Review of laminoplasty versus laminectomy in the surgical management of cervical spondylotic myelopathy.

BACKGROUND: We reviewed the literature comparing the indications/efficacy of laminectomy (LA) with or without fusion versus laminoplasty (LP) in the treatment of cervical spondylotic myelopathy (CSM).
METHODS: We identified 14 studies in PubMed/Medline to include in our analysis. Outcomes were assessed utilizing the Japanese Orthopaedic Association (JOA) score, visual analog scale (VAS), Neck Disability Index, and Nurick scale. Variables studied included ossification of the posterior longitudinal ligament (OPLL), cervical range of motion (ROM), the C2-C7 sagittal Cobb angle, the Ishihara index, and the Hirabayashi scale. Patients with cervical trauma/fracture, infection, or tumor were excluded from the study.
RESULTS: In these 14 studies, there were no significant differences between LA and LP groups in terms of preoperative versus postoperative: JOA scores (e.g., including the improvement rate), VAS scores, and ROM. However, the LA patients demonstrated greater postoperative cervical lordosis versus those in the LP group.
CONCLUSION: At present, there are no guidelines for choosing LA versus LP for treating CSM. Factors that should be considered when choosing one procedure over the other should include the patients' preoperative clinical status, the type of CSM, the pathological extent of OPLL, and whether there is a sufficient cervical lordotic curvature. Copyright:

INTRODUCTION

Multilevel cervical spondylotic myelopathy (CSM) is largely attributed to spondyloarthrosis (e.g., including disc disease, spurs, and osteophytes), congenital cervical canal stenosis, and/or ossification of the posterior longitudinal ligament (OPLL). The surgical decompression for CSM may include either laminectomy (LA) with/without fusion versus laminoplasty (LP).[3,4,7] Here, we performed a systematic review of the literature comparing these two techniques for managing CSM.

MATERIALS AND METHODS

In the literature, we identified 14 prospective/retrospective studies involving at least 20 adults with CSM undergoing LA versus LP (e.g., including meta-analysis using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses from PubMed [MEDLINE]) [Figure 1]. Two reviewers (R.P. and M.R.F.) independently reviewed all abstracts, and full-text articles outcomes were measured using the following; Japanese Orthopaedic Association (JOA) score, neck visual analog scale (VAS), Neck Disability Index (NDI), Nurick scale, and SF36v2 scores (36-Item Short Form Survey). Clinical variables studied included OPLL, cervical range of motion (ROM), C2-C7 sagittal Cobb angle, the Ishihara index, and the Hirabayashi scale. Those within histories of trauma/ fractures, infections, or tumors were eliminated [Table 1].

Figure 1:

Flow diagram of study selection.

Table 1:

Studies comparing laminoplasty with laminectomy with or without fusion: characteristic of included studies.

Comparison of clinical results

Clinical outcome

There is some disagreement regarding which procedure, the LP versus LA, results in better clinical outcomes. In Heller’s et al. study, there were no statistically significant differences in the Nurick score between LP and LA with fusion groups, although those undergoing LA/fusion had higher complication rates.[6] Other authors have agreed with these findings [Table 2].[1,4,9] However, to the contrary in Kaminsky’s et al. study, myelopathy improved in 44% of LP patients versus 18% following LA, leading to the conclusion that LP was more clinically effective than LA with fewer complications [Table 2].[7]

Table 2:

Studies comparing LP with LA with or without fusion: comparison of clinical results.

NDI

Lee et al. assessed functional improvement using the NDI score following LP versus LA; they found no significant differences for NDI between the two groups (P = 0.84).[11] Alternatively, Stephens et al. found statistically significant improvement in NDI scores for LP patients versus LA patients undergoing fusions [Table 2].[14]

Neck pain

Lee et al. and Yuan et al. documented no significant differences in clinical outcomes and VAS score for LP versus LA.[11,15] Alternatively, Kaminsky et al. focused on the greater benefits and lower postoperative neck pain scores with LP, while Lee et al. documented greater improvement of neck pain utilizing LA [Table 2].[7,12]

Cervical ROM

Ha et al. study found significantly greater ROM preservation in flexion, extension, and side bending for those undergoing LP versus LA with fusion (P = 0.0006).[5] Alternatively, Chang et al. documented no differences in preoperative Cobb angle/ ROM between the two cohorts [Table 2].[2]

Cervical alignment

Lau et al. documented that preoperative and postoperative C2–C7 sagittal vertical and cervical Cobb angle were similar between patients undergoing LP versus LA (P = 0.454).[10] However, the studies by Lee et al. and Lee et al. both reported a significant loss of cervical lordosis overtime following both operations [Table 2].[11,12]

OPLL progression

Lee et al. showed no significant difference in OPLL progression after LP (45.5%) versus LA (52.5%), while Kang et al. showed the faster OPLL progression for LA with fusion [Table 2].[8,11]

Relative postoperative lordosis for LP versus LA

Some authors found statistically significant differences regarding the postoperative preservation of cervical lordosis and ROM for LP versus LA.[12,13] Kang et al. found that the final C2–C7 lordosis decreased in the LA group and in the LP group and the mean magnitude of these changes was larger in the LA group, but was not statistically significant.[8]

CONCLUSION

Although there are no present guidelines for choosing to treat CSM utilizing either LA versus LP, surgeons should play close attention to patients’ preoperative clinical status, the type of CSM present, (e.g., with/without stenosis/OPLL), and whether the cervical lordotic curvature has been preserved.