Cervical Laminoplasty

Dorn Spinal Therapy

Spine Healing Therapy

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Adrian T.H. Casey1^, H. Alan Crockarda a Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, and b Spinal Surgery Unit, The Royal National Orthopaedic Hospital, Stanmore, UK

Cervical laminoplasty is very much a Japanese invention. Its popularity in Japan arises from the formidable challenges of anterior decompression for ossification of the posterior longitudinal ligament [1-5]. These anterior multilevel surgeries would be frequently complicated by dural tears as the dura is usually intimately associated with the ossified ligament [1, 6-9]. There was also a significant risk of instrumentation or graft failure [2]. It has been reported that the rate of these complications including cerebrospinal fluid leakage and dislodg-ment or pseudarthrosis of the strut grafted bone was 24% and the rate of the salvage operation required was 12.5% [10].

In the past, laminectomy has been the most common method to achieve posterior decompression of the cervical spine in these patients. However, the procedure has been complicated by postoperative instability resulting in deformity, particularly kyphosis [11-15], which may exacerbate neurological symptoms.

Kyphosis and instability may leave the spine more vulnerable to cervical spine trauma, especially flexion injuries. In addition, postlaminectomy membranes have been implicated in arachnoiditis and restenosis after simple laminec-tomy [16, 17]. To avoid the disadvantages of laminectomy, several authors have described the technique of cervical laminoplasty whereby decompression is achieved without removal of the posterior spinal elements, maintaining the bio-mechanical integrity of the cervical spine and the spinal cord-protective features of the posterior elements [3, 18-25]. This is a more physiological solution. Expansive open-door laminoplasty was first described by Hirabayashi et al. [26] as a development of the air drill laminectomy technique of Kirita [27] and has since been modified by Hirabayashi et al. and many others [3, 18-25, 28]. The authors of this chapter present a modification of the technique using titanium miniplates to stabilize the posterior elements in the open position [22].

Table l. Indications for expansive cervical laminoplasty

OPLL over multiple levels (with maintained cervical lordosis)

Congenital canal stenosis (with maintained cervical lordosis)

Multilevel cervical spondylosis (with maintained cervical lordosis)

Posterior compression from ligamentous hypertrophy (with maintained cervical lordosis)

As part of a staged anterior and posterior canal expanding procedure

OPLL = Ossification of the posterior longitudinal ligament.

Table 2. Contraindications for expansive cervical laminoplasty

Significant anterior compression Established absolute kyphosis Isolated radiculopathy

Loss of anterior column support resulting from tumour, trauma or infection

This method has the advantage of technical simplicity and allows for postoperative magnetic resonance imaging because the use of stainless steel implants is avoided. It has been used in the authors' departments in more than 300 cases now, with good short- and long-term results. The technique is no longer limited to ossification of the posterior longitudinal ligament, which is rare in Caucasians. Its most frequent use is now for multilevel cervical spondylotic myelopathy associated with varying degrees of constitutional canal stenosis. The indications and contraindications are listed in tables 1 and 2.

Kyphosis is a contraindication to laminectomy [29] and probably laminoplasty [30, 31].

There are several technical variations. The two main differences are whether the opening is in the midline (French door) or to one side (open door). Then there are differences in how to keep the door open. Initially the techniques were quite cumbersome and involved suturing or wiring the bony posterior elements to muscle. Inevitably they did not always keep the door as open as it may have been originally at the time of surgery. The Queen Square technique uses titanium miniplates with no bone graft to keep the door open. In our experience this has been a simple and reliable technique. Alternative techniques have used ceramic spacers or bone graft to keep the doors open.

Three types of Z plasty may be performed: on the lamina using the method of Hattori as reported by Oyama et al. [32], between each lamina using the reciprocal method of Tomimura and Morizono [33] and between two segmental laminae using the Chiba University technique [34]. The variety of reported techniques are illustrated in figure 1.

Laminoplasty Images

Fig. 1. Different techniques reported.

Tomita et al. have [3] championed the use of their thread wire saw to achieve the opening. This is similar to a very fine Gigli saw. It was developed for en bloc vertebrectomy. This is a clever technical innovation, however it does require sublaminar passage of the wire. This is very much finer than sublaminar wires and indeed cables which have been implicated in neurological deterioration. The majority of the other techniques require a high-speed drill.

Queen Square Technique [22]

Surgical technique (C3-C6): The patient is placed in a prone position with the head slightly flexed secured by Mayfield pins. The body is supported by a Montreal mattress. Somatosensory evoked potentials are recorded. A standard posterior midline approach allows exposure of the cervical laminas from the caudal edge of C2 to the cranial edge of C7 and laterally to the lateral aspect of the facet joints. Care is taken to preserve the facet capsules and soft tissue attachments to the lateral masses. The spinous processes and interspinous ligaments are preserved.

Using a 3-mm spherical cutting burr, two channels are drilled bilaterally. These are placed at the junction of the lamina and the medial aspect of the lateral masses (fig. 2a). Care is taken to avoid damage to the facet joints. Using this technique, the canal is entered laterally, where spinal cord compression is less severe. Inadvertent plunging penetration of the canal is prevented by the shelf created in the medial aspect of the lateral masses. The depth of the channels is increased until the ventral cortex of the lamina is identified. The laminoplasty is opened on the side with clinical evidence of unilateral radiculopathy or with asymmetric canal or foraminal stenosis identified on the preoperative scans. Specific radiculopathies can also be addressed with foraminal decompressions. If there is no unilateral radiculopathy or asymmetric stenosis, either side may be opened.

On the side to be opened, the channel is completed through the ventral cortex of the lamina with a diamond burr or 1-mm Kerrison up-cutting rongeur. Alternatively, the craniotome attachment for the Midas Rex (Midas Rex Pneumatic Tools, Fort Worth, Tex., USA) may be used to transect the lamina on the opening side. This is in fact our most usual technique. There have been no dural tears or neurological deteriorations in our series, using the craniotome attachment to open the door. On the hinge side, the ventral cortex of the lamina is thinned until the posterior elements can be rotated dorsally to effect decompression of the spinal cord (fig. 2b). This is done en bloc because the interspinous ligament and ligamentum flavum are intact from the occiput through C7. Hirabayashi et al. [26] suggest a limited osteotomy of the spinous process of C7 (or most caudal vertebra) to allow a sufficient opening of the door.

Resection Ligament FlavumCervical Laminoplasty Single Door

Fig. 2. Operative sequence showing preparation of the bilateral channels for the hinge side (right) and opening side (left) of the laminoplasty (a), mobilization and rotation of the posterior elements (b), and stabilization of the open-door laminoplasty with titanium miniplates (c) [modified from 22].

Release of ligamentum flavum, dural adhesions, and bridging vessels is performed on the opening side as required to elevate the posterior elements. At C2-C3 and C6-C7, partial resection of the intraspinous ligaments on the opening side and partial subperiosteal release of the intraspinous ligaments of C2 and C7 on the hinge side may be necessary to allow adequate mobilization and rotation of the posterior elements, achieving full decompression (fig. 2b). Vigorous epidural bleeding is occasionally encountered on release of the stenotic canal. This can be controlled with bipolar coagulation and haemostatic material. After adequate decompression, the dura is typically pulsatile, indicating satisfactory decompression. When the open door has been adequately mobilized, it is stabilized with titanium miniplates (Lehbinger, Freiburg, Germany).

Hirabayashi et al. [35] unflex the neck prior to fixing their laminoplasty. This they claim helps maintain and secure cervical lordosis. We most often use a straight five-hole plate bent into sigmoid shape/open Z configuration (fig. 2c) to allow one hole for fixation into the lamina and 2 screws into the corresponding lateral mass. Longer or shorter plates can be fashioned as needed to achieve adequate opening. The plates are held in position with 2 or 3 screws 5-9 mm in length. An attempt is made to angle the screws away from the facet joints. We typically use one plate per level, if possible, to distribute the forces over multiple fixation points (fig. 3). No formal attempt is made to graft bone to the operative site. However, on the hinge side, where the adjacent lamina and lateral masses are still connected, the dorsal cortex of these structures are

Interval Cervical Laminoplasty
Fig. 3. Schematic diagram showing the orientation of the titanium miniplates in a C3-C6 laminoplasty and adjacent anatomic structures.

brought into contact as the hinge side trough is closed during elevation and rotation of the posterior elements into the open position. This is analogous to a green stick fracture. The morbidity associated with harvesting bone graft is avoided. A soft collar is used to facilitate patient comfort while mobilizing during the first few days after surgery. No other external orthosis is used after surgery.

Discussion

Anterior and posterior decompression are established techniques in the management of multilevel cervical canal stenosis resulting in myeloradiculopathy. Anterior cervical discectomy and fusion immobilize segments of the cervical spine and result in high mechanical demands on the adjacent intervertebral segments. Over the patient's lifetime, abnormal mechanical stresses can produce significant radiographic and clinical evidence of deterioration. Hilibrand et al. [36] in a consecutive series of 374 patients reported that symptomatic adjacent-segment disease occurred at a relatively constant incidence of 2.9%/year (range 0.0-4.8%/year) during the 10 years after the operation. Survivorship analysis predicted that 25.6% of the patients (95% confidence interval, 20-32%) who had an anterior cervical arthrodesis would have new disease at an adjacent level within 10 years after the operation. However, contrary to their hypothesis, they found that the risk of new disease at an adjacent level was significantly lower following a multilevel arthrodesis than it was following a single-level arthrodesis (p = 0.001).

Nonetheless there is an intellectual reluctance to perform a multilevel trench procedure with fusion in a young patient. The incidence of complications for anterior multilevel corpectomy has been reported to be high even in expert hands. Saunders et al. [37] did a retrospective analysis of 31 cases of cervical spondylotic myelopathy treated by four-level subaxial cervical corpectomy. Three patients died within 3 weeks of surgery (9.7%). Delayed radiculopathy occurred in 4 patients after surgery, 3 had acute graft complications, and 1 had pseudomeningocoele, resulting in a morbidity rate of 25.8%. There were no cases of infection or increasing myelopathy. In another series by these authors, on 40 cases of cervical corpectomy, they reported a perioperative complication rate of 47.5%, with a 7.5% incidence of persistent sequelae [37-39]. Fessler et al. [40] have reported their extensive experience of cervical corpectomy in a retrospective series of 93 cases over 10 years with a lower complication rate. In another more recent series Edwards et al. [41] have attempted to compare the neurological outcome and complications of cervical corpectomy and cervical laminoplasty. Medical records of all patients treated for multilevel cervical myelopathy with either multilevel corpectomy or laminoplasty between 1994 and 1999 at the Emory Spine Center were reviewed. From a pool of 38 patients meeting stringent inclusion and exclusion criteria, 13 patients who underwent multilevel corpectomy were blindly matched with 13 patients who underwent laminoplasty based on known prognostic criteria. Improvement in function averaged 1.6 Nurick grades after laminoplasty and 0.9 grades after multilevel corpectomy (p > 0.05). Subjective improvements in strength, dexterity, sensation, pain, and gait were similar for the two operations. The prevalence of axial discomfort at the latest follow-up was the same for each cohort, but the analgesic requirements tended to be greater for patients who underwent multilevel corpectomy. This is the opposite finding to the larger study of Hosono et al. [42] on pain. Sagittal motion from C2 to C7 decreased by 57% after multilevel cor-pectomy and by 38% after laminoplasty. One complication (C6-C7 herniated nucleus pulposus requiring anterior discectomy with fusion) occurred in the laminoplasty group [41]. Multilevel corpectomy complications included the progression of myelopathy, non-union, persistent dysphagia, persistent dyspho-nia, and subjacent motion segment ankylosis.

An alternative posterior decompressive procedure to laminoplasty is cervical laminectomy with posterior fixation/fusion. Today this would be performed using the lateral mass screw/rod system. This will also prevent postoperative kyphus. It will more reliably immobilize the spine. Adams and Logue [43, 44] have shown that one of the reasons for delayed deterioration following cervical laminectomy is hypermobility. Screw/rod fixation is therefore an attractive option. However the extra rigidity is probably not required as Herkowitz [45, 46] concluded from his 'biomechanical study' that stability of the cervical spine after laminoplasty was not significantly different from that of the intact control. Laminoplasty affords some rigidity, but still preserves motion [47]. The long-term effects of laminoplasty on cervical movement and alignment were investigated by radiography and CT scans in a study of 56 patients with multi-segmental myelopathy who had undergone a C3 to C7 open-door laminoplasty. Follow-up averaged 5.8 years. Satisfactory neurological improvement occurred in 73%. Cervical flexion decreased by 35% and extension by 57%; the decrease of both movements was statistically significant. Decreased vertebral slip as well as slightly reduced lordosis was seen after operation.

Cervical laminectomy and laminoplasty have been compared in a retrospective study [48]. This is another study from Emory, with similar design principles to the corpectomy/laminoplasty study described above (an independent matched cohort analysis), involving 13 patients in each arm. Both objective improvement in patient function (Nurick score) and the number of patients reporting subjective improvement in strength, dexterity, sensation, pain, and gait tended to be greater in the laminoplasty cohort [48]. Whereas no complications occurred in the laminoplasty cohort, there were 14 complications in 9 patients that underwent laminec-tomy with fusion. Complications included progression of myelopathy, non-union, instrumentation failure, development of a significant kyphotic alignment, persistent bone graft harvest site pain, subjacent degeneration requiring reoperation, and deep infection. The marked difference in complications and functional improvement between these matched cohorts suggests that laminoplasty may be preferable to laminectomy with fusion, as a posterior procedure for multilevel cervical myelopathy [48]. Similar findings were found in a less well-controlled study by Herkowitz [49]. In this retrospective study he compared the results and complications of 45 patients with at least a 2-year follow-up, who had undergone anterior fusion, cervical laminectomy, or cervical laminoplasty for the surgical management of multiple level cervical radiculopathy due to cervical spondylosis. Eighteen patients (58 levels) underwent anterior fusion, 12 patients (38 levels) had a cervical laminectomy, and 15 patients (57 levels) underwent a cervical laminoplasty. In another study by Baisden et al. [50], radiographic and biomechanical results in the goat model revealed that laminoplasty was superior to laminectomy in maintaining cervical alignment and preventing postoperative spinal deformities. Quite how this relates to humans is debatable.

Complications

There are two notable complications with cervical laminoplasty - radiculopathy and pain. These have been the subject of several studies [51]. C5,C6 radicular pain and/or paresis are the most frequent complications that occur in approximately 5-10% of the patients in the series of Hirabayashi et al. [35] of 350 patients although most complications resolve spontaneously within 2 years. Of 365 patients who had undergone laminoplasty, 20 patients (5.5%) developed postoperative radiculopathy. Using data from postoperative computed tomography scans and other sources, these patients were compared with 211 patients with no radiculopathy, who had undergone laminoplasty during the same period, to identify risk factors related to patient characteristics and surgical techniques. Of various risk factors studied, the narrowest level of the spinal canal, preoperative symptomatic severity, flatness of the spinal cord assessed by computed tomography myelopathy at C4-C5, cervical curvature, anterior protrusion of the superior articular process as assessed by computed tomography scan, laterality of the osteophytes, and ossification of the posterior longitudinal ligament could not significantly discriminate between patients with and without postoperative radiculopathy. The angle of lamina as measured by using computed tomography scans obtained after expansion in the patients with radiculopathy was greater on both the opened and hinged sides and was significantly greater than the angle in patients without radiculopathy (p < 0.05). The incidence of radiculopathy on both the opened and hinged sides was significantly higher in patients in whom the bony gutter had been cut on the lateral side of the medial aspect of the zygapophyseal joint. An alternative theory is that too radical a decompression allows slumping backwards of the spinal cord, putting traction on the anatomically vulnerable C5 nerve root. This is the theory espoused for C5 radiculopathy following the trench corpectomy procedure. Here it now recommended limiting the decompression to 15 mm from right to left. Friction heat generated by drilling on the open and hinge sides, traumatic use of Kerrison rongeurs, and a drop of the hinge into the canal are also by some considered as causes of such injury. However, these types of trauma during the operation are likely to damage the posterior root rather than the anterior root; therefore, the sensory disturbance is expected to be stronger. Nevertheless, in most cases, sensory disturbance at C5 or C6 was absent. This lends credence to the tethering action on the anterior root [35].

Pain

There is an increasing recognition that this is quite a painful procedure in the short term, mainly with pain in the trapezius region. In the long run a fair number of patients experience neck pain. This has been studied by Hosono et al. [42]. Ninety-eight patients had surgery for their disability secondary to cervical spondylotic myelopathy. Of those patients, 72 had laminoplasty and 26 had anterior interbody fusion. The presence or absence of axial symptoms was investigated before and after surgery. The duration, severity, and laterality of symptoms were also recorded. The prevalence of postoperative axial symptoms was significantly higher after laminoplasty than after anterior fusion (60 vs. 19%; p < 0.05). In 18 patients (25%) from the laminoplasty group, the chief complaints after surgery were related to axial symptoms for more than 3 months, whereas in the anterior fusion group, no patient reported having such severe pain after surgery. In this group shoulder pain developed exclusively on the hinged side.

In conclusion, open door expansive laminoplasty is a versatile, easy and effective method for achieving multilevel decompression of the cervical spine affected by ossification of the posterior longitudinal ligament or cervical spondylosis [51].

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Professor Alan Crockard, DSc FRCS, FRCS (Ed)

Department of Surgical Neurology

National Hospital for Neurology and Neurosurgery

Box 3, Queen Square, London WC1N 3BG (UK)

E-Mail [email protected], [email protected]

Haid RW Jr, Subach BR, Rodts GE Jr (eds): Advances in Spinal Stabilization. Prog Neurol Surg. Basel, Karger, 2003, vol 16, pp 154-164

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