Cervical Laminectomy with Lateral Mass Screw Fixation in Cervical Spondylotic Myelopathy: Neurological and Sagittal Alignment Outcome: Do We Need Lateral Mass Screws at each Segment?

Manoj Dayalal Singrakhia, Nikhil Ramdas Malewar, Sonal Manoj Singrakhia, Shivaji Subhash Deshmukh, Manoj Dayalal Singrakhia, Nikhil Ramdas Malewar, Sonal Manoj Singrakhia, Shivaji Subhash Deshmukh

Abstract

Background: Anterior cervical decompression and fusion is the standard procedure used for treating patients with cervical myelopathy. However, these procedures are associated with complications such as pseudarthrosis, construct failure, and neurological complications. Posterior cervical laminectomy and instrumentation is an alternative procedure to treat multilevel cervical myelopathy. In this study, we raised questions whether instrumentation is required at all levels and whether stabilizing the spine in neutral or lordotic contour with indirect decompression leads to neurological improvement with radiological evidence of anterior decompression. The results of posterior cervical laminectomy and instrumentation with lateral mass screw in terms of radiological and functional outcome in patients with multilevel cervical myelopathy are prospectively evaluated.

Materials and methods: In this prospective study conducted between June 2006 and December 2015, we have evaluated 112 patients with multilevel cervical myelopathy who underwent multilevel cervical laminectomy and instrumentation with lateral mass screw. All patients were evaluated preoperatively and postoperatively with Nurick's grading and Modified Japanese Orthopaedic Association (mJOA) scale for neurological function. Cooper scale and British Medical Research Council grading system for motor function. Curvature index was used to measure the alignment of cervical spine preoperatively and postoperatively. Alignment of the cervical spine was done preoperatively and postoperatively by calculating the curvature index. Axial MRI was used to calculate the severity of compression preoperatively which was calculated as per Singh's criteria and postoperatively to assess the adequacy of decompression at the operated level.

Results: In our study, there were 112 patients including 99 males and 13 females, with mean age of 59.53 years. The mean duration of followup of patients was 33.24 months. In total, cervical laminectomy was performed at 342 levels in 112 patients with an average of 3.05 laminectomies, and in total, 112 lateral mass screws were inserted. On postoperative followup, the mJOA and Nurick's grading showed improvement in all cases as compared to preoperative findings. The mean mJOA improved significantly from 8.56 preoperatively to 13.57 postoperatively (P < 0.001). The mean Nurick's grading also improved significantly from 2.59 preoperatively to 0.66 postoperatively (P < 0.001). The mean Cooper scale also showed significant improvement in both upper and lower limbs postoperatively (P < 0.001). The mean preoperative Cooper scale was 1.75 and postoperative was 0.31 for upper limbs, and the mean Cooper scale was 2.14 preoperatively and 0.56 postoperatively for lower limbs. X-rays done on routine followups showed good alignment of the cervical spine with maintenance of curvature index in all patients. The mean grade of compression as seen on preoperative MRI was 2.46 which reduced significantly postoperatively to 0.16 (P < 0.001).

Conclusion: The multilevel cervical laminectomy and instrumentation with lateral mass screw for multilevel cervical myelopathy is a safe technique that provides decompression of the spinal cord, prevents the development of kyphotic spinal deformity and posterior tension band of the spinal cord as associated with laminoplasty or uninstrumented laminectomy.

Keywords: Bone screws; Cervical laminectomy; cervical myelopathy; indirect decompression; laminectomy; lateral mass screw; myelopathy; spinal cord compression.

Conflict of interest statement

There are no conflicts of interest.

Figures

Figure 1
Figure 1
T2W MRI axial cut showing (a) Grade 0-360° cushion of cerebrospinal fluid around the spinal cord. (b) Grade 1 - loss of cerebrospinal fluid cushion without indention of spinal cord. (c) Grade 2 - mild spinal cord compression. (d) Grade 3 - severe spinal cord compression
Figure 2
Figure 2
(a) Immediate postoperative X-ray of cervical spine anteroposterior and lateral views following C3–C7 laminectomy and instrumentation done with lateral mass screw at C3, C5, and C7. (b) 2-year followup X-ray of the same patient showing well-maintained alignment of the cervical spine. Screws and rods are in good position
Figure 3
Figure 3
(a) Immediate postoperative X-ray of cervical spine anteroposterior and lateral views following C3–C6 laminectomy and instrumentation done with lateral mass screw at C3 and C6. (b) 3-year followup X-ray of the same patient showing well-maintained alignment of the cervical spine. Screws and rods are in good position
Figure 4
Figure 4
Sagittal MRI T2WI of cervical spine showing (a) multilevel spinal cord compression secondary to ossification of posterior longitudinal ligament. (b) Well decompressed spinal cord which has moved substantially away from anterior pathology. (c) Preoperative axial scan showing severe compression of the spinal cord. (d) Postoperative axial scan showing well-decompressed cord with 360° cushioning of cerebrospinal fluid
Figure 5
Figure 5
Sagittal MRI T2WI of cervical spine showing (a) multilevel spinal cord compression secondary to cervical spondylosis. (b) Well decompressed spinal cord which has moved substantially away from anterior pathology in postoperative image. (c) Preoperative axial scan showing severe compression of the spinal cord. (d) Postoperative axial scan showing well-decompressed cord with 360° cushioning of cerebrospinal fluid

References

    1. Miyazaki M, Kodera R, Yoshiiwa T, Kawano M, Kaku N, Tsumura H. Prevalence and distribution of thoracic and lumbar compressive lesions in cervical spondylotic myelopathy. Asian Spine J. 2015;9:218–24.
    1. Edwards CC, 2nd, Riew KD, Anderson PA, Hilibrand AS, Vaccaro AF. Cervical myelopathy. Current diagnostic and treatment strategies. Spine J. 2003;3:68–81.
    1. Ellingson BM, Salamon N, Hardy AJ, Holly LT. Prediction of neurological impairment in cervical spondylotic myelopathy using a combination of diffusion MRI and proton MR spectroscopy. PLoS One. 2015;10:e0139451.
    1. Fei Q, Li J, Su N, Wang B, Li D, Meng H, et al. Comparison between anterior cervical discectomy with fusion and anterior cervical corpectomy with fusion for the treatment of cervical spondylotic myelopathy: A meta-analysis. Ther Clin Risk Manag. 2015;11:1707–18.
    1. Liu T, Xu W, Cheng T, Yang HL. Anterior versus posterior surgery for multilevel cervical myelopathy, which one is better. A systematic review? Eur Spine J. 2011;20:224–35.
    1. Lao L, Zhong G, Li X, Qian L, Liu Z. Laminoplasty versus laminectomy for multi-level cervical spondylotic myelopathy: A systematic review of the literature. J Orthop Surg Res. 2013;8:45.
    1. Song M, Zhang Z, Lu M, Zong J, Dong C, Ma K, et al. Four lateral mass screw fixation techniques in lower cervical spine following laminectomy: A finite element analysis study of stress distribution. Biomed Eng Online. 2014;13:115.
    1. Chang V, Lu DC, Hoffman H, Buchanan C, Holly LT. Clinical results of cervical laminectomy and fusion for the treatment of cervical spondylotic myelopathy in 58 consecutive patients. Surg Neurol Int. 2014;5(Suppl 3):S133–7.
    1. Zhu B, Xu Y, Liu X, Liu Z, Dang G. Anterior approach versus posterior approach for the treatment of multilevel cervical spondylotic myelopathy: A systemic review and meta-analysis. Eur Spine J. 2013;22:1583–93.
    1. Komotar RJ, Mocco J, Kaiser MG. Surgical management of cervical myelopathy: Indications and techniques for laminectomy and fusion. Spine J. 2006;6(6 Suppl):252S–67S.
    1. Fehlings MG, Barry S, Kopjar B, Yoon ST, Arnold P, Massicotte EM, et al. Anterior versus posterior surgical approaches to treat cervical spondylotic myelopathy: Outcomes of the prospective multicenter AOSpine North America CSM study in 264 patients. Spine (Phila Pa 1976) 2013;38:2247–52.
    1. Tian P, Fu X, Li ZJ, Sun XL, Ma XL. Hybrid surgery versus anterior cervical discectomy and fusion for multilevel cervical degenerative disc diseases: A meta-analysis. Sci Rep. 2015;5:13454.
    1. Shriver MF, Lewis DJ, Kshettry VR, Rosenbaum BP, Benzel EC, Mroz TE. Pseudarthrosis rates in anterior cervical discectomy and fusion: A meta-analysis. Spine J. 2015;15:2016–27.
    1. McAnany SJ, Baird EO, Overley SC, Kim JS, Qureshi SA, Anderson PA. A meta-analysis of the clinical and fusion results following treatment of symptomatic cervical pseudarthrosis. Global Spine J. 2015;5:148–55.
    1. Feng NL, Zhong HL, Xuan H, Zhi C, Fang Z, Hong XS, et al. Comparison of two reconstructive techniques in the surgical management of four level cervical spondylotic myelopathy. Biomed Res Int 2015. 2015:513906.
    1. Du W, Wang L, Shen Y, Zhang Y, Ding W, Ren L. Long term impacts of different posterior operations on curvature, neurological recovery and axial symptoms for multilevel cervical degenerative myelopathy. Eur Spine J. 2013;22:1594–602.
    1. McAllister BD, Rebholz BJ, Wang JC. Is posterior fusion necessary with laminectomy in the cervical spine? Surg Neurol Int. 2012;3(Suppl 3):S225–31.
    1. Kaptain GJ, Simmons NE, Replogle RE, Pobereskin L. Incidence and outcome of kyphotic deformity following laminectomy for cervical spondylotic myelopathy. J Neurosurg. 2000;93(2 Suppl):199–204.
    1. Liu X, Min S, Zhang H, Zhou Z, Wang H, Jin A. Anterior corpectomy versus posterior laminoplasty for multilevel cervical myelopathy: A systematic review and meta-analysis. Eur Spine J. 2014;23:362–72.
    1. Epstein NE, Hollingsworth R. C5 nerve root palsies following cervical spine surgery: A review. Surg Neurol Int. 2015;6(Suppl 4):S154–63.
    1. Du W, Zhang P, Shen Y, Zhang YZ, Ding WY, Ren LX. Enlarged laminectomy and lateral mass screw fixation for multilevel cervical degenerative myelopathy associated with kyphosis. Spine J. 2014;14:57–64.
    1. Anderson PA, Matz PG, Groff MW, Heary RF, Holly LT, Kaiser MG, et al. Laminectomy and fusion for the treatment of cervical degenerative myelopathy. J Neurosurg Spine. 2009;11:150–6.
    1. Houten JK, Cooper PR. Laminectomy and posterior cervical plating for multilevel cervical spondylotic myelopathy and ossification of the posterior longitudinal ligament: Effects on cervical alignment, spinal cord compression, and neurological outcome. Neurosurgery. 2003;52:1081–7.
    1. Revanappa KK, Rajshekhar V. Comparison of nurick grading system and modified Japanese Orthopaedic Association scoring system in evaluation of patients with cervical spondylotic myelopathy. Eur Spine J. 2011;20:1545–51.
    1. Liu K, Shi J, Jia L, Yuan W. Surgical technique: Hemilaminectomy and unilateral lateral mass fixation for cervical ossification of the posterior longitudinal ligament. Clin Orthop Relat Res. 2013;471:2219–24.
    1. Chen Y, Chen D, Wang X, Lu X, Guo Y, He Z, et al. Anterior corpectomy and fusion for severe ossification of posterior longitudinal ligament in the cervical spine. Int Orthop. 2009;33:477–82.
    1. Uchida K, Nakajima H, Sato R, Yayama T, Mwaka ES, Kobayashi S, et al. Cervical spondylotic myelopathy associated with kyphosis or sagittal sigmoid alignment: Outcome after anterior or posterior decompression. J Neurosurg Spine. 2009;11:521–8.
    1. Ito M, Nagahama K. Laminoplasty for cervical myelopathy. Global Spine J. 2012;2:187–94.
    1. Cho WS, Chung CK, Jahng TA, Kim HJ. Post-laminectomy kyphosis in patients with cervical ossification of the posterior longitudinal ligament: Does it cause neurological deterioration? J Korean Neurosurg Soc. 2008;43:259–64.
    1. Kumar VG, Rea GL, Mervis LJ, McGregor JM. Cervical spondylotic myelopathy: Functional and radiographic long term outcome after laminectomy and posterior fusion. Neurosurgery. 1999;44:771–7.
    1. Huang RC, Girardi FP, Poynton AR, Cammisa FP., Jr Treatment of multilevel cervical spondylotic myeloradiculopathy with posterior decompression and fusion with lateral mass plate fixation and local bone graft. J Spinal Disord Tech. 2003;16:123–9.
    1. Geck MJ, Eismont FJ. Surgical options for the treatment of cervical spondylotic myelopathy. Orthop Clin North Am. 2002;33:329–48.
    1. Blizzard DJ, Gallizzi MA, Sheets C, Klement MR, Kleeman LT, Caputo AM, et al. The role of iatrogenic foraminal stenosis from lordotic correction in the development of C5 palsy after posterior laminectomy and fusion. J Orthop Surg Res. 2015;10:160.
    1. Yi S, Yoon DH, Kim KN, Kim SH, Shin HC. Postoperative spinal epidural hematoma: Risk factor and clinical outcome. Yonsei Med J. 2006;47:326–32.
    1. Takahashi Y, Sato T, Hyodo H, Kawamata T, Takahashi E. Symptomatic epidural haematoma after cervical laminoplasty: A report of three cases. J Orthop Surg (Hong Kong) 2016;24:121–4.

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