Laminectomy Plus Fusion and Laminoplasty Show Equivalent Efficacy in the Treatment of Degenerative Cervical Myelopathy

Michael G. Fehlings, MD, PhD, and James S. Harrop, MD, Comment

Peer Reviewed

When comparing posterior surgical approaches to treatment of degenerative cervical myelopathy, laminectomy and fusion was equally effective as laminoplasty at improving clinical disease severity, functional status, and quality of life, according to data from the AOSpine North America and International Prospective Multicenter Studies. The findings were published in the January issue of The Spine Journal.
x-ray image of cervical myelopathy“There is growing evidence that surgical treatment for degenerative cervical myelopathy (DCM) arrests the progression of neurological deterioration and improves functional recovery in the significant majority of patients”“There is growing evidence that surgical treatment for degenerative cervical myelopathy (DCM) arrests the progression of neurological deterioration and improves functional recovery in the significant majority of patients,” explained lead author Michael G. Fehlings, MD, PhD, who is Professor of Neurosurgery and Co-Director of the Spine Program at the University of Toronto in Ontario. “The principles of surgical treatment are focused on decompression of the spinal cord and reconstruction of the spinal column.”

“Laminectomy and fusion and laminoplasty evolved separately in the west (principally North America) and in the Asia Pacific region (principally Japan) to address the disadvantages of laminectomy alone, which include loss of sagittal alignment with resultant recurrent neural compression and axial pain,” Dr. Fehlings said. “Our paper demonstrates that both laminectomy and fusion and laminoplasty are effective options to manage DCM from a posterior approach.”

The prospective cohort study involved 266 surgically treated symptomatic patients with DCM who underwent laminectomy and fusion (n=166) or laminoplasty (n=100). Preoperatively, the laminoplasty group had lower scores on the modified Japanese Orthopaedic Association score (mJOA) (11.52±2.77 vs 12.30±2.85; P=.0297). The groups were similar in terms of other baseline variables, including age, gender, smoking status, number of operated levels, and baseline Nurick grade, Neck Disability Index (NDI), and Short-Form 36v2 (SF36v2) scores.

Both Groups Showed Significant Improvements
In both groups, scores on the mJOA, Nurick grade, NDI, and SF36v2 physical and mental health components were significantly improved at 24 months after surgery (P<0.0001). A comparison of the scores between the two groups showed that the laminoplasty group had significantly greater improvement on the mJOA (3.49 vs 2.39; P=0.0069).

However, in a multivariate analysis that adjusted for baseline characteristics, surgical factors, and geographic region, no significant between-group differences were found in any outcomes measures. In addition, the rate of treatment-related complications was similar in the two groups (28% in the laminectomy and fusion group and 21% in the laminoplasty group; P=0.1079).

Factors Affecting Surgical Choice
When deciding between laminectomy and fusion versus laminoplasty for an individual case, Dr. Fehlings noted that certain patient factors should be considered.

“In the setting of degenerative instability (eg, degenerative spondylolisthesis), extensive spondylosis, significant axial neck pain or a reversible kyphotic deformity (kyphosis which improves in extension), laminectomy and fusion is a preferred surgical option,” Dr. Fehlings said. “Laminoplasty can be considered a reasonable alternative to laminectomy and fusion if lordosis of the cervical spine is maintained, in the absence of degenerative instability and with minimal axial neck pain.”

“This is another important and informative manuscript that clearly identifies the neurological benefit of surgical decompression for symptomatic cervical myelopathy for surgeons and physicians,” commented James S. Harrop, MD, Professor in the Departments of Neurological and Orthopedic Surgery and Director of the Division of Spine and Peripheral Nerve Surgery at Thomas Jefferson University in Philadelphia, PA. “In addition, this paper also reviews the social and pain relief with better quality of life scores in the postoperative patients.”

Looking Ahead to Future Research
“Cervical spondylotic myelopathy is a complex and heterogenous disease process,” Dr. Harrop told SpineUniverse. “Based on this manuscript, patients do well with either operation. What the AO and other spine organizations are presently exploring is whether there are subtypes of patients with certain pathology that may benefit from one procedure over another. For example, should all patients with ossification of the posterior longitudinal ligament be treated with laminoplasties? These answers will hopefully be forthcoming in the near future.”

Dr. Fehlings also suggested the need for further prospective comparative effectiveness studies, adding that optimal surgical strategies will enhance patient outcomes. “Surgeons have many effective, safe options to manage DCM, and the outcomes of surgical treatment are favorable in the significant majority of cases,” Dr. Fehlings said.

“DCM is the commonest cause of spinal cord compromise worldwide,” Dr. Fehlings concluded. “Greater awareness among the public and general physicians is necessary to identify patients with this condition at an early stage.”

Updated on: 03/20/18
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Ossification Shape May Predict Outcomes of Laminoplasty in the Treatment of Cervical Myelopathy
Michael G. Fehlings, MD, PhD, FRCSC, FACS
Professor of Neurosurgery
University of Toronto
Toronto, ON
James S. Harrop, MD, FACS
Professor, Departments of Neurological and Orthopedic Surgery
Thomas Jefferson University
Philadelphia, PA
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