A less-invasive cervical laminoplasty for spondylotic myelopathy that preserves the semispinalis cervicis muscles and nuchal ligament

Clinical article

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Object

Modified cervical laminoplasty techniques have been developed to reduce postoperative axial neck pain and preserve function in patients with cervical spondylotic myelopathy (CSM). However, the previous studies demonstrating satisfactory surgical outcomes had a retrospective design. Here, the authors aimed to prospectively evaluate the 2-year outcomes of a modified cervical laminoplasty technique for CSM that preserves the paravertebral muscles.

Methods

Outcomes were analyzed for 40 patients (22 men and 18 women; mean age, 66.6 years; age range 44–92 years) with CSM who underwent C4–6 laminoplasty with C-3 and C-7 partial laminectomies or C-3 total and C-7 partial laminectomies and received hydroxyapatite spacers. Neurological, pain severity, and spinal radiographic evaluations were performed preoperatively and at 3, 6, 12, 18, and 24 months postoperatively. Plain radiography and MRI of the cervical spine were performed to evaluate the range of motion (ROM), sagittal alignment, and cross-sectional areas of the deep extensor muscles. The extent of bone–spacer bonding and bony union at the gutter was assessed by CT.

Results

The mean preoperative Japanese Orthopaedic Association CSM score was 10.2, but it increased to 14.4 by 24 months after surgery. Eleven patients had axial neck pain preoperatively, but only 3 reported mild pain at 24 months, and in all 3 cases the pain was mild. The mean angle of lordosis was 11.7° preoperatively and 12.0° 2 years postoperatively. Although the ROM at the C2–7 levels was significantly reduced 3 months postoperatively, an increasing trend was observed up to 12 months, and 86% of the preoperative ROM was achieved by 2 years postoperatively. The mean paravertebral muscle cross-sectional areas were 833 ± 215 mm2 preoperatively and 763 ± 197 mm2 24 months postoperatively, but the difference was not statistically significant. The rates of bone–spacer bonding and bony union at the gutter were low during the early stages but increased to 90% and 93%, respectively, by 2 years after surgery.

Conclusions

The modified laminoplasty technique used in this study ensured very good neurological status and ROM after 2 years and was associated with low incidences of axial neck pain and serious complications. This simple and easy operative method could benefit future laminoplasty protocols.

Abbreviations used in this paper:CSM = cervical spondylotic myelopathy; HA = hydroxyapatite; JOA = Japanese Orthopaedic Association; Oc = occiput; ROM = range of motion.

Article Information

Address correspondence to: Masayuki Umeda, M.D., Ph.D., Department of Orthopedic Surgery, Kansai Medical University, 2-3-1 Shinmachi, Hirakata, Osaka 573-1191, Japan. email: gnsumd@hotmail.com.

Please include this information when citing this paper: published online March 29, 2013; DOI: 10.3171/2013.2.SPINE12468.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Images obtained in a 72-year-old man with CSM. Sagittal plain radiograph (A) and sagittal CT image (B) obtained 2 years after partial laminectomy on the caudal side of the C-3 vertebra and rostral side of the C-7 vertebra.

  • View in gallery

    Illustration of open-door C4–6 laminoplasty with HA spacers. C-3 total laminectomy and C-7 dome decompressions on the proximal ventral side of the arcus vertebrae were performed. The insertions of the paravertebral muscles, including the semispinalis, into the C-2 spinous processes and the continuity of the nuchal ligament and paravertebral muscles at the C-7 spinous processes were completely conserved.

  • View in gallery

    Magnetic resonance images obtained in a 61-year-old woman with CSM. A: Preoperative sagittal T2-weighted MR image demonstrating spinal canal compression at the C2–3 and C6–7 levels. B: Postoperative sagittal T2-weighted MR image showing decompression at the C2–3 and C6–7 levels by C-3 total and C-7 partial laminectomies, respectively.

  • View in gallery

    Changes in the neurological status evaluated preoperatively and postoperatively according to the CSM scoring system of the JOA. The bars indicate standard deviations. *p < 0.05 compared with the preoperative JOA scores by the Mann-Whitney U-test.

  • View in gallery

    Incidences of axial neck pain (AP) preoperatively and at 3, 6, 12, 18, and 24 months postoperatively. Pain was classified into 4 grades: severe (pain medication or local injection regularly needed), moderate (physiotherapy or compression regularly needed), mild (no treatment needed), and none.

  • View in gallery

    Changes in the cross-sectional areas of the cervical posterior deep extensor paravertebral muscles (PVM) calculated from preoperative and postoperative axial T2-weighted MR images. The bars indicate standard deviations. *p < 0.05 compared with the preoperative measurements by the Mann-Whitney U-test.

  • View in gallery

    Postoperative changes in bone–spacer bonding and bony union at the gutters. Bone–spacer bonding was defined as the absence of a clear space between the bone and the spacer. Bony union at the gutters was considered to have occurred when both cortices were observed.

References

  • 1

    Aita IWadano YYabuki T: Curvature and range of motion of the cervical spine after laminaplasty. J Bone Joint Surg Am 82-A:174317482000

  • 2

    Baba HMaezawa YFurusawa NImura STomita K: Flexibility and alignment of the cervical spine after laminoplasty for spondylotic myelopathy. A radiographic study. Int Orthop 19:1161211995

  • 3

    Conley MSMeyer RABloomberg JJFeeback DLDudley GA: Noninvasive analysis of human neck muscle function. Spine (Phila Pa 1976) 20:250525121995

  • 4

    Conley MSStone MHNimmons MDudley GA: Specificity of resistance training responses in neck muscle size and strength. Eur J Appl Physiol Occup Physiol 75:4434481997

  • 5

    Fujimura YNishi Y: Atrophy of the nuchal muscle and change in cervical curvature after expansive open-door laminoplasty. Arch Orthop Trauma Surg 115:2032051996

  • 6

    Fukui KKataoka OSho TSumi M: Pathomechanism, pathogenesis, and results of treatment in cervical spondylotic myelopathy caused by dynamic canal stenosis. Spine (Phila Pa 1976) 15:114811521990

  • 7

    Hidai YEbara SKamimura MTateiwa YItoh HKinoshita T: Treatment of cervical compressive myelopathy with a new dorsolateral decompressive procedure. J Neurosurg 90:2 Suppl1781851999

  • 8

    Higashino KKatoh SSairyo KSakai TKosaka HYasui N: Preservation of C7 spinous process does not influence the long-term outcome after laminoplasty for cervical spondylotic myelopathy. Int Orthop 30:3623652006

  • 9

    Hirabayashi KSatomi K: Operative procedure and results of expansive open-door laminoplasty. Spine (Phila Pa 1976) 13:8708761988

  • 10

    Hosono NSakaura HMukai YFujii RYoshikawa H: C3-6 laminoplasty takes over C3-7 laminoplasty with significantly lower incidence of axial neck pain. Eur Spine J 15:137513792006

  • 11

    Hosono NSakaura HMukai YIshii TYoshikawa H: En bloc laminoplasty without dissection of paraspinal muscles. J Neurosurg Spine 3:29332005

  • 12

    Hosono NSakaura HMukai YYoshikawa H: The source of axial pain after cervical laminoplasty-C7 is more crucial than deep extensor muscles. Spine (Phila Pa 1976) 32:298529882007

  • 13

    Hosono NYonenobu KOno K: Neck and shoulder pain after laminoplasty. A noticeable complication. Spine (Phila Pa 1976) 21:196919731996

  • 14

    Hukuda SOgata MMochizuki TShichikawa K: Laminectomy versus laminoplasty for cervical myelopathy: brief report. J Bone Joint Surg Br 70:3253261988

  • 15

    Iguchi TKanemura AKurihara AKasahara KYoshiya SDoita M: Cervical laminoplasty: evaluation of bone bonding of a high porosity hydroxyapatite spacer. J Neurosurg 98:2 Suppl1371422003

  • 16

    Iizuka HNakagawa YShimegi ATsutsumi SToda NTakagishi K: Clinical results after cervical laminoplasty: differences due to the duration of wearing a cervical collar. J Spinal Disord Tech 18:4894912005

  • 17

    Iizuka HNakajima TIizuka YSorimachi YAra TNishinome M: Cervical malalignment after laminoplasty: relationship to deep extensor musculature of the cervical spine and neurological outcome. J Neurosurg Spine 7:6106142007

  • 18

    Iizuka HShimizu TTateno KToda NEdakuni HShimada H: Extensor musculature of the cervical spine after laminoplasty: morphologic evaluation by coronal view of the magnetic resonance image. Spine (Phila Pa 1976) 26:222022262001

  • 19

    Iwasaki MKawaguchi YKimura TYonenobu K: Long-term results of expansive laminoplasty for ossification of the posterior longitudinal ligament of the cervical spine: more than 10 years follow up. J Neurosurg 96:2 Suppl1801892002

  • 20

    Kaito THosono NMakino TKaneko NNamekata MFuji T: Postoperative displacement of hydroxyapatite spacers implanted during double-door laminoplasty. Clinical article. J Neurosurg Spine 10:5515562009

  • 21

    Kanemura ADoita MIguchi TKasahara KKurosaka MSumi M: Delayed dural laceration by hydroxyapatite spacer causing tetraparesis following double-door laminoplasty. J Neurosurg Spine 8:1211282008

  • 22

    Kang SHRhim SCRoh SWJeon SRBaek HC: Postlaminoplasty cervical range of motion: early results. J Neurosurg Spine 6:3863902007

  • 23

    Kawaguchi YKanamori MIshihara HOhmori KNakamura HKimura T: Minimum 10-year follow-up after en bloc cervical laminoplasty. Clin Orthop Relat Res 4111291392003

  • 24

    Kawaguchi YMatsui HIshihara HGejo RYoshino O: Axial symptoms after en bloc cervical laminoplasty. J Spinal Disord 12:3923951999

  • 25

    Kimura IShingu HNasu Y: Long-term follow-up of cervical spondylotic myelopathy treated by canal-expansive laminoplasty. J Bone Joint Surg Br 77:9569611995

  • 26

    Kimura SHomma TUchiyama SYamazaki AImura K: Posterior migration of cervical spinal cord between split laminae as a complication of laminoplasty. Spine (Phila Pa 1976) 20:128412881995

  • 27

    Lee TTGreen BAGromelski EB: Safety and stability of open-door cervical expansive laminoplasty. J Spinal Disord 11:12151998

  • 28

    McGreger M: The significance of certain measurements of the skull in the diagnosis of basilar impression. Br J Radiol 21:1711811948

  • 29

    Nakano KHarata SSuetsuna FAraki TItoh J: Spinous process-splitting laminoplasty using hydroxyapatite spinous process spacer. Spine (Phila Pa 1976) 17:S41S431992

  • 30

    Nakano NNakano TNakano K: Comparison of the results of laminectomy and open-door laminoplasty for cervical spondylotic myeloradiculopathy and ossification of the posterior longitudinal ligament. Spine (Phila Pa 1976) 13:7927941988

  • 31

    Nolan JPSherk HH: Biomechanical evaluation of the extensor musculature of the cervical spine. Spine (Phila Pa 1976) 13:9111988

  • 32

    Ono ATonosaki YYokoyama TAburakawa STakeuchi KNumasawa T: Surgical anatomy of the nuchal muscles in the posterior cervicothoracic junction: significance of the preservation of the C7 spinous process in cervical laminoplasty. Spine (Phila Pa 1976) 33:E349E3542008

  • 33

    Puttlitz CMDeviren VSmith JAKleinstueck FSTran QNThurlow RW: Biomechanics of cervical laminoplasty: kinetic studies comparing different surgical techniques, temporal effects and the degree of level involvement. Eur Spine J 13:2132212004

  • 34

    Ratliff JKCooper PR: Cervical laminoplasty: a critical review. J Neurosurg 98:3 Suppl2302382003

  • 35

    Rhee JMRegister BHamasaki TFranklin B: Plate-only open door laminoplasty maintains stable spinal canal expansion with high rates of hinge union and no plate failures. Spine (Phila Pa 1976) 36:9142011

  • 36

    Sakaura HHosono NMukai YIwasaki MYoshikawa H: Medium-term outcomes of C3-6 laminoplasty for cervical myelopathy: a prospective study with a minimum 5-year follow-up. Eur Spine J 20:9289332011

  • 37

    Sasai KSaito TAkagi SKato IOgawa R: Cervical curvature after laminoplasty for spondylotic myelopathy—involvement of yellow ligament, semispinalis cervicis muscle, and nuchal ligament. J Spinal Disord 13:26302000

  • 38

    Sasai KUmeda MWakabayashi HMaruyama TIida NAkagi S: [Comparison of bone bonding between spinous process-splitting laminoplasty and en-bloc laminoplasty using hydroxyapatite spacers in cervical spine: minimum 2 years follow-up.]. J Japan Spine Res Society 18:3712007. (Jpn)

  • 39

    Satomi KNishu YKohno THirabayashi K: Long-term follow-up studies of open-door expansive laminoplasty for cervical stenotic myelopathy. Spine (Phila Pa 1976) 19:5075101994

  • 40

    Seichi ATakeshita KOhishi IKawaguchi HAkune TAnamizu Y: Long-term results of double-door laminoplasty for cervical stenotic myelopathy. Spine (Phila Pa 1976) 26:4794872001

  • 41

    Sherk HHStability of the lower cervical spine. Kehr PWeidner A: Cervical Spine. I BerlinSpringer Verlag1987. 5964

  • 42

    Shiraishi TFukuda KYato YNakamura MIkegami T: Results of skip laminectomy-minimum 2-year follow-up study compared with open-door laminoplasty. Spine (Phila Pa 1976) 28:266726722003

  • 43

    Suda KAbumi KIto MShono YKaneda KFujiya M: Local kyphosis reduces surgical outcomes of expansive open-door laminoplasty for cervical spondylotic myelopathy. Spine (Phila Pa 1976) 28:125812622003

  • 44

    Takeshita KSeichi AAkune TKawamura NKawaguchi HNakamura K: Can laminoplasty maintain the cervical alignment even when the C2 lamina is contained?. Spine (Phila Pa 1976) 30:129412982005

  • 45

    Takeuchi KYokoyama TAburakawa SSaito ANumasawa TIwasaki T: 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) 30:254425492005

  • 46

    Takeuchi KYokoyama TOno ANumasawa TWada KItabashi T: Limitation of activities of daily living accompanying reduced neck mobility after laminoplasty preserving or reattaching the semispinalis cervicis into axis. Eur Spine J 17:4154202008

  • 47

    Takeuchi KYokoyama TOno ANumasawa TWada KKumagai G: Cervical range of motion and alignment after laminoplasty preserving or reattaching the semispinalis cervicis inserted into axis. J Spinal Disord Tech 20:5715762007

  • 48

    Takeuchi TShono Y: Importance of preserving the C7 spinous process and attached nuchal ligament in French-door laminoplasty to reduce postoperative axial symptoms. Eur Spine J 16:141714222007

  • 49

    Tomita KKawahara NToribatake YHeller JG: Expansive midline T-saw laminoplasty (modified spinous process-splitting) for the management of cervical myelopathy. Spine (Phila Pa 1976) 23:32371998

  • 50

    Tsuji TAsazuma TMasuoka KYasuoka HMotosuneya TSakai T: Retrospective cohort study between selective and standard C3-7 laminoplasty. Minimum 2-year follow-up study. Eur Spine J 16:207220772007

  • 51

    Vasavada ANLi SDelp SL: Influence of muscle morphometry and moment arms on the moment-generating capacity of human neck muscles. Spine (Phila Pa 1976) 23:4124221998

  • 52

    Yoshida MOtani KShibasaki KUeda S: Expansive laminoplasty with reattachment of spinous process and extensor musculature for cervical myelopathy. Spine (Phila Pa 1976) 17:4914971992

  • 53

    Yukawa YKato FIto KHorie YHida TIto Z: Laminoplasty and skip laminectomy for cervical compressive myelopathy: range of motion, postoperative neck pain, and surgical outcomes in a randomized prospective study. Spine (Phila Pa 1976) 32:198019852007

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