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E. Tabaraee, D. Shearer, C. Ames, S. Burch, V. Deviren, S. Berven, S. Hu, D. Chou, P. Mummaneni, B. Tay

University of California, San Francisco5/11/2013

None related to this study

� Cervical Myelopathy� Inc incidence

� Hirabayashi� Address OPLL� Noninstrumented� Motion sparing

� Safe and Efficacious…� Cervical spondylotic� OPLL

ProsMotion preservingProtectiveEasier revisionAvoid fusion/instrument complicationsCost-effective?

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� Cons�axial neck

pain� C5 palsy� closure

� Techniques� Open door� French door� w/ fusion

� Spacers� Structural rib allografts� Hydroxyapatite spacers� Metallic Plates

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� Allograft � Pros: � Effective� affordable

� Cons:� Intraop contour� Fragile� Postop bracing

� Plating � Pros:

� Rigid fixation� Early rom� Hinge healing

� Shorter op time?� Lower ebl?

� Cons:� Expensive� Hardware

complications?

� To compare outcomes, complications, and costs associated with two of the more common implants used in open-door laminoplasty.

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1. There is no difference in neck pain and nurick scores at final follow-up for laminioplasty patients with either allograft struts or metallic mini-plates

2. There is no intraoperative, immediate postoperative, or financial benefit to using metallic mini-plates

� We performed a retrospective analysis � 106 patients. � The primary outcomes were neck visual analog scale

(VAS) pain scores and Nurick scores. � Secondary outcomes included length of procedure,

estimated blood loss, length of stay, complications, and direct costs.

� Preoperative� Demographics, Charlson Comorbidity index, Nurick,

Neck-VAS� Intraoperative� EBL, operative time, # of levels, # implants

� Postoperative� Length of stay, direct costs, Nurick, Neck-VAS, f/u

months� Statistics:� Fisher, t-test

Inclusion Exclusion• Primary diagnosis of CSM or OPLL• >18 years of age• Involving 3 or 4 levels• Use of either structural rib

allograft struts or metallic mini-plates only

• Revision surgery• History of either previous or concomitant

cervical fusion• Diagnosis of spinal cord tumor, multiple

myeloma, or infection• Use of any other laminar spacers other than

rib allograft or metallic mini-plates• Use of both rib allograft and mini-plates• Diagnosis of neuromuscular disease (i.e.

cerebral palsy)• Diagnosis of neuro-autoimmune disease

(i.e. multiple sclerosis)

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Allograft (n=51) Plates (n=55) p-valueAge, mean (SD) 62.2 (1.7) 61.3 (1.7) 0.70Male Gender, no. (%) 31 (60.8) 32 (58.2) 0.84

Number of Comorbidities, mean (SD)

2.9 (0.3) 3.1 (0.3) 0.66

Charlson Comorbidities Index, mean (SD)

2.7 (0.2) 3 (0.3) 0.42

OPLL, no. (%) 4 (7.8) 10 (18.2) 0.15Total Months Follow Up, mean (SD) *

31 (3.1) 23 (1.8) 0.005

SD (standard deviation), No. (number), OPLL (ossification of posterior longitudinal ligament), * (statistically significant)

Allograft (n=51) Plates (n=55) p-value

Preop neck VAS, mean (SD)

4.3 (0.4) 3.7 (0.5) 0.33

Final Neck VAS, mean (SD)

2 (0.4) 2.2 (0.4) 0.92

Preop Nurick Score, mean (SD)

2 (0.2) 2.3 (0.2) 0.22

Final Nurick Score, mean (SD)

1.4 (0.2) 1.5 (0.2) 0.97

SD (standard deviation), VAS (visual analog scale), * (statistically significant)

Allograft (n=51)

Plates (n=55) p-value

Surgeon Specialty, no. (%)* <0.001

OrthopaedicSurgery

38 (74.5) 3 (5.5)

Neurosurgery 10 (19.6) 52 (94.6)

Combined (two surgeons from different specialties

3 (5.9) 0 (0)

Estimated blood loss, mean (SD) 287.7 (45.4) 229.9 (27.8) 0.28Foraminotomies, mean (SD)*

2.7 (0.3) 1.3 (0.2) 0.0001

Number of levels, mean (SD)

4.1 (0.1) 4 (0.1) 0.79

Number of implants, mean (SD)*

3 (0.09) 3.7 (0.1)<0.0001

Length of Procedure, mean (SD)*

161 (5) 136.6(7.3) 0.007

Length of Stay, mean (SD)

3.8 (0.4) 3.9 (0.4)0.94

Cervical collar used, no. (%)*

51 (100) 17 (30.9)<0.001

SD (standard deviation), no. (number), * (statistically significant)

Allograft (n=51) no. (%)

Plates (n=55) no. (%)

p-value

C5 palsy 4 (7.8) 3 (5.5) 0.67Persistent wound drainage 1 (2) 0 (0) 0.48

Dural tear 0 (0) 1 (1.8) 1.00Pulmonary Embolism 1 (2) 0 (0) 0.48

Deep Infection 3 (5.9) 1 (1.8) 0.35Wound Dehiscence 1 (2) 2 (3.6) 1.00

Lamina Fracture 0 (0) 1 (1.8) 1.00Foraminal Stenosis 0 (0) 2 (3.6) 0.50

Adjacent Segment Disease 0 (0) 1 (1.8) 1.00

Progressive Kyphosis 2 (3.9) 0 (0) 0.23

Readmission for pain control

1 (2) 0 (0) 0.48

Total Complications 13 ( 23.5) 11 (20) 0.81

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Allograft (n=51)no. (%)

Plates (n=55)no. (%)

p-value

Deep Infection3 (5.9) 1 (1.8) 0.35

Wound Dehiscence1 (2) 2 (3.6) 1.00

Lamina Fracture0 (0) 1 (1.8) 1.00

Foraminal Stenosis0 (0) 2 (3.6) 0.50

Adjacent Segment Disease

0 (0) 1 (1.8) 1.00Progressive Kyphosis

2 (3.9) 0 (0) 0.23Total Reoperations

6 (11.8) 7 (12.7) 1.00

allograft Plate

Collar 2 2.3

No collar N/a 1.8

� Results: Average follow-up was 27 months. � The postoperative neck VAS scores and Nurick scores

improved significantly from baseline but there was no difference in the final outcome scores or complications.

� The average length of operation and number of foraminotomies were higher for the allograft group. � Among the plate group, patients treated � without a hard collar did not experience an increase rate of

complications. � The mean direct cost for the mini-plate group was $2098

more. � Not included- Operative time, anesthesia costs, indirect cost

� Safe and effective� Kawai (Spine, 1988)� Heller (Spine, 2001)

� First to compare implants� Plates shorter op time, no bracing necessary� Allograft more affordable

� Laminoplasty implants� Cost saving vs. laminectomy/fusion� Highsmith (JNS, 2004)� $4200 per C3-6 construct

� Marcaio- OR time (J of Anes, 2005) � $62/min� Agabagi- cost of brace (jaaos, 2011) � $750

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� Retrospective- selection bias� 8 spine surgeons� No standard radiographic follow-up� Rehab protocol varied

� Not cost-effectiveness study� No accounts of indirect costs

� Structural rib allograft struts and metallic mini-plates result in similar improvements in neck pain and functional outcome scores with no difference in the rate of complications. � Potential benefits of using plates include shorter

procedure length and less need for postoperative immobilization. � This should be weighed against the 15% increase in

direct costs.� Long-term/radiographic data, cost-effectiveness

studies needed

�All authors�Dr. Hu and Dr. Tay

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