Objective
To determine the surgical indications for posterior expansive open-door laminoplasty (EOLP) extended to the C1 level.
Methods
Seventeen patients undergoing C3-7 or C2-7 open-door laminoplasty were included as the case group between September 2005 and January 2010, whose spinal cord injury symptoms were not alleviated or aggravated again because of the cervical stenosis at C1-4 level, and the causes of the surgery itself were eliminated, all of these patients underwent reoperation with decompress upward to C1 level. Fifteen patients with cervical stenosis who underwent C2-7 laminoplasty and C1 laminectomy were selected as the control group. There was no significant difference in gender, age, and disease duration between 2 groups (P gt; 0.05). The pre- and post-operative cervical curvature and spinal cord compression were evaluated according to the patients’ imaging data; the pre- and post-operative neurological recovery situation was evaluated by Japanese Orthopaedic Association (JOA) 17 score and spinal cord function Frankel grade; the neurological recovery rate (according to Hirabayashi et al. method) was used to assess the postoperative neurological recovery situation.
Results
In the case group, 8 patients underwent primary C3-7 laminoplasty. In 3 of these patients, there was a cervical stenosis at C1, 2 level, and discontinuous cerebrospinal fluid around the spinal cord was observed; 5 of them with a compression mass which diameter was exceed 7.0 mm in the C2-4 segments. The remaining 9 patients in the case group underwent primary C2-7 laminoplasty, and the diameter of the compression mass was exceed 7.0 mm in the C2-4 segments. In all 17 patients of the case group, reoperation was performed with the decompression range extended to the C1 level, and the follow-up time was 35-61 months with an average of 45.6 months. Cervical curvature: there were 11 cases of cervical lordosis, 4 cases of straight spine, and 2 cases of cervical kyphosis before operation; but after operation, 2 cases of cervical lordosis became straight spine and 1 straight case became kyphosis. The postoperative neurological improvement was excellent in 8 cases, good in 7, and fair in 2. In the control group, all the patients had a compression mass which anteroposterior diameter was exceed 7.0 mm in the C2-4 segments before operation. The follow-up time was 30-58 months with an average of 38.7 months. Cervical curvature: there were 13 cases of cervical lordosis and 2 cases of straight spine before operation; but after operation, 1 case of cervical lordosis became straight spine. The postoperative neurological improvement was excellent in 8 cases, good in 6, and fair in 1. No significant difference was found in the JOA score at pre- and post-operation between 2 groups (P gt; 0.05); however, there were significant differences (P lt; 0.05) in the JOA score between at last follow-up and at preoperation.
Conclusion
The initially surgical indications which can be used as a reference for EOLP extended to C1 are as follows:① Upper cervical (C1, 2) spinal stenosis: C1 posterior arch above the lower edge part of cerebrospinal fluid around the spinal cord signal is not continuous, and the anteroposterior diameter of the spinal canal actual is less than 8.0 mm as judgment standard. ②There is a huge compression at the lower edge of C2-4 vertebrae, and the most prominent part of the diameter is exceed 7.0 mm, which can not be removed through the anterior cervical surgery, or the operation is high-risk.
Objective
To investigate whether preoperative T1 slope (T1S) in MRI can predict the changes of cervical curvature after expansive open-door laminoplasty (EOLP) in patients with cervical spondylotic myelopathy, so as to make up for the shortcomings of difficult measurement in X-ray film.
Methods
The clinical data of 36 patients with cervical spondylotic myelopathy who underwent EOLP were retrospectively analysed. There were 21 males and 15 females with an average age of 55.8 years (range, 37-73 years) and an average follow-up time of 14.3 months (range, 12-24 months). The preoperative X-ray films at dynamic position, CT, and MRI of cervical spine before operation, and the anteroposterior and lateral X-ray films at last follow-up were taken out to measure the following sagittal parameters. The parameters included C2-C7 Cobb angle and C2-C7 sagittal vertical axis (C2-C7 SVA) in all patients before operation and at last follow-up; preoperative T1S were measured in MRI, and the patients were divided into larger T1S group (T1S>19°, group A) and small T1S group (T1S≤19°, group B) according to the median of T1S, and the preoperative T1S, C2-C7 Cobb angle, C2-C7 SVA, and the C2-C7 Cobb angle and C2-C7 SVA at last follow-up, difference in axial distance (the difference of C2-C7 SVA before and after operation), postoperative curvature loss (the difference of C2-C7 Cobb angle before and after operation), the number of patients whose curvature loss was more than 5° after operation, and the number of patients whose kyphosis changed (C2-C7 Cobb angle was less than 0° after operation).
Results
The C2-C7 Cobb angle at last follow-up was significantly decreased when compared with preoperative value (t=8.000, P=0.000), but there was no significant difference in C2-C7 SVA between pre- and post-operation (t=–1.842, P=0.074). The preoperative T1S was (19.69±3.39)°; there were 17 cases in group A and 19 cases in group B with no significant difference in gender and age between 2 groups (P>0.05). The preoperative C2-C7 Cobb angle in group B was significantly lower than that in group A (t=–2.150, P=0.039), while there was no significant difference in preoperative C2-C7 SVA between 2 groups (t=0.206, P=0.838). At last follow-up, except for the curvature loss after operation in group B was significantly lower than that in group A (t=–2.723, P=0.010), there was no significant difference in the other indicators between 2 groups (P>0.05).
Conclusion
Preoperative larger T1S (T1S>19°) in MRI had a larger preoperative lordosis angle, but more postoperative physiological curvature was lost; preoperative T1S in MRI can not predict postoperative curvature loss, but preoperative larger T1S may be more prone to kyphosis.
Objective To evaluate the reliability and the advantageof canal laminoplasty with laminoplasty over laminectomy for treatment of lumbar spinal stenosis.Methods From June 2000 to September 2004, the titanium miniplate fixation technique was applied to re-implantation of the vertebral lamina in the lumbar spine. The vertebral lamina was made with a specially made osteotome and a special technique in 18 patients with lumbar spinal stenosis. Results The patients were followed up for 1 yr and 8 mon on average (range, 3 mon4 yr and 3 mon) and were observed to have a bony fusion of the re-implanted lamina 3-9 months postoperatively. There was no nonunion, displacement of the re-implanted lamina, overgrowth of the anterior bone edge of osteotomy, recompression of the nerves or instability of the lumbar spine. Conclusion The result demonstrates that canal laminoplasty with the titanium miniplate re-implantation of the vertebral lamina in lumbar spine can restore the normal anatomy, keep stability of the spine, and avoid adhesion and scar in the canal.
Objective
To investigate an individualized treatment program of a patient with multilevel cervical spondylotic myelopathy by the method of evidence-based medicine.
Methods
One patient with multilevel cervical spondylotic myelopathy was admitted into West China Hospital on October 19th, 2015. After evaluating the patient’s condition adequately, we proposed the problem according to the " patient, intervention, control, and outcome” (PICO) principles. Then, we searched and evaluated the systematic reviews, randomized controlled trials (RCTs), cohort studies from Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Medline, Embase, PubMed, OVID ACP Journal Club, CNKI, Wanfang and so on. The search date was from January 1991 to December 2015. And the best evidences from the databases were utilized in clinical practice.
Results
Twelve studies (five systematic reviews, two RCTs, four cohort studies and one latest guideline) were listed. To patients with multilevel cervical spondylotic myelopathy with ossification of the posterior longitudinal ligament (OPLL), posterior laminoplasty was less traumatic and had less complication. Expansive open-door laminoplasty was better. And the use of mini-plate fixation also reduced the related complications.
Conclusions
Posterior expansive open-door laminoplasty with mini-plate fixation has less traumatic and complication incidence, which can treat multilevel cervical spondylotic myelopathy effectively. For the best results and avoiding adverse outcomes, the procedure should be preferred in patients with OPLL.
Objective
To investigate the technique and effectiveness of modified laminoplasty for lumbar spinal stenosis (LSS) and to explore the application value of modified laminoplasty in maintaining the stability of the spine by comparing with the conventional laminectomy.
Methods
Fifty-six patients with LSS were included between June 2012 and July 2013, and they were divided into 2 groups: 27 patients underwent modified laminoplasty in group A, and 29 patients received conventional laminectomy in group B. There was no significant difference in sex, age, disease duration, narrow segment, visual analogue scale (VAS) score of low back pain and leg pain, Japanese Orthopaedic Association (JOA) score, and walking tolerance between 2 groups (P > 0.05). The postoperative VAS score of low back pain and leg pain, JOA score, walking tolerance, X-ray film, and CT were used to evaluate the clinical results.
Results
Dural tear occurred in 2?cases of group A and 1 case of group B and were repaired during operation. All incisions primarily healed without infection. The patients were followed up 24-31 months (mean, 24.7 months) in group A, and 24-37 months (mean, 26.2 months) in group B. The bone healing time was 6-12 months (mean, 9 months) in group A. CT showed healing at the junction of spinous process and vertebral plate in group A at 12 months after operation; new scar in varying degre es was observed in group B. At last follow-up, lumbar spondylolisthesis and instability occurred in 4?and 2 cases of group B respectively, and received re-operation. The change value of slip distance was (0.27±0.23) mm in group A and was (0.83±1.22) mm in group B, showing significant difference (t=-2.405, P=0.023). The postoperative JOA score, VAS score, and walking tolerance were significantly improved when compared with preoperative ones in 2 groups (P < 0.05).?At?last follow-up, group A was better than group B in VAS score of low back pain (P < 0.05), but no significant?difference?was?found in the other indexes between 2 groups (P > 0.05).
Conclusion
The modified laminoplasty?is better than the conventional laminectomy in relieving low back pain and maintaining the stability of the lumbar spine.
ObjectiveTo investigate the feasibility and effectiveness of modified replanting posterior ligament complex (PLC) applying piezoelectric osteotomy in the treatment of primary benign tumors in thoracic spinal canal.MethodsThe clinical data of 38 patients with primary benign tumors in thoracic spinal canal between March 2014 and March 2016 were retrospectively analyzed. There were 16 males and 22 females, aged from 21 to 72 years (mean, 47.1 years). The disease duration ranged from 6 to 57 months (mean, 32.6 months). Pathological examination showed 24 cases of schwannoma, 6 cases of meningioma, 4 cases of ependymoma, 2 cases of lipoma, and 2 cases of dermoid cyst. The lesions located in 18 cases of single segment, 15 cases of double segments, and 5 cases of three segments. The length of the tumors ranged from 0.7 to 6.5 cm. There were boundaries between the tumors and the spinal cord, cauda equina, and nerve roots. The preoperative Japanese Orthopaedic Association (JOA) score was 12.2±2.3 and the thoracic Cobb angle was (11.7±2.7)°. Modified PLC replantation and microsurgical resection were performed with piezoelectric osteotomy. Continuity of uniside supraspinal and interspinous ligaments were preserved during the operation. The PLC was exposed laterally. After removing the tumors under the microscope, the pedicled PLC was replanted in situ and fixed with bilateral micro-reconstruction titanium plate. X-ray film, CT, and MRI examinations were performed to observe spinal stability, spinal canal plasty, and tumor resection after operation. The effectiveness was evaluated by JOA score.ResultsThe operation time was 56-142 minutes (mean, 77.1 minutes). The intraoperative blood loss was 110-370 mL (mean, 217.2 mL). The tumors were removed completely and the incisions healed well. Three cases complicated with cerebrospinal fluid leakage, and there was no complications such as spinal cord injury and infection. All the 38 patients were followed up 24-28 months (mean, 27.2 months). There was no internal fixation loosening, malposition, or other related complications. At last follow-up, X-ray films showed no sign of kyphosis and instability. CT showed no displacement of vertebral lamina and reduction of secondary spinal canal volume, and vertebral lamina healed well. MRI showed no recurrence of tumors. At last follow-up, the thoracic Cobb angle was (12.3±4.1)°, showing no significant difference when compared with preoperative value (t=0.753, P=0.456). JOA score increased to 23.7±3.8, showing significant difference when compared with preoperative value (t=15.960, P=0.000). Among them, 14 cases were excellent, 18 were good, 6 were fair, and the excellent and good rate was 84.2%.ConclusionModified replanting PLC applying piezoelectric osteotomy and micro-reconstruction with titanium plate for the primary benign tumors in thoracic spinal canal can reconstruct the anatomy of the spinal canal, enable patients to recover daily activities quickly. It is an effective and safe treatment.
ObjectiveTo investigate the risk factors of axial symptoms after single door laminoplasty for cervical myelopathy.
MethodsA retrospective analysis was made on the clinical data of 102 patients with cervical myelopathy who underwent single door laminoplasty and were accorded with selective standard between February 2009 and October 2011. There were 59 males and 43 females, aged 35 to 72 years (mean, 58 years). The disease duration was 1-70 months (mean, 18 months). The operated segments included C3-7 in 58 cases, C3-6 in 23 cases, C4-7 in 15 cases, and C3-5 in 6 cases. The visual analogue scale (VAS) was used to determine whether the patient had axial symptoms (group A) or not (group B). The logistic regression analysis was used to analyze the risk factors of postoperative axial symptoms by assessing the following indexes:preoperative VAS score, preoperative Japanese Orthopaedic Association (JOA) score, gender, age, disease duration, operated segment, operation time, intraoperative blood loss, wearing collar time, preoperative encroachment rate of anterior spinal canal, preoperative cervical curvature, and preoperative cervical range of motion.
ResultsA total of 102 cases were followed up 18-26 months (mean, 24 months). And no postoperative spinal cord injury, cerebrospinal fluid leakage, or infection occurred. Of 102 cases, 50 had axial symptoms (group A) and 52 had no axial symptoms (group B). There were significant differences in age, wearing collar time, preoperative cervical range of motion, preoperative cervical curvature, and preoperative encroachment rate of anterior spinal canal between 2 groups (P<0.05), but no significant difference was found in preoperative JOA score and VAS score, blood loss, gender, disease duration, operated segment, and operation time (P>0.05). The logistic regression analysis showed that the increased preoperative encroachment rate of anterior spinal canal, reduced preoperative cervical curvature, and preoperative cervical range of motion loss were the risk factors for cervical axial symptoms.
ConclusionAge, wearing collar time, preoperative cervical range of motion, preoperative encroachment rate of anterior spinal canal, and preoperative cervical curvature are relevant factors of axial symptoms; increased preoperative encroachment rate of anterior spinal canal, reduced preoperative cervical curvature, and preoperative cervical range of motion loss are risk factors for cervical axial symptoms.
Objective To evaluate and compare the relation of the cl inical results of expansion of open-door cervical laminoplasty (EOLP), C5 nerve root palsy in hinge side, and reclose of the opened laminae with different angles in lamina opendoor.Methods Between July 2006 and January 2009, 198 patients with cervical myelopathy were treated by EOLP. Accordingto different opening angles which were measured by CT scan after operation, the patients were divided into group A (gt; 30°, 76 patients including 44 males and 32 females) and group B (15-30°, 122 patients including 71 males and 51 females). There was no significant difference in gender, age, disease duration, and segmental lesions between 2 groups (P gt; 0.05). The Japanese Orthopaedic Association (JOA) score before and after operation was used for neurological assessment and improvement rate, and the postoperative C5 nerve root palsy and reclose of the opened laminae were recorded. Results There was no significant difference in operation time, bleeding volume, and hospital ization days between 2 groups (P gt; 0.05). After 3 weeks of operation, C5 nerve root palsy in the hinge side occurred in 7 patients (9.2%) of group A, and in 2 patients (1.6%) of group B, were restored after symptomatic treatment, showing significant difference between 2 groups (χ2= 4.568, P= 0.033). All patients were followed up 24 to 48 months. Between group A and group B, no significant difference was found in JOA improvement rate at 24 months after operation (P gt; 0.05), and in JOA score at preoperation and at 24 months after operation (P gt; 0.05), but JOA score was significantly improved at 24 months after operation when compared with preoperative score in the same group (P lt; 0.05). The function of l imb l ifting restored in 9 cases of C5 nerve root palsy at 24 months after operation; CT examination revealed that no reclose occured in group A and reclose occurred in 4 cases (3.3%) of group B, but no persistent symptoms or worsen situationwere found during follow-up. Conclusion Different angles in lamina open-door have the same cl inical result; C5 nerve palsy has good prognosis. The opening angle between 15° and 30° will reduce the incidence of C5 nerve root palsy in the hinge side, but the open side should be firmly fixed to prevent further reclose of the opened laminae.
Objective To evaluate the effectiveness of microplate fixation in open-door cervical expansive laminoplasty (ELP) by comparing with anchor fixation. Methods Between January 2005 and October 2008, 35 patients with multi-segment cervical spondylotic myelopathy were treated. Of them, 15 patients underwent ELP by microplate fixation (microplate group) and 20 patients underwent ELP by anchor fixation (anchor group). In microplate group, there were 10 malesand 5 females with the age of (51.2 ± 11.5) years; the disease duration ranged from 6 to 60 months (mean, 14 months); and the preoperative Japanese Orthopoaedic Association (JOA) score was 7.7 ± 2.5. In anchor group, there were 13 males and 7 females with the age of (50.7 ± 10.8) years; the disease duration ranged from 3 to 58 months (mean, 17 months); and the preoperative JOA score was 7.8 ± 2.9. There was no significant difference in the general data, such as gender, age, and JOA score between 2 groups (P gt; 0.05). Results All incisions healed by first intention. Thirty-five cases were followed up 24-68 months (mean, 32 months). The operation time was (113 ± 24) minutes in anchor group and (111 ± 27) minutes in microplate group, showing no significant difference (t=0.231 3, P=0.818 5). The rate of spinal canal expansion in microplate group (60% ± 24%) was significantly higher than that in anchor group (40% ± 18%) (t=2.820, P=0.008). The JOA scores of 2 groups at 3 months and 24 months after operation were significantly higher than the preoperative scores (P lt; 0.01). There was no significant difference in JOA score between 2 groups at 3 months after operation (t=1.620 5, P=0.114 6), but the JOA score of microplate group was significantly higher than that of anchor group at 24 months after operation (t=3.454 3, P=0.001 5). X-ray film, MRI, and CT scan at 3-6 months after operation displayed that door spindle reached bony fusion. There was no occurrence of ‘‘re-close of door’’ in 2 groups. The rate of compl ication in microplate group (13.3%, 2/15) was significantly lower than that in anchor group (25.0%, 5/20) (χ2=7.160 0, P=0.008 6). Conclusion ELP by microplate fixation can achieve the stabil ity quickly after operation, which can help patients to do functional exercises early, and has satisfactory effectiveness and less complications.
【Abstract】 Objective To review the progress in the research of complications after expansive laminoplasty such as axial symptom, kyphotic deformity, and segmental motor paralysis. Methods Recent articles about complications after expansive laminoplasty were reviewed, and comprehensive analysis was done. Results The pathogenesis of axial symptom, kyphotic deformity, and segmental motor paralysis has not yet fully been understood, but has brought new finding, such as the importance of the spinous process-ligament-muscle complex, C5 palsy theory, and the involvement of the spinal cord mechanism. Conclusion The pathogenesis of axial symptom, kyphotic deformity, and segmental motor paralysis should be further investigated to prevent and treat the complications.
