Arch Orthop Trauma Surg (2014) 134:1–7 DOI 10.1007/s00402-013-1881-8
ORTHOPAEDIC SURGERY
Laminoplasty versus skip laminectomy for the treatment of multilevel cervical spondylotic myelopathy: a systematic review Wei Yuan · Yue Zhu · Xinchun Liu · Xiaoshu Zhou · Cui Cui
Received: 19 August 2013 / Published online: 8 November 2013 © Springer-Verlag Berlin Heidelberg 2013
Abstract Introduction Laminoplasty and skip laminectomy are two specific posterior surgical approaches for multilevel cervical spondylotic myelopathy. The objective of this study was to perform a systematic review comparing the clinical results and complications of laminoplasty and skip laminectomy in the treatment of multilevel cervical spondylotic myelopathy. Materials and methods We reviewed and analyzed papers published from January 1969 to December 2012 through the Mediline, Embase, Cochrane review library, and other databases regarding the comparison between laminoplasty and skip laminectomy for multilevel cervical spondylotic myelopathy. Results One randomized controlled trial and three nonrandomized controlled trials were included in this systematic review. In three studies, the preoperative and postoperative JOA score was similar in both laminoplasty and skip laminectomy groups. In addition, for recovery rate, there was no significant difference between the groups. One study reported that, regarding SF12 scores, there was no significant difference in physical health and mental health after surgery. However, regarding cervical pain, the skip laminectomy group was better than the laminoplasty group significantly. No difference was presented in postoperative ROM and the cervical lordosis between the groups. But the ROM % (post/pre) was reported to be significantly better in the skip laminectomy group in three studies. Less blood
W. Yuan · Y. Zhu (*) · X. Liu · X. Zhou · C. Cui Department of Orthopedics, First Hospital of China Medical University, No. 155 Nanjing Bei Street, Heping District, Shenyang, Liaoning, China e-mail: [email protected]
loss and shorter operation time were observed in skip laminectomy rather than laminoplasty. Conclusions Based on the results above, the skip laminectomy group presented better outcomes in a variety of aspects: ROM % (post/pre), complication rate, surgical trauma, etc. However, as limited study samples were included in the paper, a claim of superiority of the two approaches could not be justified. Further studies are required on the comparison between laminoplasty and skip laminectomy. Keywords Laminoplasty · Skip laminectomy · Cervical spondylotic myelopathy · Systematic review
Introduction Cervical spondylotic myelopathy (CSM) is the leading cause of spinal cord dysfunction in adult population. Compared with non-surgical treatment, surgery for moderate to severe or progressive CSM has shown significant improvement in functional status [1]. And the surgery for CSM involving one or two levels can be successfully performed by anterior decompression and fusion with a low incidence of complications [2, 3]. However, when three or more levels are involved (multilevel cervical spondylotic myelopathy, MCSM), accelerated complication rates associated with anterior surgery, particularly fusion failure, adjacent level degeneration, instrumentation failure and dysphagia were observed in multilevel corpectomies [4, 5], making posterior approach gain more attention. The laminoplasty procedure was first performed and developed by Japanese surgeons in the late 1970s [6]. Postoperative complications such as persistent axial pain, C5 paresis, restriction of neck movement, and loss of lordotic
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alignment are known to be associated with this procedure [7]. Skip laminectomy, recently developed by Shiraishi [8], is a minimally invasive procedure to prevent postsurgical problems often seen after laminoplasty, which can decompress four levels of spinal cord while limiting surgical excision to the posterior structures. Although some studies on the two approaches have been done, controversy over which surgical approach would yield better outcome remains. No systematic review of laminoplasty and skip laminectomy in the treatment for MCSM has been published yet. The purpose of this study was to perform a systematic review of randomized and nonrandomized controlled studies to compare laminoplasty and skip laminectomy in the treatment of MCSM, specifically evaluating their clinical and radiographic results and complications, which would provide guidance for clinical decision-making.
Materials and methods
Arch Orthop Trauma Surg (2014) 134:1–7
After the two reviews searching articles from the database, the title abstracts were individually reviewed to identify articles to confirm inclusion/exclusion criteria. Data extraction The data extraction was conducted by two reviewers independently mentioned above based on a standardized form [9]. The data included study design, enrollment, year published, patient characteristics, interventions, treatment allocation, follow-up, clinical outcomes, radiographic results, and complications. Any disagreement in inclusion–exclusion criteria or data abstraction was solved by consensus discussing with at least two reviewers. Strength of the evidence The risk of bias was assessed with the criteria proposed by the Cochrane Back Review Group [10]. The level of evidence was assessed according to the guidelines of the GRADE working group [11].
Search strategy We searched databases including Medline, Embase, the Cochrane library, and other databases such as ebsco, web of knowledge, Springer to find randomized or non-randomized controlled trials comparing laminoplasty and skip laminectomy for MCSM up to December 2012. Reference lists from the included studies were also selected by computer searching to identify further relevant trials that met the inclusion criteria in this systematic review. The language was limited to English. The medical subject heading (Mesh) and free words applied the following: cervical spondylotic myelopathy, cervical myelopathy, cervical spondylosis, cervical stenosis, skip laminectomy, segment laminectomy, laminoplasty, dorsal, and posterior. Selection of studies The following inclusion criteria were applied: (1) types of studies: randomized controlled trials (RCT) or non-randomized controlled studies; (2) population: MCSM with no previous cervical surgeries; (3) types of interventions: laminoplasty compared with skip laminectomy in the treatment of MCSM; (4) outcome measures: neurological, radiologic outcomes and complications. The publications were excluded from the systematic review if: (1) they did not meet the inclusion criteria above; (2) they described novel techniques, as well as case reports, letters, comments and reviews; (3) the study was not aimed to compare results between different procedures and it did not distinguish myelopathy from OPLL.
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Results After the computerized search and extensively crosschecked reference lists, 512 citations were included. These citations were reviewed and a total of 81 abstracts were screened. At last, 4 articles comparing laminoplasty and skip laminectomy in treating MCSM were included in this systematic review. Description of the studies There were three non-randomized controlled clinical studies and one RCT study. Three of the studies took place in Japan, while the one in UK. All studies reported the common characteristics, including age, gender, follow-up, and no differences were noted between groups preoperatively, specifically for Japanese Orthopedic Association (JOA) score, SF12 score, ROM (Table 1). The number of patients in each group was equal, with the exception of Otani et al. [12], who had approximately the double number of patients in the skip group. Patient allocation to treatment was not recorded in the Otani et al. [12] and Sivaraman et al. [13] studies. Patients in one RCT [14] randomized to laminoplasty or skip laminectomy group according to their birth month. Before a certain time period, surgeons in Shiraishi’s [15] study performed the laminoplasty for MCSM, and then changed their surgical technique to skip laminectomy after 1998. Follow-up was between 2 and 5 years on average in these studies.
Lamp laminoplasty, Skip skip laminectomy, NR not reported
Follow-up (months)
Treatment allocated
Disease duration (months) Intervention
60
Lamp: 13; skip: 26 Lamp: 10M/3F; skip: 20M/6F Lamp: 62 ± 7 (42–71); skip: 64 ± 9 (46–76) Lamp: 34 ± 35 (3–120) Skip: 35 ± 40 (1–120) Lamp: traditional C3–C7 expansive open door laminoplasty; Skip: the C4, 6 laminae were removed, the cephaled third of C5, 7 laminae and ligamenta flavum were removed. NR
No. patients Gender
Age (year)
2009 Non-randomized controlled trial 1993–1998 Japan To compare the outcomes between skip laminectomy and traditional C3–C7 expansive open door laminoplasty for treatment of MCSM
Published year Design of study Enrollment Location Object
Otani et al. [12]
Table 1 Comparison of study settings, participants, and interventions
24 (26.4–51.6)
Lamp: C3–6 double-door laminoplasty; Skip: the C4, 6 laminae were removed, the cephaled third of C5, 7 laminae and ligamenta flavum were removed. NR
2010 Non-randomized controlled trial NR UK To compare the skip laminectomy and laminoplasty in terms of decompression extent, axial pain, postoperative range of cervical motion, patient and surgical outcomes Lamp:25; skip:25 Lamp: 14M/11F; skip: 12M/13F Lamp: 62.4; skip: 69.6 NR
Sivaraman et al. [13]
Lamp: 51; skip: 43 Lamp: 32M/19F; skip: 24M/19F Lamp: 67 (36–81); skip: 69 (50–84) NR
2003 Non-randomized controlled trial NR Japan To compare the results of skip laminectomy with open door laminoplasty in treatment of MCSM
Shiraishi et al. [15]
28.1 (10.1)
Lamp:43 (24–66); skip:30 (24–41)
Lamp: C3–6 double-door laminoLamp: traditional C3–C7 expansive plasty; Skip: the C4, 6 laminae were open door laminoplasty; removed, the cephaled third of C5, 7 laminae and ligamenta flavum were removed. Randomized to Lamp group or Skip Before they started Skip, they had group according to their birth month underwent Lamp since 1998 (even Lamp; oss Skip) December.
Lamp: 21; skip: 20 Lamp: 8M/13F; skip: 5M/15F Lamp: 62.3 ± 11.4; skip: 66.1 ± 10.8 NR
2007 Randomized controlled trial NR Japan To compare modified laminoplasty and skip laminectomy in terms of surgical invasiveness, postoperative range of motion, axial pain, and surgical outcomes.
Yukawa et al. [14]
Arch Orthop Trauma Surg (2014) 134:1–7 3
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Arch Orthop Trauma Surg (2014) 134:1–7
Table 2 Quality of studies according to GRADE Author
Otani et al. [12]
Sivaraman et al. [13]
Yukawa et al. [14]
Shiraishi et al. [15]
Design
Non-randomized controlled trial −1 0 N/A −1 0 0
Non-randomized controlled trial −1 0 N/A −1 0 0
Randomized controlled trial −1 0 −1 0 0 0
Non-randomized controlled trial −1 0 N/A −1 0 0
−2
−2
−2
−2
Risk of bias Indirectness Imprecision Publication Bias Large effect Plausible residual confounding Total Quality of evidence
Very low
Very low
All studies were identified with high risk of bias. The RCT [14] did not report the process of randomization, allocation, blinding or dealing with missing data, and the quality of evidence using GRADE was very low (Table 2). Therefore, a meta-analysis was not possible.
Very low
Very low
the laminoplasty group than in the skip laminectomy group. Table 5 presents the detailed complications in each study of this systematic review.
Discussion Clinical outcome All studies showed clinical improvement after surgical intervention. JOA scores were reported in three studies [12, 14, 15]. And after the surgery, there was no significant difference between the two groups in any of the studies regarding JOA scores, and recovery rates. In the study by Sivaraman et al. [13], there was no significant difference in SF12 scores for physical health and mental health after surgery, but for cervical pain, the skip laminectomy group was better than the laminoplasty group significantly. Spinal cord cross-sectional area in the skip laminectomy group was larger than the laminoplasty group significantly in Sivaraman’s [13] study. The final ROM and lordosis were recorded in Otani et al. [12] and Yukawa’s [14] studies, and there was no significant difference between the two groups. But according to Otani et al. [12], Sivaraman et al. [13] and Shiraishi et al. [15], ROM % (post/pre) was significantly better in the skip laminectomy group. Three studies [13– 15] reported blood loss and operation time in patients who underwent laminoplasty and skip laminectomy, from which we draw the conclusion that compared with skip laminectomy, the blood loss was less and operation time was shorter in the laminoplasty group (Tables 3, 4). Complications No worsening of neural function was reported in each study. Axial symptoms, difficulty in looking around, C5 paresis and wound infection were reported in three studies [12, 13, 15]. In total, more complications were observed in
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A number of parameters are required to take into consideration when choosing a proper approach for CSM, including number of levels compressed, sagittal alignment and patient health status. Posterior approaches to spinal cord decompression are generally preferred in patients with a neutral or lordotic cervical alignment and multilevel myelopathy involving three or more motion segments [2, 16]. According to a recent systematic review by Cunningham et al. [17], who compared different surgical treatments (ACDF, corpectomy, laminectomy and laminoplasty) for CSM, the laminoplasty approach presented fewer complications, possibly greater ROM, and similar neurologic recovery compared with the other surgery approaches. But the posterior surgical treatment (laminoplasty and skip laminectomy) for MCSM remains controversial. As the well-established posterior procedure of laminectomy has presented unsatisfactory outcomes, laminoplasty is becoming an increasingly popular procedure in the treatment of MCSM [6]. Recently, a modified posterior surgical procedure called “skip laminectomy” [8] was developed, which could achieve adequate decompression of spinal cord with the separate resection of C4 and C6 laminae, limiting surgical excision to the posterior structures. In this study, we searched the Medline, Embase, Cochrane review library, and other databases, and found studies comparing laminoplasty and skip laminectomy for treatment of MCSM. Due to the lack of randomized controlled trials, disparity of surgical interventions and heterogeneity of outcome measures, we could not perform a meta-analysis. Instead, we performed a systematic review involving the
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Arch Orthop Trauma Surg (2014) 134:1–7 Table 3 Comparison of neurological results and surgical trauma
JOA
Otani et al. [12]
Sivaraman et al. [13]
Yukawa et al. [14]
Shiraishi et al. [15]
Preo: lamp: 9.5 ± 3.4, skip: 11.1 ± 2.6
NR
Preo: lamp: 11.1, skip: 10.1 Posto: lamp: 14.4, skip: 13.6
NR
NR
Lamp: 60.6 %, skip: 57.5 % NR
Lamp: 60 %, skip: 59 % NR
Lamp: 43.8 + 40.2, skip: 43 + 56.1
Lamp: 249, skip: 18
Lamp: 62.9 + 18.6, skip: 77.3 + 35.8
Lamp: 133, skip: 114
JOA recovery rate
Posto: lamp: 12.8 ± 3.1, skip:1 4.2 ± 1.7 Lamp: 42 %, Skip: 55 %
SF12
NR
Blood loss (mL)
NR
Operative time (min)
NR
Physical health Preo: lamp: 10.35, skip: 10.15 Posto: lamp: 11.85, skip: 12.33 Mental health Preo: lamp: 15.8, skip: 15.12 Posto: lamp: 17.85, skip: 18.04 Cervical pain Preo: lamp: 1.88, skip: 1.79 Posto: lamp: 2.95, skip 3.45(St) Lamp: 105 (50–600), skip: 50 (45–120) Lamp: 108 (75–165), skip: 70 (43–137)
JOA recovery rate = (postoperative (m)JOA−preoperative (m)JOA)/(17−preoperative (m)JOA) × 100 % Lamp laminoplasty, Skip skip laminectomy, Preo preoperation, Posto postoperation, St significant, NR not reported Table 4 Radiological evaluation in each study Otani et al. [12] ROM
Preo: Lamp: 39.8 ± 18.6, skip: 39.9 ± 14.3 Posto: lamp: 17.1 ± 16.4, skip: 24.8 ± 9.3 ROM % (post/pre) Lamp: 40.1 ± 27.4, skip: 67.4 ± 24.5(St) Preo: lamp: 10.2 ± 12.2, skip: Lordosis 9.9 ± 9.3
Sivaraman et al. [13] Yukawa et al. [14]
Shiraishi et al. [15]
NR
NR
Lamp:46, skip:84(St) NR
Posto: lamp: 6.7 ± 16.9, skip: 8.5 ± 12.6
Preo: lamp: 49.0 ± 10.7, skip: 43.4 ± 10.4 Posto: lamp: 35.8 ± 10.2, skip: 37.2 ± 9.5 Lamp: 77.4 ± 32.2, skip: 88.6 ± 25.6 Preo: lamp: 10.5 ± 10.9, skip: 11.7 ± 10.3
Lamp: 44, skip: 98(St) NR
Posto: lamp: 8.5 ± 11.1, skip: 10.2 ± 14.4
Lamp laminoplasty, Skip skip laminectomy, Preo preoperation, Posto postoperation, St significant, NR not reported
Table 5 Complications in each study Study
Complications Lamp
Skip
Otani et al. [12] Sivaraman et al. [13] Yukawa et al. [14]
Neck/shoulder symptoms: 7/13 (54 %) Wound infection: 1/25 (4 %) No complications happened
Neck/shoulder symptoms: 5/26 (19 %) Wound infection: 1/25 (4 %) No complications happened
Shiraishi et al. [15]
Axial symptoms: 34/51 (66.7 %), difficulty in looking around: 39/51 (76 %), C5 paresis: 3/51 (5.7 %)
Axial symptoms: 1/43 (2 %), difficulty in looking around: 0/43, C5 paresis: 0/43
Lamp laminoplasty, Skip skip laminectomy
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findings of aforementioned studies to determine which surgical treatment is more effective. For the clinical results, there was no significant difference between the laminoplasty group and the skip laminectomy group in preoperative and postoperative JOA scores, and the same finding was observed in the JOA recovery rate. It indicated that these two procedures were generally identical in terms of neural outcomes. However, in Sivaraman’s [13] study, a significantly greater degree of decompression was achieved in the skip laminectomy group, as indicated by the cervical spinal cord cross-sectional area at the compression site on axial MRI scans. In addition, the postoperative ROM, and the cervical lordosis did not differ significantly between the groups. But the ROM % (post/ pre) was significantly better in the skip laminectomy group in Otani et al. [12], Sivaraman et al. [13], Shiraishi’s [15] studies, indicating better movement of cervical spine after surgery. Operation time and blood loss were chosen to evaluate surgical trauma. The overall analyses revealed more blood loss and longer operation time in the laminoplasty group compared with the skip laminectomy group in Sivaraman et al. [13], Yukawa et al. [14] and Shiraishi’s [15] studies. Therefore, in the laminoplasty approach, deep extensor muscles were widely dissected and ligamentous structures were transected. In Shiraishi et al. [15] study, C3–7 atrophy rate of deep extensor muscles in skip laminectomy group was significantly lower than that of the laminoplasty group, indicating that in the treatment of MCSM, the surgical trauma associated with laminoplasty was much higher than that associated with skip laminectomy. The advantages of posterior approach included indirect decompression without destabilizing the disc space, intuitive operation while exposing multiple levels, and lower risk of postoperative instability with adjacent segment degeneration. But postoperative problems of posterior surgery, such as neck pain, C5 palsy, restriction of neck motion, loss of lordotic curvature, segmental instability, perineural adhesions, and late neurologic deterioration, were also noted [7, 18]. Shiraishi et al. [15] found that the complication rate in the skip laminectomy group was significantly lower than that of the laminoplasty group. But complications reported in Otani et al. [12], Sivaraman et al. [13], Yukawa’s [14] studies reported no significant difference in the two groups. Generally speaking, the complication rate of laminoplasty seemed to be higher. There are some limitations in this systematic review. First, as we only searched the studies in English, the studies in other languages might be missed out, and selection bias might exist. Second, as only four studies were included in this review, three of which took place in Japan [12, 14, 15] and another in UK [13], regional bias might exist. In addition, two types of laminoplasty (traditional expansive open
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Arch Orthop Trauma Surg (2014) 134:1–7
door laminoplasty and double-door laminoplasty) may influence the operation outcomes. Third, only one identified RCT was included. Furthermore, to evaluate which surgical method is better based on clinical results and complication rate, more high quality and well-designed randomized, controlled, multicenter trials are needed. In conclusion, based on the results above, laminoplasty shared similar postoperative neural functions with the skip laminectomy for treating MCSM. But the skip laminectomy group presented better outcomes in a variety of aspects: ROM % (post/pre), complication rate, surgical trauma, etc. As a limited number of study samples were included in the paper, a claim of superiority of the two approaches could not be justified. Further studies are required on the comparison between laminoplasty and skip laminectomy. Conflict of interest None.
References 1. Tracy JA, Bartleson JD (2010) Cervical spondylotic myelopathy. Neurologist 16(3):176–187. doi:10.1097/NRL.0b013e3181da3a2 9 2. Yalamanchili PK, Vives MJ, Chaudhary SB (2012) Cervical spondylotic myelopathy: factors in choosing the surgical approach. Adv Orthop 2012:783762. doi:10.1155/2012/783762 3. Bayerl S, Wiendieck K, Koeppen D, Topalovic M, Ubelacker A, Kroppenstedt S, Cabraja M (2013) Single- and multi-level anterior decompression and fusion for cervical spondylotic myelopathy: a long term follow-up with a minimum of 5 years. Clin Neurol Neurosurg. doi:10.1016/j.clineuro.2013.05.031 4. Song KJ, Lee KB, Song JH (2012) Efficacy of multilevel anterior cervical discectomy and fusion versus corpectomy and fusion for multilevel cervical spondylotic myelopathy: a minimum 5-year follow-up study. Eur Spine J 21(8):1551–1557. doi:10.1007/ s00586-012-2296-x 5. Jiang SD, Jiang LS, Dai LY (2012) Anterior cervical discectomy and fusion versus anterior cervical corpectomy and fusion for multilevel cervical spondylosis: a systematic review. Arch Orthop Trauma Surg 132(2):155–161. doi:10.1007/s00402-011-1402-6 6. Mitsunaga LK, Klineberg EO, Gupta MC (2012) Laminoplasty techniques for the treatment of multilevel cervical stenosis. Adv Orthop 2012:307916. doi:10.1155/2012/307916 7. Woods BI, Hohl J, Lee J, Donaldson W 3rd, Kang J (2011) Laminoplasty versus laminectomy and fusion for multilevel cervical spondylotic myelopathy. Clin Orthop Relat Res 469(3):688–695. doi:10.1007/s11999-010-1653-5 8. Shiraishi T (2002) Skip laminectomy––a new treatment for cervical spondylotic myelopathy, preserving bilateral muscular attachments to the spinous processes: a preliminary report. Spine J 2(2):108–115 9. Wright RW, Brand RA, Dunn W, Spindler KP (2007) How to write a systematic review. Clin Orthop Relat Res 455:23–29. doi: 10.1097/BLO.0b013e31802c9098 10. Furlan AD, Pennick V, Bombardier C, van Tulder M (2009) 2009 updated method guidelines for systematic reviews in the Cochrane back review group. Spine (Phila Pa 1976) 34(18):1929– 1941. doi:10.1097/BRS.0b013e3181b1c99f 11. Guyatt G, Oxman AD, Akl EA, Kunz R, Vist G, Brozek J, Norris S, Falck-Ytter Y, Glasziou P, DeBeer H, Jaeschke R, Rind
Arch Orthop Trauma Surg (2014) 134:1–7 D, Meerpohl J, Dahm P, Schunemann HJ (2011) GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables. J Clin Epidemiol 64(4):383–394. doi:10.1016/j.jclinepi.2010.04.026 12. Otani K, Sato K, Yabuki S, Iwabuchi M, Kikuchi S (2009) A segmental partial laminectomy for cervical spondylotic myelopathy: anatomical basis and clinical outcome in comparison with expansive open-door laminoplasty. Spine (Phila Pa 1976) 34(3):268– 273. doi:10.1097/BRS.0b013e318195b27a 13. Sivaraman A, Bhadra AK, Altaf F, Singh A, Rai A, Casey AT, Crawford RJ (2010) Skip laminectomy and laminoplasty for cervical spondylotic myelopathy: a prospective study of clinical and radiologic outcomes. J Spinal Disord Tech 23(2):96–100. doi:10. 1097/BSD.0b013e318198c92a 14. Yukawa Y, Kato F, Ito K, Horie Y, Hida T, Ito Z, Matsuyama Y (2007) Laminoplasty and skip laminectomy for cervical compressive myelopathy: range of motion, postoperative neck pain, and surgical outcomes in a randomized prospective study. Spine
7 (Phila Pa 1976) 32(18):1980–1985. doi:10.1097/BRS.0b013e318 133fbce 15. Shiraishi T, Fukuda K, Yato Y, Nakamura M, Ikegami T (2003) Results of skip laminectomy-minimum 2-year follow-up study compared with open-door laminoplasty. Spine (Phila Pa 1976) 28(24):2667–2672. doi:10.1097/01.BRS.0000103340.78418.B2 16. Zhu B, Xu Y, Liu X, Liu Z, Dang G (2013) Anterior approach versus posterior approach for the treatment of multilevel cervical spondylotic myelopathy: a systemic review and meta-analysis. Eur Spine J 22(7):1583–1593. doi:10.1007/s00586-013-2817-2 17. Cunningham MR, Hershman S, Bendo J (2010) Systematic review of cohort studies comparing surgical treatments for cervical spondylotic myelopathy. Spine (Phila Pa 1976) 35(5):537– 543. doi:10.1097/BRS.0b013e3181b204cc 18. Mayer M, Meier O, Auffarth A, Koller H (2013) Cervical laminectomy and instrumented lateral mass fusion: techniques, pearls and pitfalls. Eur Spine J. doi:10.1007/s00586-013-2838-x
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ORTHOPAEDIC SURGERY
Laminoplasty versus skip laminectomy for the treatment of multilevel cervical spondylotic myelopathy: a systematic review Wei Yuan · Yue Zhu · Xinchun Liu · Xiaoshu Zhou · Cui Cui
Received: 19 August 2013 / Published online: 8 November 2013 © Springer-Verlag Berlin Heidelberg 2013
Abstract Introduction Laminoplasty and skip laminectomy are two specific posterior surgical approaches for multilevel cervical spondylotic myelopathy. The objective of this study was to perform a systematic review comparing the clinical results and complications of laminoplasty and skip laminectomy in the treatment of multilevel cervical spondylotic myelopathy. Materials and methods We reviewed and analyzed papers published from January 1969 to December 2012 through the Mediline, Embase, Cochrane review library, and other databases regarding the comparison between laminoplasty and skip laminectomy for multilevel cervical spondylotic myelopathy. Results One randomized controlled trial and three nonrandomized controlled trials were included in this systematic review. In three studies, the preoperative and postoperative JOA score was similar in both laminoplasty and skip laminectomy groups. In addition, for recovery rate, there was no significant difference between the groups. One study reported that, regarding SF12 scores, there was no significant difference in physical health and mental health after surgery. However, regarding cervical pain, the skip laminectomy group was better than the laminoplasty group significantly. No difference was presented in postoperative ROM and the cervical lordosis between the groups. But the ROM % (post/pre) was reported to be significantly better in the skip laminectomy group in three studies. Less blood
W. Yuan · Y. Zhu (*) · X. Liu · X. Zhou · C. Cui Department of Orthopedics, First Hospital of China Medical University, No. 155 Nanjing Bei Street, Heping District, Shenyang, Liaoning, China e-mail: [email protected]
loss and shorter operation time were observed in skip laminectomy rather than laminoplasty. Conclusions Based on the results above, the skip laminectomy group presented better outcomes in a variety of aspects: ROM % (post/pre), complication rate, surgical trauma, etc. However, as limited study samples were included in the paper, a claim of superiority of the two approaches could not be justified. Further studies are required on the comparison between laminoplasty and skip laminectomy. Keywords Laminoplasty · Skip laminectomy · Cervical spondylotic myelopathy · Systematic review
Introduction Cervical spondylotic myelopathy (CSM) is the leading cause of spinal cord dysfunction in adult population. Compared with non-surgical treatment, surgery for moderate to severe or progressive CSM has shown significant improvement in functional status [1]. And the surgery for CSM involving one or two levels can be successfully performed by anterior decompression and fusion with a low incidence of complications [2, 3]. However, when three or more levels are involved (multilevel cervical spondylotic myelopathy, MCSM), accelerated complication rates associated with anterior surgery, particularly fusion failure, adjacent level degeneration, instrumentation failure and dysphagia were observed in multilevel corpectomies [4, 5], making posterior approach gain more attention. The laminoplasty procedure was first performed and developed by Japanese surgeons in the late 1970s [6]. Postoperative complications such as persistent axial pain, C5 paresis, restriction of neck movement, and loss of lordotic
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alignment are known to be associated with this procedure [7]. Skip laminectomy, recently developed by Shiraishi [8], is a minimally invasive procedure to prevent postsurgical problems often seen after laminoplasty, which can decompress four levels of spinal cord while limiting surgical excision to the posterior structures. Although some studies on the two approaches have been done, controversy over which surgical approach would yield better outcome remains. No systematic review of laminoplasty and skip laminectomy in the treatment for MCSM has been published yet. The purpose of this study was to perform a systematic review of randomized and nonrandomized controlled studies to compare laminoplasty and skip laminectomy in the treatment of MCSM, specifically evaluating their clinical and radiographic results and complications, which would provide guidance for clinical decision-making.
Materials and methods
Arch Orthop Trauma Surg (2014) 134:1–7
After the two reviews searching articles from the database, the title abstracts were individually reviewed to identify articles to confirm inclusion/exclusion criteria. Data extraction The data extraction was conducted by two reviewers independently mentioned above based on a standardized form [9]. The data included study design, enrollment, year published, patient characteristics, interventions, treatment allocation, follow-up, clinical outcomes, radiographic results, and complications. Any disagreement in inclusion–exclusion criteria or data abstraction was solved by consensus discussing with at least two reviewers. Strength of the evidence The risk of bias was assessed with the criteria proposed by the Cochrane Back Review Group [10]. The level of evidence was assessed according to the guidelines of the GRADE working group [11].
Search strategy We searched databases including Medline, Embase, the Cochrane library, and other databases such as ebsco, web of knowledge, Springer to find randomized or non-randomized controlled trials comparing laminoplasty and skip laminectomy for MCSM up to December 2012. Reference lists from the included studies were also selected by computer searching to identify further relevant trials that met the inclusion criteria in this systematic review. The language was limited to English. The medical subject heading (Mesh) and free words applied the following: cervical spondylotic myelopathy, cervical myelopathy, cervical spondylosis, cervical stenosis, skip laminectomy, segment laminectomy, laminoplasty, dorsal, and posterior. Selection of studies The following inclusion criteria were applied: (1) types of studies: randomized controlled trials (RCT) or non-randomized controlled studies; (2) population: MCSM with no previous cervical surgeries; (3) types of interventions: laminoplasty compared with skip laminectomy in the treatment of MCSM; (4) outcome measures: neurological, radiologic outcomes and complications. The publications were excluded from the systematic review if: (1) they did not meet the inclusion criteria above; (2) they described novel techniques, as well as case reports, letters, comments and reviews; (3) the study was not aimed to compare results between different procedures and it did not distinguish myelopathy from OPLL.
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Results After the computerized search and extensively crosschecked reference lists, 512 citations were included. These citations were reviewed and a total of 81 abstracts were screened. At last, 4 articles comparing laminoplasty and skip laminectomy in treating MCSM were included in this systematic review. Description of the studies There were three non-randomized controlled clinical studies and one RCT study. Three of the studies took place in Japan, while the one in UK. All studies reported the common characteristics, including age, gender, follow-up, and no differences were noted between groups preoperatively, specifically for Japanese Orthopedic Association (JOA) score, SF12 score, ROM (Table 1). The number of patients in each group was equal, with the exception of Otani et al. [12], who had approximately the double number of patients in the skip group. Patient allocation to treatment was not recorded in the Otani et al. [12] and Sivaraman et al. [13] studies. Patients in one RCT [14] randomized to laminoplasty or skip laminectomy group according to their birth month. Before a certain time period, surgeons in Shiraishi’s [15] study performed the laminoplasty for MCSM, and then changed their surgical technique to skip laminectomy after 1998. Follow-up was between 2 and 5 years on average in these studies.
Lamp laminoplasty, Skip skip laminectomy, NR not reported
Follow-up (months)
Treatment allocated
Disease duration (months) Intervention
60
Lamp: 13; skip: 26 Lamp: 10M/3F; skip: 20M/6F Lamp: 62 ± 7 (42–71); skip: 64 ± 9 (46–76) Lamp: 34 ± 35 (3–120) Skip: 35 ± 40 (1–120) Lamp: traditional C3–C7 expansive open door laminoplasty; Skip: the C4, 6 laminae were removed, the cephaled third of C5, 7 laminae and ligamenta flavum were removed. NR
No. patients Gender
Age (year)
2009 Non-randomized controlled trial 1993–1998 Japan To compare the outcomes between skip laminectomy and traditional C3–C7 expansive open door laminoplasty for treatment of MCSM
Published year Design of study Enrollment Location Object
Otani et al. [12]
Table 1 Comparison of study settings, participants, and interventions
24 (26.4–51.6)
Lamp: C3–6 double-door laminoplasty; Skip: the C4, 6 laminae were removed, the cephaled third of C5, 7 laminae and ligamenta flavum were removed. NR
2010 Non-randomized controlled trial NR UK To compare the skip laminectomy and laminoplasty in terms of decompression extent, axial pain, postoperative range of cervical motion, patient and surgical outcomes Lamp:25; skip:25 Lamp: 14M/11F; skip: 12M/13F Lamp: 62.4; skip: 69.6 NR
Sivaraman et al. [13]
Lamp: 51; skip: 43 Lamp: 32M/19F; skip: 24M/19F Lamp: 67 (36–81); skip: 69 (50–84) NR
2003 Non-randomized controlled trial NR Japan To compare the results of skip laminectomy with open door laminoplasty in treatment of MCSM
Shiraishi et al. [15]
28.1 (10.1)
Lamp:43 (24–66); skip:30 (24–41)
Lamp: C3–6 double-door laminoLamp: traditional C3–C7 expansive plasty; Skip: the C4, 6 laminae were open door laminoplasty; removed, the cephaled third of C5, 7 laminae and ligamenta flavum were removed. Randomized to Lamp group or Skip Before they started Skip, they had group according to their birth month underwent Lamp since 1998 (even Lamp; oss Skip) December.
Lamp: 21; skip: 20 Lamp: 8M/13F; skip: 5M/15F Lamp: 62.3 ± 11.4; skip: 66.1 ± 10.8 NR
2007 Randomized controlled trial NR Japan To compare modified laminoplasty and skip laminectomy in terms of surgical invasiveness, postoperative range of motion, axial pain, and surgical outcomes.
Yukawa et al. [14]
Arch Orthop Trauma Surg (2014) 134:1–7 3
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Table 2 Quality of studies according to GRADE Author
Otani et al. [12]
Sivaraman et al. [13]
Yukawa et al. [14]
Shiraishi et al. [15]
Design
Non-randomized controlled trial −1 0 N/A −1 0 0
Non-randomized controlled trial −1 0 N/A −1 0 0
Randomized controlled trial −1 0 −1 0 0 0
Non-randomized controlled trial −1 0 N/A −1 0 0
−2
−2
−2
−2
Risk of bias Indirectness Imprecision Publication Bias Large effect Plausible residual confounding Total Quality of evidence
Very low
Very low
All studies were identified with high risk of bias. The RCT [14] did not report the process of randomization, allocation, blinding or dealing with missing data, and the quality of evidence using GRADE was very low (Table 2). Therefore, a meta-analysis was not possible.
Very low
Very low
the laminoplasty group than in the skip laminectomy group. Table 5 presents the detailed complications in each study of this systematic review.
Discussion Clinical outcome All studies showed clinical improvement after surgical intervention. JOA scores were reported in three studies [12, 14, 15]. And after the surgery, there was no significant difference between the two groups in any of the studies regarding JOA scores, and recovery rates. In the study by Sivaraman et al. [13], there was no significant difference in SF12 scores for physical health and mental health after surgery, but for cervical pain, the skip laminectomy group was better than the laminoplasty group significantly. Spinal cord cross-sectional area in the skip laminectomy group was larger than the laminoplasty group significantly in Sivaraman’s [13] study. The final ROM and lordosis were recorded in Otani et al. [12] and Yukawa’s [14] studies, and there was no significant difference between the two groups. But according to Otani et al. [12], Sivaraman et al. [13] and Shiraishi et al. [15], ROM % (post/pre) was significantly better in the skip laminectomy group. Three studies [13– 15] reported blood loss and operation time in patients who underwent laminoplasty and skip laminectomy, from which we draw the conclusion that compared with skip laminectomy, the blood loss was less and operation time was shorter in the laminoplasty group (Tables 3, 4). Complications No worsening of neural function was reported in each study. Axial symptoms, difficulty in looking around, C5 paresis and wound infection were reported in three studies [12, 13, 15]. In total, more complications were observed in
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A number of parameters are required to take into consideration when choosing a proper approach for CSM, including number of levels compressed, sagittal alignment and patient health status. Posterior approaches to spinal cord decompression are generally preferred in patients with a neutral or lordotic cervical alignment and multilevel myelopathy involving three or more motion segments [2, 16]. According to a recent systematic review by Cunningham et al. [17], who compared different surgical treatments (ACDF, corpectomy, laminectomy and laminoplasty) for CSM, the laminoplasty approach presented fewer complications, possibly greater ROM, and similar neurologic recovery compared with the other surgery approaches. But the posterior surgical treatment (laminoplasty and skip laminectomy) for MCSM remains controversial. As the well-established posterior procedure of laminectomy has presented unsatisfactory outcomes, laminoplasty is becoming an increasingly popular procedure in the treatment of MCSM [6]. Recently, a modified posterior surgical procedure called “skip laminectomy” [8] was developed, which could achieve adequate decompression of spinal cord with the separate resection of C4 and C6 laminae, limiting surgical excision to the posterior structures. In this study, we searched the Medline, Embase, Cochrane review library, and other databases, and found studies comparing laminoplasty and skip laminectomy for treatment of MCSM. Due to the lack of randomized controlled trials, disparity of surgical interventions and heterogeneity of outcome measures, we could not perform a meta-analysis. Instead, we performed a systematic review involving the
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Arch Orthop Trauma Surg (2014) 134:1–7 Table 3 Comparison of neurological results and surgical trauma
JOA
Otani et al. [12]
Sivaraman et al. [13]
Yukawa et al. [14]
Shiraishi et al. [15]
Preo: lamp: 9.5 ± 3.4, skip: 11.1 ± 2.6
NR
Preo: lamp: 11.1, skip: 10.1 Posto: lamp: 14.4, skip: 13.6
NR
NR
Lamp: 60.6 %, skip: 57.5 % NR
Lamp: 60 %, skip: 59 % NR
Lamp: 43.8 + 40.2, skip: 43 + 56.1
Lamp: 249, skip: 18
Lamp: 62.9 + 18.6, skip: 77.3 + 35.8
Lamp: 133, skip: 114
JOA recovery rate
Posto: lamp: 12.8 ± 3.1, skip:1 4.2 ± 1.7 Lamp: 42 %, Skip: 55 %
SF12
NR
Blood loss (mL)
NR
Operative time (min)
NR
Physical health Preo: lamp: 10.35, skip: 10.15 Posto: lamp: 11.85, skip: 12.33 Mental health Preo: lamp: 15.8, skip: 15.12 Posto: lamp: 17.85, skip: 18.04 Cervical pain Preo: lamp: 1.88, skip: 1.79 Posto: lamp: 2.95, skip 3.45(St) Lamp: 105 (50–600), skip: 50 (45–120) Lamp: 108 (75–165), skip: 70 (43–137)
JOA recovery rate = (postoperative (m)JOA−preoperative (m)JOA)/(17−preoperative (m)JOA) × 100 % Lamp laminoplasty, Skip skip laminectomy, Preo preoperation, Posto postoperation, St significant, NR not reported Table 4 Radiological evaluation in each study Otani et al. [12] ROM
Preo: Lamp: 39.8 ± 18.6, skip: 39.9 ± 14.3 Posto: lamp: 17.1 ± 16.4, skip: 24.8 ± 9.3 ROM % (post/pre) Lamp: 40.1 ± 27.4, skip: 67.4 ± 24.5(St) Preo: lamp: 10.2 ± 12.2, skip: Lordosis 9.9 ± 9.3
Sivaraman et al. [13] Yukawa et al. [14]
Shiraishi et al. [15]
NR
NR
Lamp:46, skip:84(St) NR
Posto: lamp: 6.7 ± 16.9, skip: 8.5 ± 12.6
Preo: lamp: 49.0 ± 10.7, skip: 43.4 ± 10.4 Posto: lamp: 35.8 ± 10.2, skip: 37.2 ± 9.5 Lamp: 77.4 ± 32.2, skip: 88.6 ± 25.6 Preo: lamp: 10.5 ± 10.9, skip: 11.7 ± 10.3
Lamp: 44, skip: 98(St) NR
Posto: lamp: 8.5 ± 11.1, skip: 10.2 ± 14.4
Lamp laminoplasty, Skip skip laminectomy, Preo preoperation, Posto postoperation, St significant, NR not reported
Table 5 Complications in each study Study
Complications Lamp
Skip
Otani et al. [12] Sivaraman et al. [13] Yukawa et al. [14]
Neck/shoulder symptoms: 7/13 (54 %) Wound infection: 1/25 (4 %) No complications happened
Neck/shoulder symptoms: 5/26 (19 %) Wound infection: 1/25 (4 %) No complications happened
Shiraishi et al. [15]
Axial symptoms: 34/51 (66.7 %), difficulty in looking around: 39/51 (76 %), C5 paresis: 3/51 (5.7 %)
Axial symptoms: 1/43 (2 %), difficulty in looking around: 0/43, C5 paresis: 0/43
Lamp laminoplasty, Skip skip laminectomy
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findings of aforementioned studies to determine which surgical treatment is more effective. For the clinical results, there was no significant difference between the laminoplasty group and the skip laminectomy group in preoperative and postoperative JOA scores, and the same finding was observed in the JOA recovery rate. It indicated that these two procedures were generally identical in terms of neural outcomes. However, in Sivaraman’s [13] study, a significantly greater degree of decompression was achieved in the skip laminectomy group, as indicated by the cervical spinal cord cross-sectional area at the compression site on axial MRI scans. In addition, the postoperative ROM, and the cervical lordosis did not differ significantly between the groups. But the ROM % (post/ pre) was significantly better in the skip laminectomy group in Otani et al. [12], Sivaraman et al. [13], Shiraishi’s [15] studies, indicating better movement of cervical spine after surgery. Operation time and blood loss were chosen to evaluate surgical trauma. The overall analyses revealed more blood loss and longer operation time in the laminoplasty group compared with the skip laminectomy group in Sivaraman et al. [13], Yukawa et al. [14] and Shiraishi’s [15] studies. Therefore, in the laminoplasty approach, deep extensor muscles were widely dissected and ligamentous structures were transected. In Shiraishi et al. [15] study, C3–7 atrophy rate of deep extensor muscles in skip laminectomy group was significantly lower than that of the laminoplasty group, indicating that in the treatment of MCSM, the surgical trauma associated with laminoplasty was much higher than that associated with skip laminectomy. The advantages of posterior approach included indirect decompression without destabilizing the disc space, intuitive operation while exposing multiple levels, and lower risk of postoperative instability with adjacent segment degeneration. But postoperative problems of posterior surgery, such as neck pain, C5 palsy, restriction of neck motion, loss of lordotic curvature, segmental instability, perineural adhesions, and late neurologic deterioration, were also noted [7, 18]. Shiraishi et al. [15] found that the complication rate in the skip laminectomy group was significantly lower than that of the laminoplasty group. But complications reported in Otani et al. [12], Sivaraman et al. [13], Yukawa’s [14] studies reported no significant difference in the two groups. Generally speaking, the complication rate of laminoplasty seemed to be higher. There are some limitations in this systematic review. First, as we only searched the studies in English, the studies in other languages might be missed out, and selection bias might exist. Second, as only four studies were included in this review, three of which took place in Japan [12, 14, 15] and another in UK [13], regional bias might exist. In addition, two types of laminoplasty (traditional expansive open
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Arch Orthop Trauma Surg (2014) 134:1–7
door laminoplasty and double-door laminoplasty) may influence the operation outcomes. Third, only one identified RCT was included. Furthermore, to evaluate which surgical method is better based on clinical results and complication rate, more high quality and well-designed randomized, controlled, multicenter trials are needed. In conclusion, based on the results above, laminoplasty shared similar postoperative neural functions with the skip laminectomy for treating MCSM. But the skip laminectomy group presented better outcomes in a variety of aspects: ROM % (post/pre), complication rate, surgical trauma, etc. As a limited number of study samples were included in the paper, a claim of superiority of the two approaches could not be justified. Further studies are required on the comparison between laminoplasty and skip laminectomy. Conflict of interest None.
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