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Cervical Laminoplasty for Multilevel Cervical Myelopathy  [PDF]
Murali Krishna Sayana,Hassan Jamil,Ashley Poynton
Advances in Orthopedics , 2011, DOI: 10.4061/2011/241729
Abstract: Cervical spondylotic myelopathy can result from degenerative cervical spondylosis, herniated disk material, osteophytes, redundant ligamentum flavum, or ossification of the posterior longitudinal ligament. Surgical intervention for multi-level myelopathy aims to decompress the spinal cord and maintain stability of the cervical spine. Laminoplasty was major surgical advancement as laminectomy resulted in kyphosis and unsatisfactory outcomes. Hirabayashi popularised the expansive open door laminoplasty which was later modified several surgeons. Laminoplasty has changed the way surgeons approach multilevel cervical spondylotic myelopathy. 1. Introduction Chronic compression of the cervical spinal cord leads to a clinical syndrome of cervical spondylotic myelopathy (CSM). In degenerative cervical spondylosis, herniated disk material, osteophytes, redundant ligamentum flavum, or ossification of the PLL (OPLL) can all cause spinal cord compression. The effect on spinal cord compression is much more pronounced if a patient has a congentially small spinal canal. The aetiopathogenesis, clinical manifestations, investigations, and nonoperative management are discussed in other articles of this special edition. The primary aims of surgical intervention for multilevel myelopathy are to decompress the spinal cord and maintain stability of the cervical spine. Secondary aims are to minimize complications which include long-term pain and motion loss. This can be achieved by anterior approach and/or posterior approach to cervical spine. Anterior approach would involve multilevel discectomy at times with corpectomy and fusion. Posterior approach would involve laminectomy with or without fusion or laminoplasty. This article will focus on cervical laminoplasty for multilevel myelopathy. 2. Evolution of Laminoplasty Kirita, in 1968, devised a sophisticated operative technique, in which the laminae were thinned and divided at the midline using a high-speed drill followed by their en bloc resection to achieve total decompression of the compressed spinal cord [1]. Although this technique improved the results and bettered the technique of conventional laminectomy, complications like postoperative kyphosis and membrane formation resulted. Oyama et al. reported a Z-plasty (Hattori technique) of the cervical spine laminae in 1973 [2]. This procedure was technically demanding and had not been adopted widely other surgeons. In the year 1977, Hirabayashi et al. described an expansive open door laminoplasty (ELAP), which is a relatively easier and safer procedure than laminectomy [3].
Laminoplasty and Laminectomy Hybrid Decompression for the Treatment of Cervical Spondylotic Myelopathy with Hypertrophic Ligamentum Flavum: A Retrospective Study  [PDF]
Huairong Ding, Yuan Xue, Yanming Tang, Dong He, Zhiyang Li, Ying Zhao, Yaqi Zong, Yi Wang, Pei Wang
PLOS ONE , 2014, DOI: 10.1371/journal.pone.0095482
Abstract: Objective To report the outcomes of a posterior hybrid decompression protocol for the treatment of cervical spondylotic myelopathy (CSM) associated with hypertrophic ligamentum flavum (HLF). Background Laminoplasty is widely used in patients with CSM; however, for CSM patients with HLF, traditional laminoplasty does not include resection of a pathological ligamentum flavum. Methods This study retrospectively reviewed 116 CSM patients with HLF who underwent hybrid decompression with a minimum of 12 months of follow-up. The procedure consisted of reconstruction of the C4 and C6 laminae using CENTERPIECE plates with spinous process autografts, and resection of the C3, C5, and C7 laminae. Surgical outcomes were assessed using Japanese Orthopedic Association (JOA) score, recovery rate, cervical lordotic angle, cervical range of motion, spinal canal sagittal diameter, bone healing rates on both the hinge and open sides, dural sac expansion at the level of maximum compression, drift-back distance of the spinal cord, and postoperative neck pain assessed by visual analog scale. Results No hardware failure or restenosis was noted. Postoperative JOA score improved significantly, with a mean recovery rate of 65.3±15.5%. Mean cervical lordotic angle had decreased 4.9 degrees by 1 year after surgery (P<0.05). Preservation of cervical range of motion was satisfactory postoperatively. Bone healing rates 6 months after surgery were 100% on the hinge side and 92.2% on the open side. Satisfactory decompression was demonstrated by a significantly increased sagittal canal diameter and cross-sectional area of the dural sac together with a significant drift-back distance of the spinal cord. The dural sac was also adequately expanded at the time of the final follow-up visit. Conclusion Hybrid laminectomy and autograft laminoplasty decompression using Centerpiece plates may facilitate bone healing and produce a comparatively satisfactory prognosis for CSM patients with HLF.
Efficacy of Modified Expansive Open-Door Laminoplasty for Cervical Myelopathy  [PDF]
Eiren Toh, Yukihiro Yamamoto, Daisuke Sakai, Masato Sato, Masahiko Watanabe, Joji Mochida
Surgical Science (SS) , 2012, DOI: 10.4236/ss.2012.312112
Abstract: Objectives: Expansive open-door laminoplasty is used widely for the treatment of cervical spondylosis and Ossification of the Posterior Longitudinal Ligament (OPLL). We have developed a unique modification of the surgical procedure to keep the lamina expanded, with the aim of preventing reclosure of the vertebral arch. To examine the effectiveness of and problems associated with the modified expansive open-door laminoplasty technique developed at our institution by evaluating the surgical outcomes. Methods and Materials: Fifty-six patients (46 men and 10 women) underwent the modified expansive open-door laminoplasty and were followed up for at least 1 year. Thirty-eight had Cervical Spondylotic Myelopathy (CSM) and 18 had OPLL. The patients were 34 to 89 years of age (mean: 60.9 years). The severity of myelopathy was evaluated according to the Japanese Orthopaedic Association’s scoring system. Surgical outcomes were evaluated using Hirabayashi’s system for determining recovery rate. In the radiographic analysis, the following angles were measured before and after surgery: lordosis angle and Range of Motion (ROM) at C2 - C7 on lateral radiographs, and opening angle on computerized tomography (CT). The presence and absence of axial pain and postoperative C5 palsy were also evaluated. Results: The rate of JOA score improvement was about 60%, the lordosis angle observed on lateral radiographs was maintained. ROM decreased after surgery in both the CSM and OPLL groups, and the extent of the decrease was similar to that in previous reports. The opening angle of the lamina was 62°- 65° on post-operative CT. Axial pain was reported by 34% of patients. Conclusions: Our modified procedure produced satisfactory postoperative outcomes based on the clinical data and imaging findings for both CSM and OPLL. The advantage of this procedure is that it avoids potential complications associated with bone grafts or implants.
Cervical Laminoplasty for Multilevel Cervical Myelopathy  [PDF]
Murali Krishna Sayana,Hassan Jamil,Ashley Poynton
Advances in Orthopedics , 2011, DOI: 10.4061/2011/241729
Abstract: Cervical spondylotic myelopathy can result from degenerative cervical spondylosis, herniated disk material, osteophytes, redundant ligamentum flavum, or ossification of the posterior longitudinal ligament. Surgical intervention for multi-level myelopathy aims to decompress the spinal cord and maintain stability of the cervical spine. Laminoplasty was major surgical advancement as laminectomy resulted in kyphosis and unsatisfactory outcomes. Hirabayashi popularised the expansive open door laminoplasty which was later modified several surgeons. Laminoplasty has changed the way surgeons approach multilevel cervical spondylotic myelopathy.
Operative Techniques for Cervical Radiculopathy and Myelopathy  [PDF]
C. Moran,C. Bolger
Advances in Orthopedics , 2012, DOI: 10.1155/2012/916149
Abstract: The surgical treatment of cervical spondylosis and resulting cervical radiculopathy or myelopathy has evolved over the past century. Surgical options for dorsal decompression of the cervical spine includes the traditional laminectomy and laminoplasty, first described in Asia in the 1970's. More recently the dorsal approch has been explored in terms of minimally invasive options including foraminotomies for nerve root descompression. Ventral decompression and fusion techniques are also described in the article, including traditional anterior cervical discectomy and fusion, strut grafting and cervical disc arthroplasty. Overall, the outcome from surgery is determined by choosing the correct surgery for the correct patient and pathology and this is what we hope to explain in this brief review.
Operative Outcomes for Cervical Degenerative Disease: A Review of the Literature  [PDF]
Kazuya Nishizawa,Kanji Mori,Yasuo Saruhashi,Yoshitaka Matsusue
ISRN Orthopedics , 2012, DOI: 10.5402/2012/165050
Abstract: To date, several studies were conducted to find which procedure is superior to the others for the treatment of cervical myelopathy. The goal of surgical treatment should be to decompress the nerves, restore the alignment of the vertebrae, and stabilize the spine. Consequently, the treatment of cervical degenerative disease can be divided into decompression of the nerves alone, fixation of the cervical spine alone, or a combination of both. Posterior approaches have historically been considered safe and direct methods for cervical multisegment stenosis and lordotic cervical alignment. On the other hand, anterior approaches are indicated to the patients with cervical compression with anterior factors, relatively short-segment stenosis, and kyphotic cervical alignment. Recently, posterior approach is widely applied to several cervical degenerative diseases due to the development of various instruments. Even if it were posterior approach or anterior approach, each would have its complication. There is no Class I or II evidence to suggest that laminoplasty is superior to other techniques for decompression. However, Class III evidence has shown equivalency in functional improvement between laminoplasty, anterior cervical fusion, and laminectomy with arthrodesis. Nowadays, each surgeon tends to choose each method by evaluating patients’ clinical conditions. 1. Introduction Cervical degenerative disease can result in manifestations distinct from degenerative disease of extremities. The cervical vertebrae contain the spinal cord; its compression by means of deteriorated cervical spine may lead to a generalized debility that sometimes culminates in tetraparesis as well as significant pain. When symptoms do not respond to conservative treatment, surgical treatment is considered. The goal of surgical treatment should be to decompress the nerves, restore the alignment of the vertebrae, and stabilize the spine. Consequently, the treatment of cervical degenerative disease can be divided into decompression of the nerves alone, fixation of the cervical spine alone or a combination of both. In addition, it can be divided into anterior or posterior procedures in terms of approach to the cervical spine. The purpose of this paper is to review the features of the operative treatment of cervical degenerative disease and outline the advantages and disadvantages of each approach and technique. 2. Posterior Approach Posterior approaches have historically been considered safe and direct methods for cervical compression myelopathy with favorable clinical outcomes without fatal
Cervical Spondylotic Myelopathy: Factors in Choosing the Surgical Approach  [PDF]
Praveen K. Yalamanchili,Michael J. Vives,Saad B. Chaudhary
Advances in Orthopedics , 2012, DOI: 10.1155/2012/783762
Abstract: Cervical spondylotic myelopathy is a progressive disease and a common cause of acquired disability in the elderly. A variety of surgical interventions are available to halt or improve progression of the disease. Surgical options include anterior or posterior approaches with and without fusion. These include anterior cervical discectomy and fusion, anterior cervical corpectomy and fusion, cervical disc replacement, laminoplasty, laminectomy with and without fusion, and combined approaches. Recent investigation into the ideal approach has not found a clearly superior choice, but individual patient characteristics can guide treatment. 1. Introduction Cervical degenerative disease, or cervical spondylosis, is an age-related change affecting the cervical spinal column. Radiographic evidence of cervical spondylosis can be found in 85% of individuals over sixty years of age [1]. Certain occupations and activities that place increased loads on the head may have a predisposition for cervical degenerative disease. Cervical myelopathy is a clinical syndrome that may result from cervical spondylosis. When cervical myelopathy is a result of spondylosis, it is referred to as cervical spondylotic myelopathy (CSM). Cervical spondylotic myelopathy manifests as long-tract clinical findings in the upper and lower extremities caused by spinal cord compression [2]. Patients present with a variety of findings, including clumsiness, loss of manual dexterity, difficulty with gait or balance, urinary complaints, motor weakness, sensory changes, and abnormal or pathologic reflexes. Appropriate initial imaging of CSM consists of plain static radiographs and flexion extension views to evaluate for instability. The advancing imaging of choice is magnetic resonance imaging (MRI) of the cervical spine to evaluate the soft tissues about the spine and the spinal cord. Clinical correlation is important when evaluating MRI changes as MRI can be overly sensitive and reveal abnormalities in asymptomatic adults [3]. Electrodiagnostic studies may be helpful to exclude other causes of upper extremity symptoms, such as suspected peripheral nerve entrapment syndromes. The natural history of CSM is a progression of symptoms in a stepwise fashion over time [4]. Patients with mild myelopathy (that does not interfere with function) may be offered a trial of nonoperative management, whereas progressive, long-standing, or severe myelopathy is candidates for surgical decompression of the spinal cord in the affected areas [5, 6]. Operative intervention may be via anterior, posterior, or combined
Operative Techniques for Cervical Radiculopathy and Myelopathy  [PDF]
C. Moran,C. Bolger
Advances in Orthopedics , 2012, DOI: 10.1155/2012/916149
Abstract: The surgical treatment of cervical spondylosis and resulting cervical radiculopathy or myelopathy has evolved over the past century. Surgical options for dorsal decompression of the cervical spine includes the traditional laminectomy and laminoplasty, first described in Asia in the 1970's. More recently the dorsal approch has been explored in terms of minimally invasive options including foraminotomies for nerve root descompression. Ventral decompression and fusion techniques are also described in the article, including traditional anterior cervical discectomy and fusion, strut grafting and cervical disc arthroplasty. Overall, the outcome from surgery is determined by choosing the correct surgery for the correct patient and pathology and this is what we hope to explain in this brief review. 1. Introduction Cervical spondylosis is a common pathology, and the surgical treatment of the resulting radiculopathy, myelopathy, or myeloradiculopathy has evolved over the past century. The basic aim of all techniques is to decompress the affected neural structure. Advances in fixation techniques [1–3] and motion-preserving options [4–7] are more recent elements of this evolution. Once the decision is made to manage the patient operatively the principal decision is whether to choose the ventral or the dorsal approach. In cervical spondylosis several variables including the location of pathology (ventral, dorsal, circumferential); extent of pathology (limited to interspace, extensive behind vertebral body); the number of levels affected; the presence of instability or the presence of kyphotic deformity require consideration. In general, any procedure chosen should decompress the affected spinal cord or nerve roots, maintain or restore stability, and correct or prevent kyphotic deformity. 2. Dorsal Decompression A range of posterior surgical procedures exist, including laminectomy, laminoplasty, and laminectomy with posterior fusion. Until the 1960’s the traditional way to decompress the cervical spine in spondylotic patients was via a dorsal approach and a decompressive laminectomy. This surgery effectively enlarges the spinal canal area, allowing the spinal canal to drift away from ventral compression, however, while doing this it also destabilizes the dorsal structures and can lead to progressive kyphotic deformity. 3. Laminectomy A high speed drill is used to create a gutter, through the outer cortical bone and cancellous bone to the thin inner cortical bone at the junction of the lamina and the medial aspect of the lateral mass. Using a 1?mm Kerrison rongeur the
Lift-up laminoplasty for myelopathy caused by ossification of the posterior longitudinal ligament of the cervical spine
Takami T,Ohata K,Goto T,Nishikawa M
Neurology India , 2004,
Abstract: Background and Aims: We have utilized lift-up laminoplasty to treat patients with myelopathy caused by ossification of the posterior longitudinal ligament (OPLL) of the cervical spine. The preliminary surgical outcome with computer-assisted morphological assessment is presented. Material and Methods: The surgical technique of lift-up laminoplasty includes standard posterior exposure of the cervical spine, en-bloc laminectomy, and expansion of the cervical canal by lift-up of the laminae with custom-designed hydroxyapatite laminar spacers and stabilization of the laminae using titanium miniplates. From 1998 to 2003, 10 consecutive patients with cervical myelopathy secondary to OPLL have been treated with this method and comprehensively evaluated. Care was taken to tailor the treatment to individual patients by using different sizes of spacers to adjust the degree of expansion depending on the amount of stenosis of the cervical spine. The degree of expansion of the cervical canal was altered by design, based on the preoperative imaging simulation. Results: Preliminary surgical outcome, evaluated at 6 months after surgery, revealed a significant improvement of neurological function. Image analysis revealed that the cervical canals were significantly expanded, with a mean reduction of 13.1% in the stenosis ratio. Lift-up laminoplasty was effective in the treatment of patients with myelopathy secondary to cervical OPLL, and the amount of expansion could be individually adjusted at the discretion of the surgeon. Conclusion: Although analysis with a larger population and a longer follow-up period needs to be undertaken, our method of lift-up laminoplasty appears to be a viable choice among standard posterior cervical approaches for cervical OPLL.
The results of surgical treatment for cervical spondylotic myelopathy  [PDF]
Radulovi? Danilo,Ivanovi? S.,Jokovi? M.,Tasi? G.
Acta Chirurgica Iugoslavica , 2005, DOI: 10.2298/aci0501091r
Abstract: Objective: Cervical spondylotic myelopathy is the most serious consequence of cervical intervertebral disc degeneration. The purpose of this study is to evaluate functional results of surgical treatment of patients with cervical spondylotic myelopathy who underwent anterior or posterior decompressive operations. Methods: we prospectively analyzed 57 patients with cervical spondylotic myelopathy who were operated in Institute for Neurosurgery in Belgrade (1995-2002). The severity of myelopathy is graded by Nurick myelopathy grading system. The average follow-up period was 20 months. Results: Postoperative improvement showed 75% of patients and 21% remained unchanged. Myelopathy worsening was observed in two patients, 4%. We didn't have serious operative complications. Selection of surgical approach was not significantly correlated with surgical outcome. Conclusion: surgical decompression of cervical medulla is safe treatment that gives good chances for functional recovery in patients with cervical spondylotic myelopathy.
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