Biportal endoscopic cervical open-door laminoplasty to treat cervical spondylotic myelopathy.

BACKGROUND: Although cervical laminoplasty is a frequently utilized surgical intervention for cervical spondylotic myelopathy, it is primarily performed using conventional open surgical techniques. We attempted the minimally invasive cervical laminoplasty using biportal endoscopic approach. METHODS: Contralateral lamina access is facilitated by creating space through spinous process drilling, followed by lamina hinge formation. Subsequently, the incised lamina is elevated from ipsilateral aspect, and secure metal plate fixation is performed. CONCLUSION: We successfully performed the cervical open door laminoplasty using biportal endoscopic approach. Biportal endoscopic cervical open-door laminoplasty may be a minimally invasive technique that can prevent complications related with open surgery.

Prospective Investigation of the Posterior Longitudinal Ligament and Disc Complex after Posterior Stabilization and Decompression Surgery in Patients With Non-OPLL (Ossification of the Posterior Longitudinal Ligament) Cervical Spondylotic Myelopathy.

BACKGROUND: Cervical spondylotic myelopathy (CSM) is a prevalent cause of spinal cord dysfunction in adults, primarily from degenerative changes. The efficacy of treatment strategies, especially surgical approaches, remains debated. OBJECTIVE: This study aimed to assess the long-term impact of posterior fusion laminectomy on the posterior longitudinal ligament (PLL) thickness, disc complex, and myelomalacia signal changes in CSM patients. METHODS: A single-centre, prospective study from January 2020 to December 2021 included CSM patients without ossified posterior longitudinal ligament (OPLL). Magnetic resonance imaging (MRI) data from baseline, 6, and 12 months postoperatively were collected. Measurements on the MRI were performed using the Osirix MD software, focusing on the PLL width, myelopathic foci dimensions, and canal diameter. RESULTS: Out of the 82 initially enrolled patients, 64 were considered for analysis. Postoperatively, a significant reduction in PLL width and myelopathic foci dimensions was observed, alongside a considerable increase in the canal diameter. Clinical outcomes based on the Modified Japanese Orthopaedic Association (mJOA) scale also showcased marked improvements post-surgery. CONCLUSIONS: Posterior fusion laminectomy effectively reduces anterior pressure in CSM patients. This treatment may represent an optimal surgical approach for selected CSM cases. Furthermore, more extensive studies with extended follow-up are advocated.

Racial/Ethnic Disparities Among Patients Undergoing Anterior Cervical Discectomy and Fusion or Posterior Cervical Decompression and Fusion for Cervical Spondylotic Myelopathy: A National Administrative Database Analysis.

INTRODUCTION: The aim of this study was to investigate the impact of racial disparities on surgical outcomes for cervical spondylotic myelopathy (CSM). METHODS: Adult patients undergoing anterior cervical discectomy and fusion (ACDF) or posterior cervical decompression and fusion (PCDF) for CSM were identified from the 2016 to 019 National Inpatient Sample Database using the International Classification of Diseases codes. Patients were categorized based on approach (ACDF or PCDF) and race/ethnicity (White, Black, Hispanic). Patient demographics, comorbidities, operative characteristics, adverse events, and health care resource utilization were assessed. Multivariate logistic regression analyses were used to identify independent predictors of extended length of stay (LOS), nonroutine discharge (NRD), and exorbitant costs. RESULTS: A total of 46,500 patients were identified, of which 36,015 (77.5%) were White, 7465 (16.0%) were Black, and 3020 (6.5%) were Hispanic. Black and Hispanic patients had a greater comorbidity burden compared to White patients (P = 0.001) and a greater incidence of any postoperative complication (P = 0.001). Healthcare resource utilization were greater in the PCDF cohort than the ACDF cohort and greater in Black and Hispanic patients compared to White patients (P < 0.001). Black and Hispanic patient race were significantly associated with extended hospital LOS ([Black] odds ratio [OR]: 2.24, P < 0.001; [Hispanic] OR: 1.64, P < 0.001) and NRD ([Black] OR: 2.33, P < 0.001; [Hispanic] OR: 1.49, P = 0.016). Among patients who underwent PCDF, Black race was independently associated with extended hospital LOS ([Black] OR: 1.77, P < 0.001; [Hispanic] OR: 1.47, P = 0.167) and NRD ([Black] OR: 1.82, P < 0.001; [Hispanic] OR: 1.38, P = 0.052). CONCLUSIONS: Our study suggests that patient race may influence patient outcomes and healthcare resource utilization following ACDF or PCDF for CSM.

Failure of Surgical Equipoise in Posterior Cord Syndrome Myelopathy.

We suggest that a clinical diagnosis of posterior cord syndrome indicates primary posterior decompression in cervical spondylotic myelopathy cases. We present two unique cases of failed anterior decompression in neutrally aligned necks with compressive myelopathy and a literature review. Two recent cases of cervical spondylotic myelopathy that failed to respond after anterior surgical decompression and fusion surgery were observed at our institution. Both patients had motor strength preservation but were unable to stand and walk independently and had other clinical findings consistent with posterior cord syndrome rather than the more common anterior or central cord syndromes, and both responded well to staged posterior decompression. Posterior cervical decompression successfully relieved posterior cord syndrome symptoms after a failed anterior decompression in both of our cases. Posterior cord syndrome is a rare syndrome best diagnosed clinically and should be considered in cases of cervical spondylotic myelopathy in which motor strength testing is preserved.

Investigation of the Efficacy of Bilateral Osteoligamentous Decompression via Hemilaminectomy in Cervical Spondylotic Myelopathy: A Clinical Study.

OBJECTIVE: Cervical stability may deteriorate and kyphotic spinal deformities may develop in cervical spondylotic myelopathy (CSM) after laminectomy or laminoplasty. This study aimed to investigate the therapeutic efficacy of the "bilateral osteoligamentous decompression via unilateral hemilaminectomy approach (UHBOLD)" technique in CSM patients. METHODS: The study included 34 adult patients who underwent UHBOLD surgery for CSM between 2016 and 2022. A record was made for all patients of age, gender, number of operated levels, preoperative and postoperative long-term follow-up VAS scores, Nurick grade values and mJOA scores, kyphosis angles measured on X-ray, and spinal canal areas measured on T2-weighted MR axial images. RESULTS: Preoperative VAS scores of the patients were 6 (4-9), Nurick grade values were 3 (2-5), mJOA scores were 10.50 ± 3.42, kyphosis angles were -13.34 ± 13.69° and spinal canal areas were 87.11 ± 28.30 mm2. In postoperative long-term follow-up of these patients, VAS scores were 2 (1-5), Nurick grade values were 1 (0-5), mJOA scores were 13.94 ± 3.09, kyphosis angles were -15.07 ± 12.78° and spinal canal areas were 149.65 ± 42.57 mm2. A statistically significant difference was determined between the preoperative and the postoperative long-term follow-up VAS scores, Nurick grade values, mJOA scores, and spinal canal areas (P < 0.001). Kyphosis angles were not different (P = 0.198), and no instability was observed in any patient in long-term follow-up. CONCLUSIONS: The UHBOLD technique performed in multilevel CSM patients did not cause any change in cervical lordosis angle in long-term follow-up, did not cause cervical kyphotic deformity or cervical instability, and significantly improved Nurick grade values, and VAS and mJOA scores.

Trends in cervical laminoplasty and 30-day postoperative complications: 10-year results from a retrospective, multi-institutional study of 1095 patients.

PURPOSE: This study aimed to investigate the recent 10-year trends in cervical laminoplasty and 30-day postoperative complications. METHODS: This retrospective multi-institutional cohort study enrolled patients who underwent laminoplasty for cervical spondylotic myelopathy (CSM) or ossification of the posterior longitudinal ligament. The primary outcome was the occurrence of all-cause 30-day complications. Trends were investigated and compared in the early (2008-2012) and late (2013-2017) periods. RESULTS: Among 1095 patients (mean age, 66 years; 762 [70%] male), 542 and 553 patients were treated in the early and late periods, respectively. In the late period, patients were older at surgery (65 years vs. 68 years), there were more males (66% vs. 73%), and open-door laminoplasty (50% vs. 69%) was the preferred procedure, while %CSM (77% vs. 78%) and the perioperative JOA scores were similar to the early period. During the study period, the rate of preservation of the posterior muscle-ligament complex attached to the C2/C7-spinous process (C2, 89% vs. 93%; C7, 62% vs. 85%) increased and the number of laminoplasty levels (3.7 vs. 3.1) decreased. While the 30-day complication rate remained stable (3.9% vs. 3.4%), C5 palsy tended to decrease (2.4% vs. 0.9%, P = 0.059); superficial SSI increased significantly (0% vs. 1.3%, P = 0.015), while the decreased incidence of deep SSI did not reach statistical significance (0.6% vs. 0.2%). CONCLUSIONS: From 2008 to 2017, there were trends toward increasing age at surgery and surgeons' preference for refined open-door laminoplasty. The 30-day complication rate remained stable, but the C5 palsy rate halved.

Comparing two surgical approaches for treating multilevel cervical spondylotic myelopathy: A meta-analysis.

PURPOSE: This meta-analysis aims to evaluate the therapeutic efficacy of anterior versus posterior surgical approaches for multisegment cervical spondylotic myelopathy (MCSM). METHODS: Eligible studies published between the period of January 2001 and April 2022 and comparing the anterior and posterior surgical approaches for treating cervical spondylotic myelopathy were retrieved from the PubMed, Web of Science, Embase, and Cochrane databases. RESULTS: A total of 17 articles were selected based on the inclusion and exclusion criteria. This meta-analysis failed to show any significant difference in the duration of surgery, the hospitalization time, or the improvement in the Japanese Orthopedic Association score between the anterior and posterior approaches. The anterior approach, however, exhibited increased efficacy in the improvement of the neck disability index, reduction in the visual analog scale for cervical pain, and improvement in the cervical curvature compared with the posterior approach. CONCLUSION: Bleeding was also less with the anterior surgical approach. The posterior approach provided a significantly higher range of motion of the cervical spine and showed fewer postoperative complications compared with the anterior approach. While both the surgical approaches have good clinical outcomes and show postoperative neurological function improvement, the meta-analysis shows that both anterior and posterior approaches have certain merits and shortcomings. A meta-analysis of a larger number of randomized controlled trials with longer follow-up can conclusively determine which of the surgical approaches is more beneficial in the treatment of MCSM.

Up to 10-year surveillance comparison of survivability in single-level cervical disc replacement versus anterior cervical discectomy and fusion in New York.

OBJECTIVE: Cervical disc replacement (CDR) is an alternative treatment to anterior cervical discectomy and fusion (ACDF), which is the current gold standard, for degenerative cervical diseases such as cervical spondylotic myelopathy and cervical radiculopathy. CDR has several theoretical benefits over ACDF, including preservation of motion, earlier return to unrestricted activity, and potentially a lower risk of adjacent-segment disease. Recent literature has reported positive clinical results for CDR, but few studies have investigated the long-term risk of revision surgery of CDR versus ACDF. The purpose of this study was to identify and analyze the epidemiological, clinical, and operative risk factors that affect revision rates following single-level CDR and ACDF procedures. METHODS: A retrospective cohort was extracted from the Statewide Planning and Research Cooperative System using ICD-9 and CPT codes. Inclusion criteria were adult patients undergoing primary, subaxial (C3-7), single-level ACDF or CDR for cervical radiculopathy and/or cervical spondylotic myelopathy between 2005 and 2013. Survivability was defined as the time between the index procedure and the presence of a subsequent discharge record for cervical spinal fusion or disc replacement. Statistical analyses were performed using chi-square tests, t-tests, Cox proportional hazards models, and a Kaplan-Meier plot. RESULTS: A total of 7450 patients were included in this study (6615 ACDF and 835 CDR). When adjusted for patient demographics, the hazard ratios showed no significant differences in the incidence of revision risk between the two cohorts. The CDR cohort had a higher incidence of postoperative dysphagia (p < 0.05). Patients undergoing ACDF had a longer average hospital stay (2.8 vs 1.9 days, p < 0.001). There was no significant difference in time to revision surgery (p = 0.486). CONCLUSIONS: CDR and ACDF have both been shown to be effective treatments for cervical spine disease. CDR patients had a shorter average inpatient hospital stay compared with ACDF patients but tended to experience dysphagia more frequently. There was a tendency toward increased survivability of CDR; however, this was not found to be statistically significant at any time point. The large size and heterogeneity of each cohort and the availability of > 10 years of surveillance data differentiate this study from other published literature. This investigation has limitations inherent to large data analysis studies, including the implementation and inaccuracy of diagnosis and procedural coding; however, this reflects real-world use of coding by practitioners.

Using Electrical Stimulation of the Ulnar Nerve Trunk to Predict Postoperative Improvement in Hand Clumsiness in Patients With Cervical Spondylotic Myelopathy.

STUDY DESIGN: A prospective cohort study. OBJECTIVE: To investigate whether the immediate and short-term effects of preoperative electrical peripheral nerve stimulation (ePNS) on performance of the 10-second test could predict the early postoperative outcomes of patients with cervical spondylotic myelopathy (CSM). SUMMARY OF BACKGROUND DATA: Previous studies have shown that early clinical improvement in CSM patients may be because of reversal of spinal cord ischemia after spinal cord compression. MATERIALS AND METHODS: We conducted a 10-second test before surgery, after ePNS, and at discharge (one week after surgery) in 44 patients with CSM who underwent C3-C7 laminoplasty and evaluated their correlations. The effects of the procedures (ePNS or operation) and sides (stimulated or nonstimulated side) for the 10-second test were analyzed using repeated measures analysis of variance. The Pearson correlation coefficient was used to measure the relationship between the 10-second test values according to the method (after ePNS vs. surgery). In addition, the Bland-Altman method was used to evaluate the degree of agreement between the 10-second test obtained after ePNS versus shortly after surgery. RESULTS: The preoperative 10-second test showed the most improvement immediately after the administration of ePNS, with a gradual decrease for the first 30 minutes after completion. After the initial 30 minutes, performance decreased rapidly, and by 60 minutes performance essentially returned to baseline. The 10-second post-ePNS had a strong positive correlation with the 10-second test in the early postoperative period (at discharge=one week after surgery). These phenomena were observed with the left hand, the side stimulated with ePNS, as well as the right hand, the side not stimulated. CONCLUSIONS: Early postoperative outcomes after CSM surgery may be predicted by the results of preoperative ePNS. LEVEL OF EVIDENCE: Level 3.

A Five-Year Cost-Utility Analysis Comparing Synthetic Cage Versus Allograft Use in Anterior Cervical Discectomy and Fusion Surgery for Cervical Spondylotic Myelopathy.

STUDY DESIGN: Retrospective cost-utility analysis. OBJECTIVE: To conduct a cost-analysis comparing synthetic cage (SC) versus allograft (Allo) over a five-year time horizon. SUMMARY OF BACKGROUND DATA: SC and Allo are two commonly used interbody choices for anterior cervical discectomy and fusion (ACDF) surgery. Previous analyses comparative analyses have reached mixed conclusions regarding their cost-effectiveness, yet recent estimates provide high-quality evidence. MATERIALS AND METHODS: A decision-analysis model comparing the use of Allo versus SC was developed for a hypothetical 60-year-old patient with cervical spondylotic myelopathy undergoing single-level ACDF surgery. A comprehensive literature review was performed to estimate probabilities, costs (2020 USD) and quality-adjusted life years (QALYs) gained over a five-year period. A probabilistic sensitivity analysis using a Monte Carlo simulation of 1000 patients was carried out to calculate incremental cost-effectiveness ratio and net monetary benefits. One-way deterministic sensitivity analysis was performed to estimate the contribution of individual parameters to uncertainty in the model. RESULTS: The use of Allo was favored in 81.6% of the iterations at a societal willing-to-pay threshold of 50,000 USD/QALY. Allo dominated (higher net QALYs and lower net costs) in 67.8% of the iterations. The incremental net monetary benefits in the Allo group was 2650 USD at a willing-to-pay threshold of 50,000 USD/QALY. One-way deterministic sensitivity analysis revealed that the cost of the index surgery was the only factor which significantly contributed to uncertainty. CONCLUSION: Cost-utility analysis suggests that Allo maybe a more cost-effective option compared with SCs in adult patients undergoing ACDF for cervical spondylotic myelopathy.

Cervical spondylotic myelopathy with severe axial neck pain: is anterior or posterior approach better?

OBJECTIVE: The aim of this study was to determine whether multilevel anterior cervical discectomy and fusion (ACDF) or posterior cervical laminectomy and fusion (PCLF) is superior for patients with cervical spondylotic myelopathy (CSM) and high preoperative neck pain. METHODS: This was a retrospective study of prospectively collected data using the Quality Outcomes Database (QOD) CSM module. Patients who received a subaxial fusion of 3 or 4 segments and had a visual analog scale (VAS) neck pain score of 7 or greater at baseline were included. The 3-, 12-, and 24-month outcomes were compared for patients undergoing ACDF with those undergoing PCLF. RESULTS: Overall, 1141 patients with CSM were included in the database. Of these, 495 (43.4%) presented with severe neck pain (VAS score > 6). After applying inclusion and exclusion criteria, we compared 65 patients (54.6%) undergoing 3- and 4-level ACDF and 54 patients (45.4%) undergoing 3- and 4-level PCLF. Patients undergoing ACDF had worse Neck Disability Index scores at baseline (52.5 ± 15.9 vs 45.9 ± 16.8, p = 0.03) but similar neck pain (p > 0.05). Otherwise, the groups were well matched for the remaining baseline patient-reported outcomes. The rates of 24-month follow-up for ACDF and PCLF were similar (86.2% and 83.3%, respectively). At the 24-month follow-up, both groups demonstrated mean improvements in all outcomes, including neck pain (p < 0.05). In multivariable analyses, there was no significant difference in the degree of neck pain change, rate of neck pain improvement, rate of pain-free achievement, and rate of reaching minimal clinically important difference (MCID) in neck pain between the two groups (adjusted p > 0.05). However, ACDF was associated with a higher 24-month modified Japanese Orthopaedic Association scale (mJOA) score (ß = 1.5 [95% CI 0.5-2.6], adjusted p = 0.01), higher EQ-5D score (ß = 0.1 [95% CI 0.01-0.2], adjusted p = 0.04), and higher likelihood for return to baseline activities (OR 1.2 [95% CI 1.1-1.4], adjusted p = 0.002). CONCLUSIONS: Severe neck pain is prevalent among patients undergoing surgery for CSM, affecting more than 40% of patients. Both ACDF and PCLF achieved comparable postoperative neck pain improvement 3, 12, and 24 months following 3- or 4-segment surgery for patients with CSM and severe neck pain. However, multilevel ACDF was associated with superior functional status, quality of life, and return to baseline activities at 24 months in multivariable adjusted analyses.

Long-Term Follow-Up After Cervical Laminectomy without Fusion for Cervical Spondylotic Myelopathy.

OBJECTIVE: The objectives were to study the effect of cervical laminectomy without fusion on the incidence of further cervical surgeries, the risk for cervical misalignment, and current functional status. METHODS: We retrospectively analyzed the clinical data of 340 patients who had undergone simple laminectomy for cervical spondylotic myelopathy (CSM) at Helsinki University Hospital between 2000 and 2011. RESULTS: Forty-one patients (12.1%) had later undergone another cervical surgery during the follow-up of a mean of 8.5 years (maximum, 17.5 years). The most common indication for further surgery was residual stenosis at adjacent or other cervical levels (34%). Five patients (1%) required further surgery for correction of a sagittal balance problem. The mean Neck Disability Index was 28% at a median of 9.0 years after laminectomy. The mean EQ-5D (EuroQol 5 Dimension 3 Level) index score was 58.8 for patients and 77.2 for age-matched and gender-matched general population controls (P = 0.000), indicating patients' reduced health-related quality of life. Worse preoperative condition in the Nurick score was related to a lower (i.e., worse) EQ-5D score. In an additional arm of the study with radiographic imaging (40 patients), the mean change in sagittal alignment was 4.0° toward lordotic, and a newly developed kyphosis was found in 7.5% of patients. CONCLUSIONS: Because CSM is a serious degenerative progressive condition resulting in decreased health-related quality of life even after surgical treatment, the low rate of corrective surgery needed for alignment issues per se indicates that simple laminectomy can be a viable treatment option in treating multilevel CSM.

Residual anterior cord compression after laminoplasty for cervical spondylotic myelopathy: evaluation of risk factors according to the most severely stenotic vertebral segment.

OBJECTIVE: Residual anterior spinal cord compression (RASCC) after cervical laminoplasty, which has been confirmed on postoperative MRI, is reportedly associated with poor clinical outcomes. To date, only a few studies have described the risk factors associated with RASCC. The aim of this study was to identify the factors that can predict the occurrence of RASCC after laminoplasty for cervical spondylotic myelopathy (CSM), focusing on the location of the most stenotic segment. METHODS: In this retrospective, single-center study, 120 patients who underwent C3-7 laminoplasty for multilevel CSM were included. Different techniques were used for C3 decompression, i.e., partial (dome-laminotomy) or complete (laminoplasty/laminectomy) decompression. RASCC was diagnosed using MRI conducted 3 weeks postoperatively. The patients were divided into two groups according to the segment with the most severe stenosis (Seg-MSS; C3-4 vs C4-7). Demographics, radiological data, and C3 decompression technique were compared between the two groups. Furthermore, intergroup comparisons were performed based on Seg-MSS. A logistic regression model was constructed to identify the factors predicting RASCC after patient stratification according to Seg-MSS. RESULTS: Forty patients (33.3%) had RASCC. The patients with Seg-MSS at C3-4 (51.3%) had a significantly higher incidence of RASCC (p = 0.003) than those with Seg-MSS at C4-7 (24.7%). Logistic regression analysis showed that in patients with Seg-MSS at C3-4, C3 partial decompression demonstrated a greater association with RASCC as opposed to complete decompression. Conversely, in patients with Seg-MSS at C4-7, kyphotic segmental lordotic angle was associated with an increased risk of RASCC. CONCLUSIONS: The risk factors for RASCC differed depending on the location of the most stenotic segment (C3-4 vs C4-7). If there is segmental kyphosis at the most stenotic segment at C4-7, anterior decompression and fusion should be considered. If C3-4 is the most stenotic segment, anterior surgery is also recommended, but alternatively, one can choose laminoplasty with complete C3 laminectomy and resection of the C2-3 ligamentum flavum.

Analysis of the Risk Factors for C5 Nerve Palsy After Cervical Posterior Open-Door Laminoplasty for Patients with Cervical Spondylotic Myelopathy-From the Perspective of Cervical Sagittal Parameters.

OBJECTIVE: This study was performed to explore the sagittal radiological parameters related to the occurrence of C5 nerve palsy after cervical posterior open-door laminoplasty for the patients with cervical spondylotic myelopathy. METHODS: Sixty-two patients who underwent cervical posterior open-door laminoplasty were reviewed retrospectively from March 2017 to March 2022. The C2-7 Cobb angle, C2-7 sagittal vertex axis, thoracic inlet angle, neck tilt, T1 slope, and encroachment ratio of ossification were measured on X-rays. The enrolled patients were divided into C5 nerve palsy and control groups. Logistic regression was performed to analyze the potential risk factors for the occurrence of C5 nerve palsy. The receiver operating characteristic (ROC) curve and the area under the ROC curve (AUC) were used to evaluate the significance of the results and the optimal diagnostic value. RESULTS: The results of logistic regression showed that only the T1 slope and encroachment ratio were variables that were responsible for C5 nerve palsy (P = 0.024; P = 0.04). The ROC curve analysis for the T1 slope showed that the cutoff value was 21.3° and the AUC was 0.796. The ROC curve analysis for the encroachment ratio revealed that the cutoff value was 0.21 and the AUC was 0.763. Both analyses demonstrated good diagnostic value for C5 nerve palsy. CONCLUSIONS: The preoperative T1 slope and encroachment ratio were variables that were risk factors for C5 nerve palsy in patients who underwent cervical posterior open-door laminoplasty.

Intraoperative ultrasonography in laminectomy for degenerative cervical spondylotic myelopathy: a clinical and radiological evaluation.

BACKGROUND: The incidence of cervical myelopathy due to spinal stenosis is constantly growing in an aging population. Especially in multisegmental disease, dorsal laminectomy is the intervention of choice. Intraoperative imaging with ultrasound might provide additional information about extent and sufficiency of spinal cord decompression. METHODS: In this prospective study, the width of the subarachnoid space was systematically measured by intraoperative ultrasound at predefined sites at the cranial and caudal edge of decompression in axial and sagittal reconstruction. These data were compared with corresponding sites on postoperative T2-weighted MRI imaging. In addition, the functional outcome was assessed by modified Japanese Orthopaedic Association (mJOA) score. A historical patient cohort treated without ultrasound-guided laminectomy served as control group. RESULTS: Altogether, 29 patients were included. According to mJOA score at last follow-up, 7/29 patients reported stable symptoms and 21/29 patients showed a substantial benefit with no or minor residual neurological deficits. One patient suffered from a new C5 palsy. Intraoperative ultrasound-guided posterior decompression provided excellent overview in all cases. Measurement of the width of the subarachnoid space acquired by intraoperative ultrasound and postoperative MRI images showed a very high correlation, especially at the cranial level (p < 0.001, r = 0.880). Bland-Altman analysis showed that most patients were within the 1.96 × SD limits of agreement throughout all measurements. No ultrasound procedure-related complications were observed. Compared to a historical cohort of 27 patients, no significant differences were found regarding functional outcome (p = 0.711). CONCLUSION: Intraoperative sonography visualises the surgically achieved restoration of the subarachnoid space in good correlation with postoperative MRI and might serve as a fast, precise and reliable tool for intraoperative imaging in cervical laminectomy. However, we could not demonstrate a clinical benefit with regard to functional outcome.

Analysis of Functional Outcomes and Risk Factors for Facet Joint Distraction During Anterior Cervical Discectomy and Fusion for Cervical Spondylotic Myelopathy.

OBJECTIVE: This study aimed to clarify functional outcomes of facet joint distraction (FJD) and identify specific risk factors for excessive FJD during single-level anterior cervical discectomy and fusion (ACDF) for cervical spondylotic myelopathy (CSM). METHODS: This study retrospectively analyzed 100 patients who underwent single-level ACDF for CSM from January 2016 to May 2020. Anteroposterior and lateral radiographs were obtained before surgery and 12 months after surgery. Radiographic parameters including anterior intervertebral height (AIH), posterior intervertebral height, facet joint gap, cage posterior depth (CPD), upper vertebral length, cervical segmental Cobb angle (CSCA), C2-C7 Cobb angle, and C2-C7 sagittal vertical axis were analyzed. Functional outcomes were evaluated using the modified Japanese Orthopedic Association Score, visual analog scale (VAS), and Neck Disability Index (NDI). RESULTS: Comparison between the appropriate FJD and excessive FJD groups showed statistically significant differences in the NDI, VAS, CPD, and ΔAIH (P < 0.05). Multivariate logistic regression analysis showed that independent factors associated with excessive FJD were as follows: a ΔAIH > 2.28 mm (odds ratio [OR] = 6.792, 95% confidence interval [CI] = 1.885-24.470, P = 0.003), CPD > 12.45 mm (OR = 5.876, 95% CI = 1.828-18.895, P = 0.003), and post-CSCA < 0° (OR = 6.251, 95% CI = 1.275-30.633, P = 0.024). Furthermore, receiver operating characteristic curve analysis for the multilevel logistic regression model produced an area under the curve of 0.783 (P < 0.001). CONCLUSION: Patients with an FJD of >0.905 mm had worse NDI and VAS pain scores, but not a poorer modified Japanese Orthopedic Association Score recovery rate. Our findings suggested that a ΔAIH > 2.28 mm, CPD > 12.45 mm, and post-CSCA < 0° were independent risk factors for excessive FJD after single-level ACDF for CSM.

Clinical and radiological outcomes following open door laminoplasty: a single center evolution of the technique.

BACKGROUND: The aim of the present study was to compare and describe clinical and radiological outcomes after two different variants of open door laminoplasty for cervical spondylotic myelopathy (CSM). METHODS: Fifty-five patients underwent cervical laminoplasty for CSM. Between 2005 to 2009, 32 patients underwent open-door laminoplasty (Group A) performed with a monolateral exposure with contralateral "green stick" laminar fracture. A technical variant consisting in bilateral exposure, spinous process removal and symmetrical muscular closure was applied in the other 23 (Group B), from 2009 to 2016. A retrospective analysis of surgical results between the two groups was performed. RESULTS: In group B, the mean operative time was longer, and the mean volume of intraoperative blood loss was much higher than in group A. Both differences were not significant (P=0.1601 and P=0.0884, respectively). The average hospitalization was non-significantly longer in group B (7.3±1.8 vs. 6.5±1.6 d; P=0.0947). Postoperatively, axial neck pain was more severe in group A at last follow-up than preoperatively (P>0.05). mJOA scores and Nurick grades improved significantly in both groups at last follow-up; in group A, the mean recovery rates were 41.5% by mJOA scores and 29.4% by Nurick grades, whereas in group B they were 52.7% and 36.8%, respectively. CONCLUSIONS: Applying some few variations to a standard monolateral approach, although slightly more time and blood consuming, could reduce the incidence of long-term axial symptoms and, in our experience, are not burdened by worsening of outcomes. A prospective, multicentric study with a longer follow-up should be conducted in order to confirm our findings.

Clinical and Radiological Outcomes of Two Modified Open-door Laminoplasties Based on a Novel Paraspinal Approach for Treatment of Multilevel Cervical Spondylotic Myelopathy.

STUDY DESIGN: A case-control study. OBJECTIVES: The aim of this study was to evaluate the outcomes of two modified laminoplasties (LPs) based on a novel paraspinal approach for treating multilevel cervical spondylotic myelopathy. SUMMARY OF BACKGROUND DATA: No laminoplasty through a natural intermuscular plane mimicking Wiltse approach to minimize intraoperative injury to extensor muscles has ever been developed and studied. METHODS: Ninety-two patients were enrolled, including patients treated with either modified LP and patients treated with concurrent conventional LP. Operation time, blood loss, and complications were recorded. Clinical outcomes were evaluated by VAS, JOA scores, and recovery rate. Cervical sagittal alignment was measured on cervical radiographs. Spinal canal expansion was assessed on CT scans. Cross-sectional area (CSA) and atrophy rate (AR) of cervical deep extensors were evaluated on MRI. RESULTS: The average follow-up duration was 33.05, 31.55, 33.02, and 32.52 months, respectively in each group. Compared to concurrent conventional procedure, unilateral muscle-preserving procedure displayed similar, whereas bilateral muscle-preserving procedure showed significantly increased operation time and blood loss; each modified procedure resulted in comparable and satisfied perioperative clinical scores, spinal canal expansion while achieving significantly lower axial pain incidence, better cervical lordosis maintenance, and better deep extensor preservation. AR of deep extensors on the open side was significantly lower than that on the hinge side. Bilateral paraspinal approach demonstrated significantly better muscle-preservation on the open side and increased operation duration, with similar clinical scores, axial pain incidence, cervical lordosis maintenance, and spinal canal expansion compared to unilateral paraspinal approach. Loss of cervical lordosis was strongly correlated with AR of deep extensors. CONCLUSION: Paraspinal approach is a good manner to protect deep extensor muscles; the two modified LPs have similar effects on clinical outcomes.Level of Evidence: 3.