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a S c i T e c h n o l j o u r n a lResearch Article

Journal of Spine

& Neurosurgery

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Romero et al., J Spine Neurosurg 2014, 3:5

http://dx.doi.org/10.4172/2325-9701.1000156

International Publisher of

Science, Technology and Medicine

Multilevel Cervical Myelopathyreatment - Open-DoorLaminoplasty vs. MultipleCervical ArcocristectomiesFlvio Ramalho Romero1*, Marco Antnio Zanini1, Luis Gustavo

Ducati1and Roberto Colichio Gabarra1

Abstract

Purpose: Cervical myelopathy due to posterior multiple levelcompression remains a surgical challenger. Many surgical

options have been used in the last years, but the best choice is

unclear. We compared open-door laminoplasty and multiple level

arcocristectomies on clinical and radiological ndings.

Methods: We retrospectively reviewed data from 36 patients,

nineteen (52.77%) treated by ODL and seventeen (47.23%) by MLA

between January 2008 and February 2014. Clinical ndings were

evaluated with Nurick scale. Canal diameter was evaluated with

Magnetic Resonance Images (MRI).

Results: Statistical analysis showed signicant enlargement of

the spinal canal for both ODL patients group and MLA patients

group. They also revealed a signicant improvement in the Nurick

Scale grade when the preoperative value was compared with

the immediate, 6 months and 12 months postoperative gradesseparately and together for both ODL patients group and MLA

patients group. None signicant statistical differences in clinical

(Nurick grade scale) and radiological ndings (MRI) was found

between ODL and MLA groups, both in the rst day (Nurick grade

scale, p=0,48) or 6 months after the procedure (Nurick grade Scale,

p=0,57; sagittal canal diameter on MRI, p=0,29) or 12 months of

follow up (Nurick grade scale, p=0,29).

Conclusion: Open door laminoplasty and multiple level

arcocristectomies are good options to treat cervical myelophatic

patients, with similar results regarding clinical and radiological

ndings.

Keywords

Cervical stenosis; Open door laminoplasty; Arcocristectomy; Cervical

spondylosis; Cervical myelopathy

*Corresponding author:Flvio Ramalho Romero, Division of Neurosurgery,

Botucatu Medical School, So Paulo State University, UNESP, Botucatu,

Brazil, Tel: 55 14 33543594 / 55 11 97147720; E-mail: [email protected],

[email protected]

Received:April 23, 2014Accepted:June 12, 2014Published:June 16, 2014

Classically, anterior and posterior approaches have been used.Smith and Robinson [6] and Cloward [7] described the anteriorapproach to cervical spine or cases affecting one or two levels withanterior compression o the spinal cord in a straight or kyphotic spine.By the other side, posterior approach was recommended or patientswith multilevel cervical compressions, especially those with preservedcervical spine lordosis. Laminectomy was the first classical optionused or many years, but many other techniques have been describedin last years [6-8].

Laminoplasty was first described in Japan in the early 1970s to treatossification o posterior longitudinal ligament [9], as a technique thatindirectly decompresses the spinal cord and preserves neck motionby avoiding usion. Tis is accomplished by hinging the lamina openon one or both sides to allow the spinal cord to migrate posteriorlyaway rom anterior compressive structures allowing the spinal cordand the neurooramen to be decompressed without directly removinganterior pathology. By preserving the dorsal elements o the spine,laminoplasty preserves spine stability and alignment and decreasesthe risk o post laminectomy kyphosis and instability [9].

Breig [10] described in 1972 the arcocristectomy as an optionin the treatment o cervical spondylotic stenosis. In 1991 Pereiradescribed, or the first time, multiple cervical arcocristectomies orthe treatment o this disorder [11], and Amaral et al. [11] in 2007published a series o seventeen patients treated by this technique.Arcocristectomy consists in removing the upper hal o the laminain multiple cervical levels with flavectomie, and preserving the

interspinous ligament attached to the base o the spinous process.With this technique, it was possible improve cervical canal diameterkeeping themost o posterior elements o the cervical spine.

Our purpose was to compare open-door laminoplasty (ODL) andmultilevel arcocristectomies (MLA) in the treatment o multilevelcervical myelopathy, according to clinical and radiological findings.

Methods

Patients with cervical myelopathy secondary to multilevel

spondilosis (three or more levels) treated by open-door laminoplasty

and multiple arcocristectomies between January 2008 and February

2014 were selected or our study. We retrospectively reviewed data

rom 36 patients, nineteen (52.77%) treated by ODL and seventeen

(47.23%) by MLA. wenty-two man (61.11%) and ourteen women(38.89%) were evaluated by clinical and radiological findings

preoperatively, in the first postoperative day, afer six and twelve

months. Clinical findings were evaluated by the Nurick scale. Mean

canal diameter was evaluated with Magnetic Resonance Images

(MRI), with anterior to posterior distance o cervical spine canal

between C3 and C7.

Surgical Technique Open-Door Laminoplasty (ODL)

Afer general anesthesia, patient is placed in prone position andthe head is fixedby Mayfield support without traction. A midlinelongitudinal posterior incision rom the occipital protuberance downto the 1 spinous process is perormed. With electro cautery, dissection

proceeds through the midline ascia and the spinous processes romC2 to 1 are exposed, preserving the muscular attachments to C2 as

Introduction

Cervical spondylotic myelopathy is a progressive disease thatofen requires surgical intervention [1-4]. Clinical findings are relatedto vertebral canalsmorphology and biomechanical behavior o spine[4,5], presenting with radiculopathy and myelopathy syndromes inmost o times. Despite the progressive and debilitating aspects o thisdisease, treatment choice remains controversial [1-5].
http://dx.doi.org/10.4172/2325-9701.1000156http://dx.doi.org/10.4172/2325-9701.1000156


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Citation:Romero FR, Zanini1 MA, Ducati1 LG, Gabarra RC (2014) Multilevel Cervical Myelopathy Treatment - Open-Door Laminoplasty vs. Multiple Cervical

Arcocristectomies. J Spine Neurosurg 3:5

Page 2 of 5

doi:http://dx.doi.org/10.4172/2325-9701.1000156

Volume 3 Issue 5 1000156

much as possible to minimize risk o postoperative kyphotic deormitybetween C2 and C3. Complete this midline, sub periosteal dissectiono the paravertebral muscles or the C3 to C7 spinous processes and

retract these muscles laterally off the spinous processes, lamina, andmedial aspect o the acets. Tis dissection needs to be extended asaras the lateral masses but the acet capsules must be preserved. Usingcontrolled, side-to-side brushing motions with a 2 or 3 mm cuttingburr or high-speed micro drill, a trough ismade at the junction o thelamina and lateral mass rom C3 to C7 by decorticating the posterioraspect o the lamina. Te troughs, created rostral to caudal rom onelevel above to one level below the stenotic levels, were perpendicularto the lamina, preserving the acets. Following thinning o the laminadown to a thin cortical layer, use a curette to ree the ligamentumflavum off the inerior aspect o the C7 lamina. Complete the laminarcuts just medial to the pedicles with a 2 or 3mm Kerrison punch byremoving the thin rim o remnant lamina and associated ligamentumflavum rom caudal to rostral.

Next, or the hinged side o the laminoplasty, another troughis made at the junction o the lamina and lateral mass with minimaldisruption o the acet capsule to prevent postoperative instability. Telamina is thinned removing the outer cortex and approximately onehal o the cancellous bone. Once the lamina are thinned sufficiently,the posterior elements are more flexible and the lamina can be opened

very gradually and careully by additional thinning o the hingedbone, pulling the spinous process toward the hinged side, and lifingthe lamina off the spinal cord with a curet on the opening side. Inall cases, we stabilized the lamina in an open position with suturesthrough the acet capsule and spinous processes on the hingedside. Afer hemostasis revision, closure was perormed according tostandard methods (Figure 1).

Surgical Technique - Multilevel Arcocristectomies (MLA)

All patients were placed in a sitting position afer generalanesthesia, with minimal flexion o the head to avoid a neurologicaldeficit caused by overstretching o the cervical spinal cord andinsufficiency o its blood supply due to cervical hyperflexion. Amidline posterior cervical incision was made rom the occipitalprotuberance down to the 1 spinous process, ollowed by posteriordissection o the muscular planes, with exposure o the C21posterior spinal elements. We careully avoided detaching thesemispinalis muscle rom the spinous process o C2 and so maintainedeffective cervical extension power. Te supraspinous ligament wasalso preserved. With the aid o a high-speed drill, the upper hal o

the lamina was removed while careully preserving the interspinousligament attached to the base o the spinous process. Using curettesand Kerrison rongeurs, we then perormed a flavectomy, and thedura mater was exposed. Arcocristectomy was perormed betweenC3 and C7. Te supraspinous and interspinous ligaments were alwayspreserved. Afer the procedure, closure was perormed according tostandard methods (Figure 2).

Statistical Analysis

Nonparametric tests were the choice to compare spinal sagittal

diameterand Nurick Scale grade in the pre and postoperative periods,

the Wilcoxon Sign Rank Sum est or comparisons between two

groups and the Friedman test or comparisons between more thantwo groups. Statistical results at P < 0.05 were considered significant.

In this study, numerical data are presented as the mean with the range.

o determine the distribution o our data, the Kolmogorov-Smirnov

test was perormed. Statistical analysis o the clinical and radiological

results or the first day,6 months and 12 months afer surgery were

perormed by using the 2-Way ANOVA particularly or those data

that are amenable to parametric tests (Student t test or the paired and

unpaired groups). Te significance level was established as P < 0.05.

All tests were correctedor multiple comparisons.

Results

Tirty-six adult patients were treated by these techniques. Age

mean was 59.72 years (range 39-75 years). Mean surgery time was 140minutes (range 100300 minutes) or ODL and 110 minutes (range75 to 180 minutes) or MLA. Demographic data, Nurick scale gradeand sagittal canal diameter evolution were summarized on able1.

All patients obtained a satisactory cervical range o motion.Nine patients reported cervical stiffness and pain, but dynamic x-rayfilming didnt find any motions disturbances. Almost all patientsshowed immediate improvement o their preoperative symptoms,and all o them kept long term improvement. Mean discharge timewas 2.2 days (range 2 to 6 days); the patients were discharged withouta cervical collar and were sent or rehabilitation therapy. No patienthad C-5 palsy postoperatively, and to date none has any sign o spinaldeormity or instability.

Nurick scale grade pre-operative scores were 3.36 (range 1-5) orODL patients group and 3.05 (range 1-5) or MLA patients group.

Figure 1: Example of a patient treated by ODL (case 2). A) Preoperative

MRI. B) Intraoperative view after opened the lamina thinning of the hinged

bone, pulling the spinous process toward the hinged side opening the spinalcanal (yellow arrow indicates the troughs created between C3 and C7). C)

Postoperative MRI.

Figure 2:Example of a patient treated by MLA (case 8). A) Preoperative MRI.

B) Intraoperative view, after removing the upper half of the lamina in the right

patient side, while carefully preserving the interspinous ligament attached to

the base of the spinousprocess (yellow arrows). C) Postoperative MRI.


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canal diameter afer 6 months was 10.52 mm (range 10 to 12 mm) orODL and 9.82 mm (range 9 to 11) or MLA, and afer 12 months was10.21 (range 9 to 12) or ODL and 9.52 (range 8 to 11) or MLA. Teseresults showed an approximately 5-mm enlargement in the sagittaldiameter o the spinal canal and successul decompression o thespinal cord in all patients (able 2).

Results o the statistical analysis showed significant enlargement othe spinal canal (preoperative sagittal spinal diameter x postoperative

Te mean postoperative Nurick Scale grade was 1.89 (range 05) or

ODL and 2.11 (range 0-3) or MLA. Afer 6 months, mean Nurick

Scale grade was 1.36 (range 03) or ODL and 1.58 (range 0-3) or

MLA, and afer 12 months was 1.10 (range 0-3) or ODL and 1.35

(range 0-3) or MLA. Te mean pre-operative sagittal canal diameter

was 4.84 mm (range 4 to 7 mm) or ODL and 4.76 mm (range 4 to 5mm) or MLA. All patients underwent MR imaging o the cervical

spine 6 and 12 months afer surgery, and mean postoperative sagittal

Case Age/ sex

Nurick Scale Grade

Surgery

Sagittal diam.(mm)

Pre-op 1 day

6

months 12 months Pre-op 6 months 12 months

1 67/M 5 2 1 1 ODL 5 12 12

2 48/F 5 3 3 3 ODL 4 10 9

3 62/F 4 3 2 2 MLA 4 9 9

4 59/M 3 1 1 1 ODL 5 11 11

5 71/M 4 3 3 2 MLA 5 10 10

6 69/M 1 0 0 0 ODL 4 10 10

7 56/F 4 3 2 2 MLA 5 9 9

8 59/M 3 2 1 1 MLA 4 10 9

9 61/F 4 3 3 3 ODL 6 10 10

10 75/M 1 0 0 0 MLA 4 9 9

11 49/M 4 3 2 2 ODL 5 10 9

12 54/F 4 3 3 3 ODL 7 12 10

13 39/M 1 0 0 0 MLA 4 9 9

14 65/F 4 3 2 1 ODL 5 11 11

15 49/M 3 2 1 1 MLA 4 10 9

16 53/F 4 3 3 2 MLA 5 11 10

17 45/F 3 2 1 1 ODL 4 10 10

18 71/M 4 3 3 3 MLA 4 9 9

19 54/M 1 0 0 0 ODL 4 10 10

20 60/M 3 1 1 1 ODL 6 12 11

21 49/F 4 3 2 2 MLA 4 9 9

22 70/F 5 3 2 1 ODL 4 10 10

23 65/M 4 3 2 2 MLA 5 9 9

24 59/M 3 1 0 0 ODL 4 11 11

25 57/F 1 0 0 0 MLA 4 10 9

26 69/M 4 3 1 1 ODL 4 9 9

27 51/M 5 3 3 2 MLA 4 10 10

28 73/F 4 2 1 1 ODL 5 12 11

29 72/M 1 0 0 0 MLA 7 11 11

30 57/M 4 3 3 2 ODL 4 12 10

31 65/M 1 0 0 0 MLA 6 10 10

32 58/M 3 3 2 2 MLA 4 11 10

33 49/M 1 0 0 0 ODL 7 10 10

34 52/F 5 3 3 1 ODL 4 9 8

35 66/M 1 0 0 0 ODL 5 10 10

36 72/F 5 5 3 2 MLA 4 11 11

Abbreviations:Pre-op: Preoperative; Post-op: Postoperative; ODL: Open door laminoplasty; MLA: Multiple level arcocristectomies; mm: Millimeter; Age in years.

Table 1:Summary of patients treated by open door laminoplasty or multiple level arcocristectomies.

ODL MLA

Pre op 1 day 6 months Pre op 1 day 6 months

Nurick 3,4 2,0 1,6 3,1 2,1 1,7

Sag diam 4,9 mm - 10,6 mm 4,3 mm - 9,5 mm

Abbreviations:Pre-op: Preoperative; ODL: Open door laminoplasty; MLA: Multiple level arcocristectomies; mm: millimeter

Table 2:Medium values of Nurick scale grade and sagittal canal diameter at Open Door Laminoplasty group and Multiple Level Arcocristectomies group.


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sagittal spinal diameter, p < 0.001, Wilcoxon signed rank test), orboth ODL patients group and MLA patients group. Tey also revealeda significant improvement in the Nurick Scale grade when the

preoperative value was compared with the immediate and 6 monthspostoperative grades separately and together (preoperative grade ximmediately postoperative grade, p < 0.001, Wilcoxon signed ranktest; preoperative grade x 6 months postoperative grade, p < 0.001,Wilcoxon signed rank test; and preoperative grade x immediatepostoperative grade x 6 months postoperative grade, p < 0.001,Friedman test), or both ODL patients group and MLA patients group.

Tere were no significant statistical differences in clinical (Nurickgrade scale) and radiological findings (MRI) between ODL andMLA groups, both in the first day (Nurick grade scale, p=0.48), 6months afer the procedure (Nurick grade Scale, p=0.57; sagittal canaldiameter on MRI, p=0.29) and 12 months afer the procedure (Nurickgrade scale, p=0.29; sagittal canal diameter on MRI, p=0.23) .

Discussion

Cervical spondylotic myelopathy due to multiple posterior levelcompression remains a treatment challenger. Many surgical optionshave been used in the last years, but the best choice is unclear. Singlelaminectomy, laminectomy plus arthrodesis, laminoplasty andmultiple level arcocristectomies are described, with advantages anddisadvantages o each one [11-15].

Spinal stability is kept by some anatomic structures responsibleto provide resistance against deorming orces, including bothosseous and ligamentous components [9,13-20]. Because posteriorspine elements are an important part to keep this stability [13-16],concerning about cervical spine instability is a critical problem

o posterior cervical approaches. Laminectomy has great risk todeveloping cervical kyphosis, even as laminoplasty techniques areunable to prevent kyphosis postoperatively. Cervical alignmentworsening in the literature varies rom 22 to 53%, a complicationthat is not avoided by usion [4,6,12,14-20]. According Amaral et al.[11], arcocristectomy improved cervical canal diameter keeping thephysiological alignment o cervical spine. In our series, we didntound signs o instability in laminoplasty or arcocristectomy group opatients. We believe this could be result o our short ollow up time.

Laminoplasty is becoming an increasingly popular treatment ormultilevel cervical stenosis due to cervical spondylotic myelopathy,

OPLL, and some other causes [1,3,16-18,20-25]. It reduces the risk ocomplications associated with other surgical options, such as graf and

usion-related complications, postoperative kyphosis and instability,and the morbidity o an anterior approach [19-22], but have its ownset o potential complications, including laminar closure, axial neckpain, nerve root palsies, and loss o cervical motion and alignment.

According to literature, laminoplasty enlarges the sagittal diameter inapproximately 4 to 8 mm. Despite the variety o surgical techniquesthat can be applied in laminoplasty, there are ewer complications

rates and better long-term results compared to laminectomy [22-30].With open door laminoplasty, we allowed enlargement o the sagittalcanal diameter in more than 5 mm, improving the patient clinical

findings. Also, stability and cervical range o motion were preserved.

Multiple cervical arcocristectomies has some physiological andbiomechanical advantages over both laminectomy and laminoplasty.

Tis technique allows keeping intact the supraspinous andinterspinous ligaments as well as the posterior vertebral arch [11]. Inour series, we improved the clinical findings and enlarged the canal

diameter more than 5 mm. Breig [9] described arcocristectomy asaprocedure to be perormed at only one level, and he used only inour patients. He reported good results with maintenance o most o

the posterior elements. Also, Pereira [11] described 10 patients whounderwent multiple arcocristectomies with immediate improvementin 80% o the patients without complications during a ollow-up o12 months.

We ound the same results comparing open door laminoplasty andmultiple level arcocristectomies or clinical and radiological findings.Both ODL and MLA patients had improvement in their myelophaticsymptoms, according to Nurick scale grade scores and enlargement osagittal diameter canal, measured by MRI exams. Moreover, dischargetime was similar and MLA patients have a shorter surgical time thanODL patients. One possible disadvantage o MLA could be the sittingposition, increasing the risk o some complications, as embolism andhemodynamic changes. But, in our series, none o this complication

was observed. Besides ODL is a good and popular technique to treatmultilevel spinal cervical stenosis, MLA had similar results in ourgroup o patients, became an excellent option or this disease.

Some limitation o our study is that consists in a retrospectivereview with small patient numbers and short ollows up time. Also,we believe that a prospective randomized study, with large patientnumbers and longer ollow up time is important to define the bestoption between these techniques.

Conclusion

Open door laminoplasty and multiple level arcocristectomiesare good options to treat cervical myelophatic patients, with similarresults regard clinical and radiological finding, allowing spinal cord

decompression with maintenance o most o the posterior elementso the cervical spine.

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Author Afliation Top1Division of Neurosurgery, Botucatu Medical School, So Paulo State

University, UNESP, Botucatu, Brazil

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