Eur Spine J DOI 10.1007/s00586-014-3634-y
OPEN OPERATING THEATRE (OOT)
Cervical laminoplasty Hossein Mehdain • Oliver M. Stokes
Springer-Verlag Berlin Heidelberg 2014
Keywords Cervical myelopathy Motion preservation Laminoplasty plate
We describe a technique that addresses these issues, preserving bony and soft tissue elements to facilitate motion preservation while widening the bony posterior neural arch.
Learning target • • •
Canal widening procedure. Bone and soft tissue preservation to facilitate motion and prevent adjacent segment degeneration. Novel method for recreation of osseous posterior arch to provide reliable early bony stability and to protect neural elements.
Introduction Cervical spondylotic myelopathy (CSM) is a progressive condition resulting in a loss of coordinated motor function of the upper and lower limbs, due to compression of the cervical spinal cord. Treatment of multi-level pathology in younger patients is challenging. Laminectomy is associated with secondary instability and kyphosis, while adding posterior spinal fusion puts adjacent segments at risk of degeneration. Motion preservation is of more importance in younger patients.
Electronic supplementary material The online version of this article (doi:10.1007/s00586-014-3634-y) contains supplementary material, which is available to authorized users.
Case description We present the case of a 39-year old male with progressive radiculomyelopathy. He complained of increasing loss of manual dexterity and altered hand sensation, left arm pain and trunk tightness. He had normal spinal alignment. He was MRC grade 4 power in myotomes C6-T1 and he was hyper-reflexive in all four limbs. His manual dexterity was impaired, with loss of co-ordinated finger movement. Plain antero-posterior radiographs confirmed a normal cervical lordosis. Magnetic Resonance Imaging (MRI) of the spine showed cord compression and the patient was diagnosed with CSM (Figs. 1 and 2). Due to the progressive nature of the condition and the degree of functional limitation surgical intervention was recommended. Surgical procedure Once the patient was anaesthetised, spinal cord monitoring electrodes were secured and 5-lbs of traction was applied through Gardner–Wells tongs and a pulley system.
Watch surgery online
H. Mehdain (&) O. M. Stokes Queens’s Medical Centre, Nottingham University Hospitals, Derby Road, Nottingham, UK e-mail: [email protected]
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Eur Spine J
Fig. 2 Pre-operative axial T2-weighted MRI of the patient demonstrating a left paracentral C5/6 disc herniation compressing the cervical spinal cord Fig. 1 Pre-operative sagittal T2-weighted MRI of the patient demonstrating multi-level cervical cord compression due to cervical disc herniations. The degree of stenosis is most severe at C5/6. The cervical lordosis is maintained
A midline posterior incision, extending from C2 to C7, was made and then monopolar diathermy was utilised to perform a subperiosteal dissection from the lower border of C2 lamina to the lower border of C7 lamina. Care was taken to expose the lateral borders of the lateral masses of C4, C5 and C6. The supraspinous and interspinous ligaments between C3 and C7 were removed and he spinous process of C4, C5 and C6 were excised. Three maxillofacial titanium plates (16–18 hole) were trimmed to size and then contoured at each level using a malleable rod as a template. A width of 2 cm was preserved at the most dorsal portion of the plates to accept a fashioned unicortical iliac bone graft. Screw holes were drilled bilaterally in the lateral masses and the plates were then temporarily secured to the lateral masses to ensure that they were the correct size. The plates were then removed and then bilateral troughs fashioned using a high-speed burr. The spinous processes of C4, C5 and C6 were split vertically using a high-speed burr and Kerrison rongeur. The canal widening laminoplasty was performed by careful plastic deformation of the laminae using a Cobb elevator. A longitudinal incision was centred over the left posterior superior iliac crest and the outer surface of the ileum exposed. A unicortical bone graft was harvested and then fashioned to create 3 unicortical bone blocks of approximately 2 cm to fit into the gap between the opened spinous processes. The bone grafts were attached to the apex of the
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pre-contoured plates using 2 mm screws and the plates refixed to the lateral masses. Plates were then removed and the bone blocks trimmed to ensure that they were optimal shape and size to hold open the laminae and to achieve a high degree of bone-on-bone contact with the laminae at each level. The bone graft-plate composites were then refixed bilaterally to the lateral masses using 2 mm screws. Confirmatory antero-posterior and lateral radiographs were obtained. The surgical wounds were closed in layers over one deep gravity drain and one superficial suction drain in the posterior cervical wound and adhesive dressings applied. There were no intraoperative complications and no loss of spinal cord monitoring. The total blood loss was 200 ml and the operative duration was two and a half hours. Postoperative information Our patient made a satisfactory recovery following surgery. Immediate improvement was noted in the trunk tightness. There was no neurological deficit or other complication and our patient was discharged when his wounds were deemed to be dry and healed. Postoperative radiographs revealed a satisfactory positioning of instrumentation (Figs. 3 and 4). Discussion and conclusion Cervical myelopathy is a serious and frequently progressive condition. It is commonly due to spondylosis. The
Eur Spine J
Fig. 3 Post-operative antero-posterior plain radiograph of the patient demonstrating the contoured maxillofacial plates affixed to C4, C5 and C6 lateral masses
Fig. 4 Post-operative lateral plain radiograph of the patient demonstrating the contoured maxillofacial plates affixed to C4, C5 and C6 lateral masses
natural history of CSM is progression in a stepwise fashion [1]. The precise clinical presentation is dependent upon the level of cord compression. The cervical spinal cord may be decompressed by an anterior, a posterior, or by a combined approach. The approach is dictated primarily by the anatomical location of the compression. Anterior surgery is generally preferred for 1 and 2 level compression due to disc herniation, but 3-level anterior surgery is associated with pseudarthrosis rates of up to 54 % [2]. Furthermore, airway complications are associated with prolonged anterior procedures ([5-h) and exposing [3 vertebral levels that include C2, C3, or C4 with [300 ml blood loss [3]. Posterior surgery is preferred by many surgeons for multi-level pathology [4]. Laminectomy is associated with post-operative kyphosis [5]. Addition of posterior spinal fusion is preferable, but associated with C5 nerve palsy, metalwork failure and adjacent segment degeneration. Laminoplasty requires 10-degrees of lordosis to allow the cord to adequately migrate posteriorly and achieve indirect decompression [6]. In 1973, the Hattori z-plasty laminoplasty was reported [7], but due to the technical demands the procedure it was not widely performed. In 1977, Hirabayashi [8] described a single open door technique. Modifications to hold open the
laminae include the use of suture anchors and plates and screws. This technique is subject to ‘‘spring-back’’ phenomenon, whereby the lamina collapses back onto the neural elements due to loss of fixation of the opened side, or fracture through the trough on the hinged side. In 1982, Kurokawa [9] described a French double-door opening technique, whereby the dorsal aspects of the spinous processes were used as grafts to hold open the laminae. Laminoplasty is not without complications, but there is a paucity of literature reporting the long-term outcomes. In one series of 80 patients treated with open door laminoplasty, followed up for 14-years 30 % of patients experienced late neurological deterioration, segmental motor paralysis occurred in 10 %, overall cervical range of motion was reduced by 36 %, but post-operative kyphosis was not found to have occurred [10]. In a series of 60 patients treated with double-door laminoplasty, late neurological deterioration occurred in 29 % of ossification of the posterior longitudinal ligament patients at an average of 8-years and in 16 % of patients with CSM at an average of 11-years [11]. Our technique is a modification of the Kurokawa double-door laminoplasty. The addition of the individually trimmed, custom-contoured plates and unicortical autologous iliac crest bone graft offers several potential
123
Eur Spine J
advantages. Our modification permits greater opening of the laminae and increase in canal diameter than would be possible by deployment of local graft alone. The use of plates offers reliable fixation and virtually eliminates the potential for ‘‘spring-back’’. Furthermore, the plates are inexpensive and readily available. The reliable recreation of the posterior neural arch serves to protect the neural structures almost immediately and may prevent a postlaminectomy membrane from forming. It is possible that this bone and soft tissue preserving, motion preservation technique may minimize the risk of C5 palsy compared to fusion surgery. Conflict of interest
None.
References 1. Nurick S (1972) The natural history and the results of surgical treatment of the spinal cord disorder associated with cervical spondylosis. Brain 95(1):101–108 2. Swank ML, Lowery GL, Bhat AL, McDonough RF (1997) Anterior cervical allograft arthrodesis and instrumentation: multilevel interbody grafting or strut graft reconstruction. Eur Spine J 6(2):138–143 3. Sagi HC, Beutler W, Carroll E, Connolly PJ (2002) Airway complications associated with surgery on the anterior cervical spine. Spine Phila Pa (1976) 27(9):949–953
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4. Hukuda S, Mochizuki T, Ogata M (1985) Operations for cervical spondylotic myelopathy. A comparison of the results of anterior and posterior procedures. J Bone Joint Surg Br 67(4):609–615 5. Ryken TC, Heary RF, Matz PG, Anderson PA, Groff MW, Holly LT, Kaiser MG, Mummaneni PV, Choudhri TF, Vresilovic EJ, Resnick DK (2009) Cervical laminectomy for the treatment of cervical degenerative myelopathy. J Neurosurg Spine 11(2): 142–149 6. Yamazaki A, Homma T, Uchiyama S, Katsumi Y, Okumura H (1999) Morphologic limitations of posterior decompression by midsagittal splitting method for myelopathy caused by ossification of the posterior longitudinal ligament in the cervical spine. Spine Phila Pa (1976) 24(1):32–34 7. Oyama M, Hattori S, Moriwaki N (1973) A new method of posterior decompression [in Japanese]. Chubuseisaisi 16:792 8. Hirabayashi K, Watanabe K, Wakano K, Suzuki N, Satomi K, Ishii Y (1983) Expansive open-door laminoplasty for cervical spinal stenotic myelopathy. Spine Phila Pa (1976) 8(7):693–699 9. Kurokawa T, Tsuyama N, Tanaka H (1982) Enlargement of spinal canal by the sagittal splitting of the spinous process. Bessatusu Seikeigeka 2:234–240 10. Chiba K, Ogawa Y, Ishii K, Takaishi H, Nakamura M, Maruiwa H, Matsumoto M, Toyama Y (2006) Long-term results of expansive open-door laminoplasty for cervical myelopathy— average 14-year follow-up study. Spine Phila Pa (1976) 31(26):2998–3005 11. Seichi A, Takeshita K, Ohishi I, Kawaguchi H, Akune T, Anamizu Y, Kitagawa T, Nakamura K (2001) Long-term results of double-door laminoplasty for cervical stenotic myelopathy. Spine Phila Pa (1976) 26(5):479–487
OPEN OPERATING THEATRE (OOT)
Cervical laminoplasty Hossein Mehdain • Oliver M. Stokes
Springer-Verlag Berlin Heidelberg 2014
Keywords Cervical myelopathy Motion preservation Laminoplasty plate
We describe a technique that addresses these issues, preserving bony and soft tissue elements to facilitate motion preservation while widening the bony posterior neural arch.
Learning target • • •
Canal widening procedure. Bone and soft tissue preservation to facilitate motion and prevent adjacent segment degeneration. Novel method for recreation of osseous posterior arch to provide reliable early bony stability and to protect neural elements.
Introduction Cervical spondylotic myelopathy (CSM) is a progressive condition resulting in a loss of coordinated motor function of the upper and lower limbs, due to compression of the cervical spinal cord. Treatment of multi-level pathology in younger patients is challenging. Laminectomy is associated with secondary instability and kyphosis, while adding posterior spinal fusion puts adjacent segments at risk of degeneration. Motion preservation is of more importance in younger patients.
Electronic supplementary material The online version of this article (doi:10.1007/s00586-014-3634-y) contains supplementary material, which is available to authorized users.
Case description We present the case of a 39-year old male with progressive radiculomyelopathy. He complained of increasing loss of manual dexterity and altered hand sensation, left arm pain and trunk tightness. He had normal spinal alignment. He was MRC grade 4 power in myotomes C6-T1 and he was hyper-reflexive in all four limbs. His manual dexterity was impaired, with loss of co-ordinated finger movement. Plain antero-posterior radiographs confirmed a normal cervical lordosis. Magnetic Resonance Imaging (MRI) of the spine showed cord compression and the patient was diagnosed with CSM (Figs. 1 and 2). Due to the progressive nature of the condition and the degree of functional limitation surgical intervention was recommended. Surgical procedure Once the patient was anaesthetised, spinal cord monitoring electrodes were secured and 5-lbs of traction was applied through Gardner–Wells tongs and a pulley system.
Watch surgery online
H. Mehdain (&) O. M. Stokes Queens’s Medical Centre, Nottingham University Hospitals, Derby Road, Nottingham, UK e-mail: [email protected]
123
Eur Spine J
Fig. 2 Pre-operative axial T2-weighted MRI of the patient demonstrating a left paracentral C5/6 disc herniation compressing the cervical spinal cord Fig. 1 Pre-operative sagittal T2-weighted MRI of the patient demonstrating multi-level cervical cord compression due to cervical disc herniations. The degree of stenosis is most severe at C5/6. The cervical lordosis is maintained
A midline posterior incision, extending from C2 to C7, was made and then monopolar diathermy was utilised to perform a subperiosteal dissection from the lower border of C2 lamina to the lower border of C7 lamina. Care was taken to expose the lateral borders of the lateral masses of C4, C5 and C6. The supraspinous and interspinous ligaments between C3 and C7 were removed and he spinous process of C4, C5 and C6 were excised. Three maxillofacial titanium plates (16–18 hole) were trimmed to size and then contoured at each level using a malleable rod as a template. A width of 2 cm was preserved at the most dorsal portion of the plates to accept a fashioned unicortical iliac bone graft. Screw holes were drilled bilaterally in the lateral masses and the plates were then temporarily secured to the lateral masses to ensure that they were the correct size. The plates were then removed and then bilateral troughs fashioned using a high-speed burr. The spinous processes of C4, C5 and C6 were split vertically using a high-speed burr and Kerrison rongeur. The canal widening laminoplasty was performed by careful plastic deformation of the laminae using a Cobb elevator. A longitudinal incision was centred over the left posterior superior iliac crest and the outer surface of the ileum exposed. A unicortical bone graft was harvested and then fashioned to create 3 unicortical bone blocks of approximately 2 cm to fit into the gap between the opened spinous processes. The bone grafts were attached to the apex of the
123
pre-contoured plates using 2 mm screws and the plates refixed to the lateral masses. Plates were then removed and the bone blocks trimmed to ensure that they were optimal shape and size to hold open the laminae and to achieve a high degree of bone-on-bone contact with the laminae at each level. The bone graft-plate composites were then refixed bilaterally to the lateral masses using 2 mm screws. Confirmatory antero-posterior and lateral radiographs were obtained. The surgical wounds were closed in layers over one deep gravity drain and one superficial suction drain in the posterior cervical wound and adhesive dressings applied. There were no intraoperative complications and no loss of spinal cord monitoring. The total blood loss was 200 ml and the operative duration was two and a half hours. Postoperative information Our patient made a satisfactory recovery following surgery. Immediate improvement was noted in the trunk tightness. There was no neurological deficit or other complication and our patient was discharged when his wounds were deemed to be dry and healed. Postoperative radiographs revealed a satisfactory positioning of instrumentation (Figs. 3 and 4). Discussion and conclusion Cervical myelopathy is a serious and frequently progressive condition. It is commonly due to spondylosis. The
Eur Spine J
Fig. 3 Post-operative antero-posterior plain radiograph of the patient demonstrating the contoured maxillofacial plates affixed to C4, C5 and C6 lateral masses
Fig. 4 Post-operative lateral plain radiograph of the patient demonstrating the contoured maxillofacial plates affixed to C4, C5 and C6 lateral masses
natural history of CSM is progression in a stepwise fashion [1]. The precise clinical presentation is dependent upon the level of cord compression. The cervical spinal cord may be decompressed by an anterior, a posterior, or by a combined approach. The approach is dictated primarily by the anatomical location of the compression. Anterior surgery is generally preferred for 1 and 2 level compression due to disc herniation, but 3-level anterior surgery is associated with pseudarthrosis rates of up to 54 % [2]. Furthermore, airway complications are associated with prolonged anterior procedures ([5-h) and exposing [3 vertebral levels that include C2, C3, or C4 with [300 ml blood loss [3]. Posterior surgery is preferred by many surgeons for multi-level pathology [4]. Laminectomy is associated with post-operative kyphosis [5]. Addition of posterior spinal fusion is preferable, but associated with C5 nerve palsy, metalwork failure and adjacent segment degeneration. Laminoplasty requires 10-degrees of lordosis to allow the cord to adequately migrate posteriorly and achieve indirect decompression [6]. In 1973, the Hattori z-plasty laminoplasty was reported [7], but due to the technical demands the procedure it was not widely performed. In 1977, Hirabayashi [8] described a single open door technique. Modifications to hold open the
laminae include the use of suture anchors and plates and screws. This technique is subject to ‘‘spring-back’’ phenomenon, whereby the lamina collapses back onto the neural elements due to loss of fixation of the opened side, or fracture through the trough on the hinged side. In 1982, Kurokawa [9] described a French double-door opening technique, whereby the dorsal aspects of the spinous processes were used as grafts to hold open the laminae. Laminoplasty is not without complications, but there is a paucity of literature reporting the long-term outcomes. In one series of 80 patients treated with open door laminoplasty, followed up for 14-years 30 % of patients experienced late neurological deterioration, segmental motor paralysis occurred in 10 %, overall cervical range of motion was reduced by 36 %, but post-operative kyphosis was not found to have occurred [10]. In a series of 60 patients treated with double-door laminoplasty, late neurological deterioration occurred in 29 % of ossification of the posterior longitudinal ligament patients at an average of 8-years and in 16 % of patients with CSM at an average of 11-years [11]. Our technique is a modification of the Kurokawa double-door laminoplasty. The addition of the individually trimmed, custom-contoured plates and unicortical autologous iliac crest bone graft offers several potential
123
Eur Spine J
advantages. Our modification permits greater opening of the laminae and increase in canal diameter than would be possible by deployment of local graft alone. The use of plates offers reliable fixation and virtually eliminates the potential for ‘‘spring-back’’. Furthermore, the plates are inexpensive and readily available. The reliable recreation of the posterior neural arch serves to protect the neural structures almost immediately and may prevent a postlaminectomy membrane from forming. It is possible that this bone and soft tissue preserving, motion preservation technique may minimize the risk of C5 palsy compared to fusion surgery. Conflict of interest
None.
References 1. Nurick S (1972) The natural history and the results of surgical treatment of the spinal cord disorder associated with cervical spondylosis. Brain 95(1):101–108 2. Swank ML, Lowery GL, Bhat AL, McDonough RF (1997) Anterior cervical allograft arthrodesis and instrumentation: multilevel interbody grafting or strut graft reconstruction. Eur Spine J 6(2):138–143 3. Sagi HC, Beutler W, Carroll E, Connolly PJ (2002) Airway complications associated with surgery on the anterior cervical spine. Spine Phila Pa (1976) 27(9):949–953
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4. Hukuda S, Mochizuki T, Ogata M (1985) Operations for cervical spondylotic myelopathy. A comparison of the results of anterior and posterior procedures. J Bone Joint Surg Br 67(4):609–615 5. Ryken TC, Heary RF, Matz PG, Anderson PA, Groff MW, Holly LT, Kaiser MG, Mummaneni PV, Choudhri TF, Vresilovic EJ, Resnick DK (2009) Cervical laminectomy for the treatment of cervical degenerative myelopathy. J Neurosurg Spine 11(2): 142–149 6. Yamazaki A, Homma T, Uchiyama S, Katsumi Y, Okumura H (1999) Morphologic limitations of posterior decompression by midsagittal splitting method for myelopathy caused by ossification of the posterior longitudinal ligament in the cervical spine. Spine Phila Pa (1976) 24(1):32–34 7. Oyama M, Hattori S, Moriwaki N (1973) A new method of posterior decompression [in Japanese]. Chubuseisaisi 16:792 8. Hirabayashi K, Watanabe K, Wakano K, Suzuki N, Satomi K, Ishii Y (1983) Expansive open-door laminoplasty for cervical spinal stenotic myelopathy. Spine Phila Pa (1976) 8(7):693–699 9. Kurokawa T, Tsuyama N, Tanaka H (1982) Enlargement of spinal canal by the sagittal splitting of the spinous process. Bessatusu Seikeigeka 2:234–240 10. Chiba K, Ogawa Y, Ishii K, Takaishi H, Nakamura M, Maruiwa H, Matsumoto M, Toyama Y (2006) Long-term results of expansive open-door laminoplasty for cervical myelopathy— average 14-year follow-up study. Spine Phila Pa (1976) 31(26):2998–3005 11. Seichi A, Takeshita K, Ohishi I, Kawaguchi H, Akune T, Anamizu Y, Kitagawa T, Nakamura K (2001) Long-term results of double-door laminoplasty for cervical stenotic myelopathy. Spine Phila Pa (1976) 26(5):479–487
