Citation
  • 36

    Machino M, Ando K, Kobayashi K, et al. . Postoperative kyphosis in cervical spondylotic myelopathy: cut-off preoperative angle for predicting the postlaminoplasty kyphosis. Spine (Phila Pa 1976).2020;45(10):641648.

    • Search Google Scholar
    • Export Citation
  • 37

    Tamai K, Suzuki A, Yabu A, et al. . Clinical impact of cervical imbalance on surgical outcomes of laminoplasty: a propensity score-matching analysis. Clin Spine Surg. 2020;33(1):E1E7.

    • Search Google Scholar
    • Export Citation
  • 38

    Sakaura H, Ohnishi A, Yamagishi A, Ohwada T. Differences in postoperative changes of cervical sagittal alignment and balance after laminoplasty between cervical spondylotic myelopathy and cervical ossification of the posterior longitudinal ligament. Global Spine J. 2019;9(3):266271.

    • Search Google Scholar
    • Export Citation
  • 39

    Lee TT, Manzano GR, Green BA. Modified open-door cervical expansive laminoplasty for spondylotic myelopathy: operative technique, outcome, and predictors for gait improvement. J Neurosurg. 1997;86(1):6468.

    • Search Google Scholar
    • Export Citation
  • 40

    Kawaguchi Y, Matsui H, Ishihara H, et al. . Surgical outcome of cervical expansive laminoplasty in patients with diabetes mellitus. Spine (Phila Pa 1976).2000;25(5):551555.

    • Search Google Scholar
    • Export Citation
  • 41

    Handa Y, Kubota T, Ishii H, et al. . Evaluation of prognostic factors and clinical outcome in elderly patients in whom expansive laminoplasty is performed for cervical myelopathy due to multisegmental spondylotic canal stenosis. A retrospective comparison with younger patients. J Neurosurg. 2002;96(2)(suppl):173179.

    • Search Google Scholar
    • Export Citation
  • 42

    Kim HJ, Moon SH, Kim HS, et al. . Diabetes and smoking as prognostic factors after cervical laminoplasty. J Bone Joint Surg Br. 2008;90(11):14681472.

    • Search Google Scholar
    • Export Citation
  • 43

    Iizuka H, Shimizu T, Tateno K, et al. . Extensor musculature of the cervical spine after laminoplasty: morphologic evaluation by coronal view of the magnetic resonance image. Spine (Phila Pa 1976).2001;26(20):22202226.

    • Search Google Scholar
    • Export Citation

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