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TOPIC OF THE ISSUE: ORIGINAL ARTICLE
Year : 2012  |  Volume : 60  |  Issue : 2  |  Page : 210-216

Clinical outcomes of two different types of open-door laminoplasties for cervical compressive myelopathy: A prospective study


Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, Sichuan, China

Date of Submission08-Jun-2011
Date of Decision21-Jun-2011
Date of Acceptance01-Sep-2011
Date of Web Publication19-May-2012

Correspondence Address:
Yueming Song
Department of Orthopedics, West China Hospital, Sichuan University, 37# Guoxue Lane, Chengdu, Sichuan - 610 041
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.96403

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 » Abstract 

Background: Hirabayashi open-door laminoplasty is the most typical surgical treatment option for cervical compressive myelopathy, however, this conventional approach has many complications. To minimize these complications, many modified approaches have been devised. Aims: To compare clinical outcomes of two different types of open-door laminoplasties for cervical compressive myelopathy. Materials and Methods: Fifty patients (31 men and 19 women) with cervical compressive myelopathy were prospectively allocated to two groups, 25 patients in each group. Patients in Group A underwent Hirabayashi open-door laminoplasty and patients in Group B underwent modified instrumented approach. The following parameters were studied: operation time, blood loss, perioperative complications, Japanese Orthopedic Association (JOA) scores, axial pain, and short-form 36 (SF-36). Cervical lordosis was reviewed as lordotic angle, measured at C2-C7. Results: Mean operation time and blood loss in both the groups were similar. Perioperative complications occurred more frequently in Group A than in Group B. Although there were no significant differences in postoperative JOA scores between the two groups, axial pain was significantly decreased in Group B at final follow-up. The scores of all subscales of SF-36 were higher in Group B than in Group A. Conclusion: Both the conventional and instrumented techniques provide similar good results but the instrumented technique provided better axial pain relief and lower incidence of perioperative complications.


Keywords: Centerpiece, cervical compressive myelopathy, open-door laminoplasty


How to cite this article:
Wang L, Song Y, Liu L, Liu H, Kong Q, Li T, Zeng J. Clinical outcomes of two different types of open-door laminoplasties for cervical compressive myelopathy: A prospective study. Neurol India 2012;60:210-6

How to cite this URL:
Wang L, Song Y, Liu L, Liu H, Kong Q, Li T, Zeng J. Clinical outcomes of two different types of open-door laminoplasties for cervical compressive myelopathy: A prospective study. Neurol India [serial online] 2012 [cited 2019 Oct 22];60:210-6. Available from: http://www.neurologyindia.com/text.asp?2012/60/2/210/96403



 » Introduction Top


In Asian countries, including China, cervical spondylosis is the common cause of cervical multilevel compressive myelopathy (CSM); other causes include cervical disc herniation (CDH) and ossification of posterior longitudinal ligament (OPLL). As the efficacy of conservative treatment for these diseases is uncertain, surgical treatment is often the option in most cases. Open-door laminoplasty is a well-established procedure and is considered to be a gold standard, especially in China. Hirabayashi open-door laminoplasty is the most classic approach in which the lamina door is kept open by stay sutures and this technique is simpler when compared to other procedures as it does not involve any additional procedure, such as bone grafting or implant placement. [1],[2] This technique results in favorable outcomes, [3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13] However, this procedure has been modified as the procedure is associated with complications like axial pain, loss of range of neck motion, postoperative laminar re-closure and late neurologic deterioration. [14],[15] There have been several modified open-door laminoplasty approaches such as suture anchor and titanium mini-plate fixation with satisfactory clinical outcomes. [16],[17],[18],[19],[20],[21] However, there has been no prospective investigation to study which surgical procedure results in a more favorable outcome and less complications. The purpose of this prospective study was to examine the clinical outcomes in patients with cervical compressive myelopathy treated with either Hirabayashi or instrumented open-door laminoplasty.


 » Materials and Methods Top


This prospective comparative study was designed to evaluate the efficacy of Hirabayashi and titanium mini-plate open-door laminoplasties for cervical multilevel compressive myelopathy. This study had the approval of our institute Ethical Committee. Inclusion criteria were patients with CSM, CDH, and OPLL. Patients with cervical kyphosis, cervical instability, cervical radiculopathy, rheumatoid arthritis, spinal tuberculosis, spondylotic amyotrophy, tumors, trauma, pyogenic spondylitis, and comorbidities such as diabetes mellitus were excluded. Fifty (31 men and 19 women) patients prospectively enrolled between January 2008 and March 2010 were allocated to two groups, 25 patients each, after obtaining informed consent. We allocated the patients to either group according to their hospitalization number. Patients with odd numbers were assigned to Group A and patients with even numbers to Group B. Patients who refused the assigned surgical approach were excluded (especially patients who psychologically refused mental internal fixator) from the study. Patients in Group A underwent classical Hirabayashi open-door laminoplasty and patients in Group B underwent modified open-door laminoplasty with utilization of centerpiece (a type of tailor-made titanium mini-plate, Medtronic Sofamor Danek, Minneapolis, MN). All operations were performed by the same spine surgeons with over 14 years of experience [Table 1].
Table 1: Primary clinical data of the patients in both groups

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Evaluation

Variables evaluated both before surgery and at final follow-up included: operation time, blood loss, perioperative complications (such as infection, C5 palsy, shoulder pain, hematoma, dural tear, cerebrospinal fluid (CSF) leakage and lamina recluse), neurologic evaluation using the Japanese Orthopedic Association (JOA scores) criteria, axial pain by visual analog scale (VAS), and overall health status using 36-Item Short-Form Health Survey (SF-36). Cervical lordosis was reviewed as lordotic angles, measured at C2-C7 according to Cobb's method on lateral plain radiograph [Figure 1]. Positive change in lordotic angle includes increased and maintained lordosis. Negative change in lordotic angle includes decreased lordosis and change from lordosis to kyphosis.
Figure 1: The diagram of cervical lordotic angle which was measured according to Cobb's method on lateral radiograph: the angle (α) was formed by the two vertical lines of the two tangential lines to the inferior endplate of C2 and C7 vertebral bodies

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Surgical procedures

We selected the surgical procedure which was developed by Hirabayashi et al., [2] as Hirabayashi open-door laminoplasty for patients in Group A and modified by Deutsch et al., [18] as titanium mini-plate open-door laminoplasty for patients in Group B. In this study, we used centerpiece as the internal fixation device. Briefly, in Hirabayashi open-door laminoplasty, we detached bilateral paravertebral muscles from the spinous processes. This was followed by making gutters on bilateral lamina from C3-C7. The gutters on one side were prepared for a hinge and the laminas on the other side were completely cut for opening. After opening the laminas manually, we used sutures to tether and hold the spinous processes on the facet capsule or C3-C7 paravertebral muscle on the hinge-side so that laminas were kept open [Figure 2]a-c. In the centerpiece open-door laminoplasty, after opening the laminas manually, we used five centerpieces to sustain the opened C3-C7 laminas and centerpieces were fixed with mini screws, then the spinal canal enlargement was completed [Figure 2]a, b, d and [Figure 3].
Figure 2: The procedure of unilateral open-door laminoplasty. Hirabayashi approach: the laminas were kept open by sutures (a.b.c). Centerpiece approach: Centerpieces were placed between the opened laminas and the lateral masses of C3-C7 (a.b.d)

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Figure 3: (a) The mimic diagram of centerpiece fixation in Group B. (b) The photo of centerpiece fixation of Patient 4 in Group B during the operation

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Statistical analysis

NCSS2007 and PASS2008 statistical software (NCSS, Kaysville, Utah) were used for all statistical analysis. Descriptive statistical methods (average, standard deviation) were used for the data evaluation. Student t test was used for the comparison of quantitative data showing a normal distribution of parameters between the two groups, and Mann-Whitney U test was used for the comparison of non-normally distributed parameters between the two groups. All parameters were analyzed by analysis of variance. A probability level of less than 0.05 was considered significant.


 » Results Top


Postoperatively patients in Group A were advised collar for six weeks and then allowed gradual mobilization. In consideration of the secure fixation provided by centerpieces, we advised patients in Group B collar for two weeks postoperatively and then allowed gradual mobilization in flexion-extension, rotation, and side bending as tolerated. One patient in Group A died in a terrible accident at three weeks after operation. Thus the patients analyzed were 24 and 25 in Group A and Group B, respectively. The minimum follow-up period was 14 months in both the groups and the mean follow-up period was 21.5 and 18.2 months in Group A and Group B respectively. Group A included 14 men and 10 women (mean age: 59.5 years) and Group B 17 men and 8 women (mean age: 60.4 year) [Table 1]. There were no significant differences in the baseline characteristics between the two groups.

Blood loss and operation time

There was no significant difference in mean operation time between the groups, Group A (155.6±36.2 min) and Group B (162.8±34.3 min (P>0.05). The mean blood loss in Group A (258.5±225.2 ml) was similar to that in Group B (264.1±188.7 ml) (P>0.05). In both the groups, no patient had excessive bleeding intraoperatively because of vascular trauma.

JOA score

There were no significant differences in preoperative JOA scores (Group A: 7.6±1.4, Group B: 7.4±1.5, P>0.05) and postoperative JOA scores at final follow-up (Group A: 13.8±2.4, Group B: 14.4±1.8, P>0.05) between the two groups.

Axial pain

Axial pain had significantly improved in Group B (preoperative, 34.4±31.5 mm vs. postoperative, 27.2±30.4 mm) as compared to Group A, where the pain became worse (preoperative, 30.3±32.0 mm; postoperative, 38.8±30.2 mm).

Perioperative complications

The incidence of perioperative complications was higher in Group A when compared to Group B. In both the groups no severe intraoperative complications such as spinal cord injury and bleeding were observed. In Group A, three patients had temporary C5 radiculopathy (weakness and radiating limb pain), and temporary C7 radiculopathy (painful dysesthesia) was seen in one patient. All the four patients were symptom-free with conservative treatment at three months. In three patients in Group A, the opened laminas returned to the original position and the spinal canals had restenosis at C3-C7 at 3~4 months after surgery. All the three patients showed neurologic recovery after anterior decompression and fusion. In Group B, one patient developed C5 radiculopathy postoperatively which recovered with conservative therapy over a period of two months. Cerebrospinal fluid leakage occurred in one patient. During follow-up no patient had fever, allergic reaction or infection because of the metal internal fixation or no implant failures such as loosening, displacement and rupture in Group B. Follow-up CT showed no spinal canal restenosis in Group B. Enlarged laminas were kept open and bony fusion was obtained on the hinged side in all the patients in Group B [Figure 4], [Figure 5] and [Figure 6]. Furthermore, magnetic resonance imaging (MRI) taken at final follow-up showed adequate decompression of the spinal cord in all the patients in Group B and no patient required reoperation. No patient had iatrogenic neural damage in both the groups [Table 2].
Figure 4: The CT scan of Patient 9 in Group A. (a) Preoperative CT scan showed significant stenosis of the cervical spinal canal. (b) Postoperative CT scan showed that the cervical spinal canal had been enlarged through the Hirabayashi approach

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Figure 5: The CT scan of Patient 4 in Group B. (a) Preoperative CT scan showed significant stenosis of the cervical spinal canal. (b) Postoperative CT scan showed that the cervical spinal canal had been enlarged through the centerpiece approach

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Figure 6: The CT scan showed bone fusion of the hinge side and the lamina healed in the open position. (a) Patient 9 in Group A, (b) Patient 4 in Group B

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Table 2: Perioperative complications

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SF-36 at final follow-up

Preoperative scores on all subscales of the SF-36 questionnaire were similar in both the groups [Figure 7]. Postoperative scores of all subscales of the SF-36 questionnaire were higher in Group B as compared to Group A. Scores for bodily pain, general health perceptions and vitality were significantly higher [Figure 8].
Figure 7: Overall preoperative result of the SF-36 questionnaire. The X axis illustrates the eight variables of the SF-36, the Y axis indicates mean score for each variable. The scores of all subscales in Group B were similar to Group A

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Figure 8: Overall postoperative result of the SF-36 questionnaire. The scores of bodily pain, general health perceptions and vitality were significantly higher in Group B than those in Group A. (PF indicates physical functioning; RP, role physical; BP, bodily pain; GH, general health perceptions; VT, vitality; SF, social functioning; RE, role emotional; MH, mental health)

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Cervical lordotic angle

The change in Cobb angle is shown in [Table 3]. All the patients had varying degrees of preoperative cervical lordosis in both the groups. Preoperative cervical lordosis was increased or maintained postoperatively in 20 and 24 patients in Group A and B respectively. Preoperative cervical lordosis was decreased after surgery in four and one patient in Group A and B respectively. In both the groups no patient had change of preoperative cervical lordosis to kyphosis. The mean change of Cobb angle (preoperative vs postoperative) for all patients was significantly more in Group B (preoperative 7.8±2.2°, postoperative 12.2±3.3°), as compared with Group A (preoperative7.5±2.6°, postoperative 9.1±2.8°) [Table 2].
Table 3: Changes of cervical lordotic angles in both groups

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 » Discussion Top


The treatment choice for multilevel cervical compressive myelopathy has been debated. [22],[23] Laminectomy had long been a standard treatment option, [24],[25] but this procedure is associated with unfavorable long-term outcomes which include postoperative kyphosis and recurrence of myelopathy due to scar tissue formation. [26],[27] In 1977, Hirabayashi et al., [1],[2],[4],[28] devised a refined technique, "expansive open-door laminoplasty", and this simple and safe procedure gained immediate and widespread acceptance and it has gradually become a preferred procedure for patients with cervical compressive myelopathy with no preoperative kyphotic deformity or segmental instability. In this classic technique, the lamina door is tethered open by sutures. This technique results in increase in spinal canal diameter and prevents worsening of myelopathy. It has also been shown that this approach is simple and safe when compared to other procedures. However, many complications such as axial pain, postoperative reclosure and late neurologic deterioration have been reported on long-term follow-up. [29] Subsequently, many modified instrumented laminoplasties have been used as an alternative solution in clinical practice. [16],[17],[18],[19],[20],[21] Centerpiece is a type of titanium mini-plate specifically designed for unilateral open- door laminoplasty. Although this procedure has been practiced for years, till date there has been no prospective study that compared this modified approach and the classic one.

In this study, Hirabayashi open-door laminoplasty technique was the procedure in Group A and the centerpiece open-door laminoplasty in Group B. The results of this comparison were: (1) mean operation time and blood loss were similar in both the groups; (2) perioperative complications such as root palsy and reclosure of the opened lamina were more frequently seen in Group A and two patients of the three underwent anterior operations for the reclosure of the opened door; and (3) postoperative axial pain was more serious in Group A than in Group B. Several mechanisms have been suggested for the axial pain: (1) damage to the spinous process ligament-muscle complex; (2) damage to posterior roots of C3-7 spinal roots; (3) damage of the suture for facet joint capsule; (4) decrease in the cervical lordotic angle and move range; and (5) long-term immobilization of neck. [8],[30],[31],[32],[33] In this study axial pain was more severe in Group A. Patients in this group were advised cervical collar for a longer period, six weeks, and cervical rehabilitation much later than the patients in Group B. Also, patients in Group A did not achieve good cervical lordotic angle and move range as compared to patients in Group B. The other important aspect is that the centerpiece does not have any interference for the facet joint capsule and offers ideal stability, so tissue restoration is likely to be faster in Group B than in Group A. [4] There was no significant difference in JOA scores at the final follow-up between the two groups, thus suggesting equal efficacy of both the surgical approaches in decompression of the spinal cord. [5] Increase in cervical lordotic angle was more in Group B than in Group A, similar to the observations in other studies. [6] The scores of all subscales of SF-36 were higher in Group B than in Group A, especially for bodily pain, general health perceptions and vitality. SF-36 was developed to quantify health-related quality of life. [34] Although the cost of the metal internal fixation (centerpiece) is high, it did not put a heavy economic burden on the 25 patients in Group B, the cost of centerpieces had been paid by either our hospital or medical insurance. The JOA score, an objective measure of neurological improvement did not differ between the two groups, thus suggesting equal efficacy of both the procedures. Postoperative cervical axial pain is the main influencing factor for the Visual Analogue Score. The results of SF-36 also could be influenced by several factors such as postoperative cervical functional status and axial pain. There was no clear correlation between the JOA score and VAS, SF-36. Similar were the observations in other studies. Taken together, these observations indicate that centerpiece open-door laminoplasty could be the better procedure for these patients.

Absence of fatigue failure or loosening of centerpieces in this study demonstrates the clear advantage of centerpiece fixation. We think there are several potential reasons for this success. First, the centerpiece is located between the lamina and the vertebral body as a bridge which can reconstruct the integrality of the spinal canal and bear minimal mechanical stress; second, the centerpiece can hold the opened laminas reliably as pinchers because of the unique shape, especially suited for patients with osteoporosis, and the risk of screw pullout is reduced; third, the screws are not subjected to pullout forces because the lamina orientation directs the stresses at the bone-screw interface in a direction perpendicular to the screws; fourth, the ideal stability offered by centerpieces was a huge boost to the bone fusion of the hinge side and the laminas healed in the open position can relieve the stresses across the centerpieces.

This prospective study had several shortcomings, most notably the lack of precise measurement of long-term final range of motion. Second, we did not demonstrate the correlation between change in cervical lordotic angle and change in axial pain. On the other hand, although the application of centerpiece has brought us satisfactory clinical outcomes, the expensive instrument placed a significant financial burden on these patients. Especially among the Chinese, many patients in the countryside cannot afford it at all. What the study demonstrated is that open-door laminoplasty with centerpieces is safe, simple, and effective, that it has a low complication rate. No patient in this study required revision for fixation failure, which could have led to reclosure of laminoplasty, thus demonstrating the advantage of centerpiece fixation in maintaining the position of the lamina.

 
 » References Top

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2.Hirabayashi K, Watanabe K, Wakano K, et al. Expansive open-door laminoplasty for cervical spinal stenotic myelopathy. Spine (Phila Pa 1976) 1983;8:693-9.  Back to cited text no. 2
    
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29.Matsumoto M, Watanabe K, Tsuji T, Ishii K, Takaishi H, Nakamura M, et al. Risk factors for closure of lamina after open-door laminoplasty. J Neurosurg Spine 2008; 9:530-7.  Back to cited text no. 29
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]

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Online since 20th March '04
Published by Wolters Kluwer - Medknow