Evaluating a paradigm shift from anterior decompression and fusion to muscle-preserving selective laminectomy: a single-center study of degenerative cervical myelopathy

Kazuya Kitamura MD, PhD1,2,3, Eddie de Dios MD3, Gergely Bodon MD4, Laszlo Barany MD, PhD5, and Anna MacDowall MD, PhD3
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  • 1 Department of Orthopaedic Surgery, National Defense Medical College, Saitama, Japan;
  • | 2 Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan;
  • | 3 Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden;
  • | 4 Department of Orthopaedic and Trauma Surgery, Klinikum Esslingen, Esslingen am Neckar, Germany; and
  • | 5 Department of Neurosurgery, University of Erlangen, Erlangen, Germany
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OBJECTIVE

Muscle-preserving selective laminectomy (SL) is an alternative to conventional decompression surgery in patients with degenerative cervical myelopathy (DCM). It is less invasive, preserves the extensor musculature, and maintains the range of motion of the cervical spine. Therefore, the preferred treatment for DCM at the authors’ institution has changed from anterior decompression and fusion (ADF), including anterior cervical discectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF), toward SL. The aim of this study was to evaluate surgical outcomes before and after this paradigm shift with patient-reported outcome measures (PROMs), complications, reoperations, and cost-effectiveness.

METHODS

This study was a retrospective register-based cohort study. All patients with DCM who underwent ADF or SL at the authors’ institution from 2008 to 2019 were reviewed. Using ANCOVA, changes in PROMs from baseline to the 2-year follow-up were compared between the two groups, adjusting for clinicodemographic parameters, baseline PROMs, number of decompressed levels, and MRI measurements (C2–7 Cobb angle, C2–7 sagittal vertical axis [SVA], and modified K-line interval [mK-line INT]). The PROMs, including the European Myelopathy Score (EMS), the Neck Disability Index (NDI), and the EQ-5D, were collected from the national Swedish Spine Register. Complications, reoperations, and in-hospital treatment costs were also compared between the two groups.

RESULTS

Ninety patients (mean age 60.7 years, 51 men [57%]) were included in the ADF group and 63 patients (mean age 68.8 years, 41 men [65%]) in the SL group. The ADF and SL groups had similar PROMs at baseline. The preoperative MR images showed similar C2–7 Cobb angles (10.7° [ADF] vs 14.1° [SL], p = 0.12) and mK-line INTs (4.08 vs 4.88 mm, p = 0.07), but different C2–7 SVA values (16.2 vs 19.3 mm, p = 0.04). The comparison of ANCOVA-adjusted mean changes in PROMs from baseline to the 2-year follow-up presented no significant differences between the groups (EMS, p = 0.901; NDI, p = 0.639; EQ-5D, p = 0.378; and EQ-5D health, p = 0.418). The overall complication rate was twice as high in the ADF group (22.2% vs 9.5%, p = 0.049), while the reoperation rate was comparable (16.7% vs 7.9%, p = 0.146). The average in-hospital treatment cost per patient was $6617 (USD) for SL, $7046 for ACDF, and $12,000 for ACCF.

CONCLUSIONS

SL provides similar PROMs after 2 years, a significantly lower complication rate, and better cost-effectiveness compared with ADF.

ABBREVIATIONS

ACCF = anterior cervical corpectomy and fusion; ACDF = anterior cervical discectomy and fusion; ADF = anterior decompression and fusion; DCM = degenerative cervical myelopathy; EMS = European Myelopathy Score; LOS = length of stay; MCID = minimal clinically important difference; mJOA = modified Japanese Orthopaedic Association; mKl-line INT = modified K-line interval; NDI = Neck Disability Index; PROM = patient-reported outcome measure; QOL = quality of life; SAE = serious adverse event; SL = selective laminectomy; SVA = sagittal vertical axis; VAS = visual analog scale.

Supplementary Materials

    • Supplementary Data (PDF 436 KB)

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