CLINICAL OUTCOMES AFTER OPEN-DOOR LAMINOPLASTY IN COMPRESSIVE CERVICAL MYELOPATHY - 20 CASES

DR.SANJOY BISWAS MS(ORTHO)SPINE FELLOW (GERMANY), SPINE FELLOW (SOUTH KOREA) DR.ABRAR AHMEDHEAD OF THE DEPARTMENT

DEPARETMENT OF SPINE SURGERYAPOLLO GLENEAGLES HOSPITAL, KOLKATA

CONCORD-2016, KOLKATA

INTRODUCTIONCircumferential narrowing of the spinal canal causes static compression over the spinal cord.

Movement of the cervical spine places the spinal cord at risk of injury secondary to dynamic forces, such as buckling of the ligamentum flavum in extension and impingement from a disc-osteophyte in flexion

Diameters less than 12 mm were found to be associated with an increased risk of developing myelopathy

Abnormalities in the corticospinal and spinocerebellar tracts lead to early lower extremity findings of ataxia, spasticity, and paresis.

As the disease progresses, upper extremity symptoms develop, with loss of strength and fine motor abilities.

Gait and sphincter disturbances may develop as the disease progresses

Operative treatment for myelopathy is indicated for patients with progressive disease.

SYSTEMATIC APPROACH

Components

Correct DiagnosisBest Treatment

complaints

ListenTouchThink

Obtain Imaging Studies

Interpretation and Synthesis

1

2

3

4

5

RETROSPECTIVE STUDY

Materials and methods

Patients who had kyphotic deformity, radiological instability, or previous spinal surgery were excluded .

Patients’ neurological functions and improvement were evaluated with Nurick score.

Preoperative and postoperative kyphosis was evaluated using the sagittal tangent method.

Preoperative and postoperative complications were recorded.

Study period

20 patients with cervical myelopathy were treated with open-door laminoplasty between 2012-2015

Study area

Sample size: 20

The goal of laminoplasty is to reposition the laminae to expand the spinal canal, allowing the spinal cord to migrate posteriorly.

SURGICAL PROCEDURE

OPEN-DOOR LAMINOPLASTY

BEAUTY LIES IN SIMPLICITYHirabayashi K, Miyakawa J, Satomi K: Maruyama T, Wakano K. Operative Results and postoperative progression of ossification among patients with ossification of cervical posterior longitudinal ligament. Spine 6: 354-364, 1981

Provide surgical expansion of the spinal canal.

1) A direct local decompression effect 2) A total decompression effect by dorsal shift of the spinal cord away from the ventral compressing elements.

SURGICAL PROCEDURE OPEN-DOOR LAMINOPLASTY

NUMBER OF PTSTITANIUM MINIPLATES AND SCREWS 17

PEEK RELIEVE [GLOBUS] 03

NEUROLOGICAL ASSESMENT

NURICKS SCALE WAS USED PREOPERATIVELY AND AT LAST

FOLLOW UP

NURICKS GRADE

0- Radiculopathy 1- Myelopathy+, No gait disturbance 2- Mild gait dist/ carry on with daily

activity 3- Mod gait dist- works without

assistance 4- Severe gait dist-works with

assistance 5- BedriddenNurick S: The pathogenesis of the spinal cord disorder associated with cervicalspondylosis. Brain 1972;95:87-100

RESULTS

We reviewed results from our hospitalfor patients with cervical myelopathywho underwent laminoplasty.

Postoperative follow-ups were performed at two months after the procedure and six months thereafter.

Serial no Age (Yr) OT time[min]

Blood loss[ml]

Nurick Grade Pre-op

Nurick Grade Post-op

Complications

Follow-Up(mnt.)

Sagittal, Alignment pre op

Sagittal Alignment post op

1 57 180 230 3 2 36 6 112 54 160 150 2 1 32 7 123 49 150 180 2 1 30 9 124 64 140 200 2 1 30 7 125 56 220 450 5 3 Dural tear 28 4 106 59 150 230 3 2 28 6 117 63 170 250 4 2 27 5 108 58 160 200 3 1 25 6 119 66 200 350 5 4 Transient C5

palsy23

4 9

10 77 180 300 4 3 21 6 1011 65 150 250 3 2 20 6 1012 64 150 200 4 2 18 5 1113 53 100 140 2 1 18 9 1314 58 120 190 2 1 18 7 1215 58 210 350 3 1 Sup.infection 14

6 11

16 36 120 150 2 1 14 8 1217 60 130 180 2 1 14 4 918 61 110 150 4 2 12 9 1319 72 150 200 2 1 12 7 1220 61 150 150 3 1 6 6 11

Patient demographic data, and clinical and sagittal alignment outcomes

M:F 18:2 (9:1) Mean age: 59.55 yrs (36-77 yrs)

MRI FINDINGS OPLL (Continuous/ Mixed)

06 MSCS (Multisegmental cervical spondylosis)

07 Lig flavum hypertrophy

04 Cord changes

03( 11 pts had more than one pathology

Duration of symptoms (months)

Number of patients

0-4 24-12 612-36 636-72 272-96 4

NURICKSGRADE

PREOPERATIVE(No. of pts)

POSTOPERATIVE(No. of pts)

GRADE 1 0 11GRADE 2 8 5GRADE 3 6 3GRADE 4 4 1GRADE 5 2 0

NURICKS GRADE

The mean preoperative Nurick grade was 3 (range, 2 to 5) post op1.6(range1 to 4)

The mean operating time was 155 minutes .

Mean blood loss was 225 cc.

Pre- and last postoperative kyphotic evaluation was measured using the sagittal tangent method [6.6 TO 11.2 DEGREE]

Wang MY, Shah S, Green BA. Clinical outcomes following cervical laminoplasty for 204 patients with cervical spondylotic myelopathy. Surg Neurol 62:487-493, 2004

Visual analog scale (VAS) and were compared -improved [ 8 TO 2 ]

CASE-1

Male/36 yr

CASE-2

Male/72 yr

CASE-3

Male/60 yr

AGHL 20[18/2] 18 59.55 OT,BL,HS,NURIC,VAS,PC

155MIN,225 ML,5 DAYS ,1.65 , VAS-1, COMPLICATIONS -3,

Excellent: All preoperative symptoms relieved; abnormal findings improved.

Good: Minimal persistence of preoperative symptoms; abnormal findings unchanged or improved

Fair: Definite relief of some preoperative symptoms; other symptoms unchanged or slightly improved

Poor: Symptoms and signs unchanged or exacerbated

Odom’s criteria

Outcome assessment was done using Odom’s criteria and using these criteria, 20 patients had a good to fair outcome.

Odom GL, Finney W, Woodhall B. Cervical disc lesions. JAMA 1958;166:223-8.

COMPLICATIONS

• CSF leak - Repaired • Superficial wound infection• Transient C5 palsy(Resolved)

Fortunately, the majorities resolve within 3–24Post-operative months without conservative treatment alone.

Radcliff KE, Limthongkul W, Kepler CK, Sidhu GD, Anderson DG, Rihn JA,et al. Cervical laminectomy width and spinal cord drift are risk factors forpostoperative C5 palsy. J Spinal Disord Tech 2014;27:86‑92.

In Gu et al. series, C5 root palsies occurred in 3.1% of double‑door laminoplasty, 4.5% of open‑door laminoplasty, and 11.3% of laminectomy.

Gu et al. also identified multiple risk factors for developing C5 palsiesfollowing posterior surgery; male gender, ossification of the posterior longitudinalligament (OPLL), narrower foramina, laminectomy, and marked spinal corddrift. Miller et al. also identified an average $1918 increased cost for physical/occupational therapy for patients with C5 palsies

Factors predisposing to C5 palsies included;

More narrowed width of the intervertebral foramen (WIF),

Anterior protrusion of the superior articular process (APSAP), A high‑signal intensity zone C3‑C5 (HIZ: C3‑C5), and OPLL; ofinterest, both groups demonstrated comparable posteriorshift of the spinal cord (PSSC)

C5 root palsy following expansile open‑door laminoplasty

Wu FL, Sun Y, Pan SF, Zhang L, Liu ZJ. Risk factors associated with upper extremity palsy after expansive open‑door laminoplasty for cervical myelopathy. Spine J 2014;14:909‑15.

The literature lacks randomized control study comparing laminectomy and laminoplasty, laminectomy with fusion and laminoplasty, or anterior corpectomy with fusion and laminoplasty.

Laminoplasty as practiced today, with early postoperative mobilization, may be able to show better stability than laminectomy and better preserved ROM than anterior fusion.

CONCLUSIONS Laminoplasty is a valuable procedure in multi-

segmental compression

For best results- should be performed before cord changes develop

THANK YOU………