Cervical Laminectomy/Laminoplasty : When & Why Tariq Elemam Elshafey Awad ESA / SCU Joint COURSE Cervical Spine Surgical Procedures Assist. Prof. of Neurosurgery & Spine Surgery Suez Canal University Alex. Desert Road , July, 2017 Al-Solaymaneyah Golf Resort

Objectives I aim to present overview of CSM When to choose the posterior approach? Literature review & EBM - EL vs. LF Comparison between EL and LF Take home message

Introduction CSM - age-related - degeneration of intervertebral discs & adjacent vertebral structures. Progressive spinal canal narrowing & nerve root compression. For single-level CSM -----an ant. approach - superior ability to provide decompression over kyphotic segments. For multi-level CSM - longer operative times + complications such as graft dislodgement, hoarseness, dysphagia.-------> Post approach

Post. approaches, treat C Post. approaches, treat C. stenosis induced myelopathy by expanding the space available for the s. cord. laminectomy alone has been the historical ttt standard for CSM decompression laminectomy + lat. mass fixation or fusion to ↓ post-operative segmental instability & kyphosis Laminoplasty represents an alternative post. approach for CSM that may enable better preservation of cervical motion, adjacent structural integrity & natural lordosis . However, some studies have reported less effective & less extensive cord decompression for EL compared to LF

Posterior Approach Indications CSM involving three or more levels, including multiple disk lesions or congenital stenosis Ossification of the PLL with resultant multilevel cord compression Myelopathy as a result of post. pathology, such as ligamentum flavum hypertropthy or calcification Spinal cord mass

Posterior Approach Contraindications Cervical kyphosis: the spinal cord will continue to stay draped along the compressing ant. structures, even when the post. arch is removed or widened. Post. approach may in fact worsen postoperative kyphosis. Instability: Post. approach should be supplemented with arthrodesis if instability is present, or an alternative fusion procedure should be performed. Rheumatoid arthritis is a relative contraindication, because such patients may be a higher risk for postoperative instability.

Laminoplasty Techniques Z-plasty technique Open-door technique Double-door technique

Usa - systemic search Pubmed Cochrane liberary – google scholar A systematic review 2013 - retrospective 6 cohort studies that met inclusion criteria – Clinical outcomes & safety Data from these studies suggests that laminoplasty & laminectomy and fusion procedures are similarly effective in treating CSM as measured by myelopathy scores and pain outcome measures.

meta-analysis - all studies of EL versus LF in adults with multilevel CSM in MEDLINE (PubMed), EMBASE, and the Cochrane library 7 studies comprising 302 and 290 patients treated with EL and LF, Conclusions Both EL and LF lead to clinical improvement and loss of lordosis evenly. There is no evidence to support EL over LF in the treatment of multilevel CSM. Any superiority between EL and LF remains in question, although the LF group shows favorable long-term results.

meta-analysis - systematically compare the safety and efficacy of the 2 post. Approaches for multi-level CSM (LF vs EL) with regards to post-operative patient-rated scores & complications. From the available low-quality evidence, LF & EL approaches for CSM demonstrates similar clinical improvement and loss of lordosis. However, a higher complication rate was found in LF group, including significantly higher nerve palsy complications. Electronic searches were performed using 6 databases from their inception to January 2016, identifying all relevant (RCTs) and non- RCTs comparing LF vs EL for multi-level cervical myelopathy. Results From 10 included studies, there were 335 patients who underwent LF compared to 320 patients who underwent EL. There was no significant difference found p.o. between LF and EL groups in terms of p.o. JOA (P = 0.39), VAS neck pain (P = 0.93), postoperative CCI (P = 0.32) and Nurich grade (P = 0.42). The total complication rate was higher for LF compared to EL (26.4 vs 15.4 %, RR 1.77, 95 % CI 1.10, 2.85, I2 = 34 %, P = 0.02). Reoperation rate was found to be similar between LF and EL groups (P = 0.52). A significantly higher pooled rate of nerve palsies was found in the LF group compared to EL (9.9 vs 3.7 %, RR 2.76, P = 0.03). No significant difference was found in terms of operative time and intraoperative blood loss.

Cohorts of 41 EL and 31 LF Single surgeon retrospective 2007 - 2011 Outcome measures C. alignment and ROM and clinical outcome measures including (JOA) scores, neck disability index (NDI), (SF-12M) and (SF-12P) composite scores and (VAS-N) & (VAS-A). Conclusions: evidence that EL may be superior to LF in preserving cervical ROM, reducing hospital stay and minimizing cost. However, the significance of these differences remains unclear, as EL clinical outcome scores were generally comparable to LF fusion. Short form-12 mental (SF-12M) and physical (SF-12P) composite scores and visual analog pain scores for neck (VASN) and arm (VAS-A).

Laminectomy with PSF is associated with greater perioperative morbidity but provides greater myelopathy resolution than laminoplasty. With similar postoperative cervical Cobb angles, pain outcomes are similar for both procedures. Cervical alignment should be considered as an important factor in pain outcomes following posterior decompression of CSM A total of 145 patients were included in the analysis: 44 laminectomy with PSF and 101 laminoplasty patients were included Cervical curvature is an important factor when deciding between laminoplasty or laminectomy with posterior spinal fusion (PSF). This study compares outcomes of laminoplasty and laminectomy with PSF in patients with matched regional sagittal balance Adults from 2011 to 2014 undergoing laminoplasty or laminectomy with PSF for CSM were identified. Matched cohorts were obtained by excluding laminectomy with PSF patients with postoperative cervical Cobb angles outside the range of laminoplasty patients.

The degree of post. movement of spinal cord is similar between laminoplasty and laminectomy and is not correlated with cervical lordosis. The outcomes of post. decompression surgery are not correlated with the degree of spinal post. movement. Preoperative JOA scores are an important determinant for postoperative outcomes. 32 patients with CSM underwent posterior decompression from C3 to C7 through laminectomy (n12) and single, open-door laminoplasty (n20). There were no signifi cant differences between laminectomy and laminoplasty in degree of spinal posterior movement, recovery rate, and curvature index

Clinical outcomes (myelopathy)   Laminectomy + Fusion Laminoplasty Op. time & bl. loss the same Hospital stay & Costs More Less ROM less more Fusion + - Adjacent Segment Clinical outcomes (myelopathy) slightly better slightly less C. Pain Slightly more Complications slightly more For more than 3 segments

Take home message First decide if you want to use the posterior approach Multiple levels Preserved C. Lordosis Post Pathology C.I to Ant. Approach. Then Decide EL Vs. LF 3 levels --------> EL More than 3 levels, dynamic instability, Facet arthropathy, Rheumatoid A. ---------> LF

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