S Tim Yoon1, Robin E Hashimoto, Annie Raich, Christopher I Shaffrey, John M Rhee, K Daniel Riew. 1. *Department of Orthopedics, Emory Spine Center, Atlanta, GA †Spectrum Research, Inc., Tacoma, WA ‡Department of Neurology and Orthopaedic Surgery, University of Virginia, Charlottesville, VA; and §Washington University Orthopedics, One Barnes-Jewish Hospital Plaza, St. Louis, MO.
Abstract
STUDY DESIGN: Systematic review. OBJECTIVE: To determine the effectiveness and safety of cervical laminoplasty versus laminectomy and fusion for the treatment of cervical myelopathy, and to identify any patient subgroups for whom one treatment may result in better outcomes than the other. SUMMARY OF BACKGROUND DATA: Cervical laminoplasty and cervical laminectomy plus fusion are both procedures that treat cervical stenosis induced myelopathy by expanding the space available for the spinal cord. Although there are strong proponents of each procedure, the effectiveness, safety, and differential effectiveness and safety of laminoplasty versus laminectomy and fusion remains unclear. METHODS: A systematic search of multiple major medical reference databases was conducted to identify studies that compared laminoplasty with laminectomy and fusion. Studies could include either or both cervical myelopathic spondylosis (CSM) and ossification of the posterior longitudinal ligament. Randomized controlled trials and cohort studies were included. Case reports and studies with less than 10 patients in the comparative group were excluded. Japanese Orthopaedic Association, modified Japanese Orthopaedic Association, and Nurick scores were the primary outcomes measuring myelopathy effectiveness. Reoperation and complication rates were evaluated for safety. Clinical recommendations were made through a modified Delphi approach by applying the Grading of Recommendations Assessment, Development and Evaluation/Agency for Healthcare Research and Quality criteria. RESULTS: The search strategy yielded 305 citations, and 4 retrospective cohort studies ultimately met our inclusion criteria. For patients with CSM, data from 3 class of evidence III retrospective cohort studies suggest that there is no difference between treatment groups in severity of myelopathy or pain: 2 studies reported no significant difference between treatment groups in severity of myelopathy, and 3 studies found no significant difference in pain outcomes between treatment groups. For patients with ossification of the posterior longitudinal ligament, one small class of evidence III retrospective cohort study reported significant improvements in myelopathy severity after laminectomy and fusion compared with laminoplasty, but no differences in long-term pain between treatment groups. The overall evidence on the comparative safety of laminoplasty compared with laminectomy and fusion is inconsistent. Reoperation rates were lower after laminoplasty in 2 of 3 studies reporting. However, the incidence of debilitating neck pain was higher after laminoplasty as reported by one study; results on neurological complications were inconclusive, with 2 studies reporting. Results on kyphotic deformity were inconsistent, with opposite results in the 2 studies reporting. After laminectomy and fusion, 1% to 38% of patients had pseudarthrosis. Infection rates were slightly lower after laminoplasty, but the results are not likely to be statistically significant. CONCLUSION: For patients with CSM, there is low-quality evidence that suggests that laminoplasty and laminectomy and fusion procedures are similarly effective in treating CSM. For patients with ossification of the posterior longitudinal ligament, the evidence regarding the effectiveness of these procedures is insufficient. For both patient populations, the evidence as to whether one procedure is safer than the other is insufficient. Higher-quality research is necessary to more clearly delineate when one procedure is preferred compared with the other. EVIDENCE-BASED CLINICAL RECOMMENDATIONS: RECOMMENDATION: For CSM, evidence suggests that laminoplasty and laminectomy-fusion procedures can be similarly effective. We suggest that surgeons consider each case individually and take into account their own familiarity and expertise with each procedure. OVERALL STRENGTH OF EVIDENCE: Low. STRENGTH OF RECOMMENDATION: Weak.
STUDY DESIGN: Systematic review. OBJECTIVE: To determine the effectiveness and safety of cervical laminoplasty versus laminectomy and fusion for the treatment of cervical myelopathy, and to identify any patient subgroups for whom one treatment may result in better outcomes than the other. SUMMARY OF BACKGROUND DATA: Cervical laminoplasty and cervical laminectomy plus fusion are both procedures that treat cervical stenosis induced myelopathy by expanding the space available for the spinal cord. Although there are strong proponents of each procedure, the effectiveness, safety, and differential effectiveness and safety of laminoplasty versus laminectomy and fusion remains unclear. METHODS: A systematic search of multiple major medical reference databases was conducted to identify studies that compared laminoplasty with laminectomy and fusion. Studies could include either or both cervical myelopathic spondylosis (CSM) and ossification of the posterior longitudinal ligament. Randomized controlled trials and cohort studies were included. Case reports and studies with less than 10 patients in the comparative group were excluded. Japanese Orthopaedic Association, modified Japanese Orthopaedic Association, and Nurick scores were the primary outcomes measuring myelopathy effectiveness. Reoperation and complication rates were evaluated for safety. Clinical recommendations were made through a modified Delphi approach by applying the Grading of Recommendations Assessment, Development and Evaluation/Agency for Healthcare Research and Quality criteria. RESULTS: The search strategy yielded 305 citations, and 4 retrospective cohort studies ultimately met our inclusion criteria. For patients with CSM, data from 3 class of evidence III retrospective cohort studies suggest that there is no difference between treatment groups in severity of myelopathy or pain: 2 studies reported no significant difference between treatment groups in severity of myelopathy, and 3 studies found no significant difference in pain outcomes between treatment groups. For patients with ossification of the posterior longitudinal ligament, one small class of evidence III retrospective cohort study reported significant improvements in myelopathy severity after laminectomy and fusion compared with laminoplasty, but no differences in long-term pain between treatment groups. The overall evidence on the comparative safety of laminoplasty compared with laminectomy and fusion is inconsistent. Reoperation rates were lower after laminoplasty in 2 of 3 studies reporting. However, the incidence of debilitating neck pain was higher after laminoplasty as reported by one study; results on neurological complications were inconclusive, with 2 studies reporting. Results on kyphotic deformity were inconsistent, with opposite results in the 2 studies reporting. After laminectomy and fusion, 1% to 38% of patients had pseudarthrosis. Infection rates were slightly lower after laminoplasty, but the results are not likely to be statistically significant. CONCLUSION: For patients with CSM, there is low-quality evidence that suggests that laminoplasty and laminectomy and fusion procedures are similarly effective in treating CSM. For patients with ossification of the posterior longitudinal ligament, the evidence regarding the effectiveness of these procedures is insufficient. For both patient populations, the evidence as to whether one procedure is safer than the other is insufficient. Higher-quality research is necessary to more clearly delineate when one procedure is preferred compared with the other. EVIDENCE-BASED CLINICAL RECOMMENDATIONS: RECOMMENDATION: For CSM, evidence suggests that laminoplasty and laminectomy-fusion procedures can be similarly effective. We suggest that surgeons consider each case individually and take into account their own familiarity and expertise with each procedure. OVERALL STRENGTH OF EVIDENCE: Low. STRENGTH OF RECOMMENDATION: Weak.