Laminoplasty Warranted for More Patients with Cervical Spondylotic Myelopathy
Key findings
- In this retrospective cohort study, two orthopedic surgeons reviewed preoperative CT or MRI studies on 250 adults with spondylotic myelopathy or myeloradiculopathy who underwent cervical laminectomy and fusion (LF) or laminoplasty (LP)
- Based on radiographic criteria, 86 of the 108 (80%) patients who underwent LF were candidates for LP
- All 142 patients who underwent LP were free of radiographic contraindications for the procedure
- Thus, 228/250 patients (91%) were radiographically candidates for LP
- Considering its clinical advantages already documented in the literature, LP may be an underutilized procedure that warrants consideration in many more cases of cervical spondylotic myelopathy
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Laminectomy and fusion (LF) and laminoplasty (LP) are the two most common posterior-based surgeries used to treat cervical spondylotic myelopathy (CSM). In many cases, the choice between these interventions comes down to surgeon preference.
In recent studies, the two procedures had similar outcomes, and in other research, LP was associated with fewer complications, lower reoperation rates, decreased estimated blood loss, shorter operative time and greater cost-effectiveness.
Yet, between 2007 and 2016, LF was performed seven times more often than LP in the U.S. Regional training may play a role and hospital contracts and financial incentives presumably do too—hospitals and surgeons in North America are reimbursed approximately half as much for LP as for LF.
In a retrospective cohort study, Wylie Y. Lopez, MD, clinical orthopaedic surgery resident, and Stuart Hershman, MD, surgeon in the Orthopaedic Spine Center at Massachusetts General Hospital, and colleagues found that most patients with CSM are candidates for LP based on radiographic findings. Their findings appear in The Spine Journal.
Study Methods
The study subjects were 250 adults with spondylotic myelopathy or myeloradiculopathy who underwent cervical LF (n=108) or cervical LP (n=142) between 2017 and 2019 and had preoperative CT or MRI.
To determine which patients who underwent LF had also been eligible for LP, two orthopedic surgeons calculated preoperative C2–C7 Cobb angles and evaluated whether segmental instability was present. In the event of disagreement, a senior surgeon made the decision.
In line with previous literature, the researchers considered the following to be contraindications for LP:
- Kyphosis >13°
- >3.5 mm of listhesis on static imaging
- >2.5 mm of motion on flexion–extension or standing–supine films
Interrater Agreement
Interrater reliability for cervical alignment measurements was excellent (intraclass coefficient, 0.9). There was 97% agreement between raters (105/108 patients) about preoperative stability in the LF group.
Candidates for LP
- 86 of the 108 patients who underwent LF (80%) were radiographically candidates for LP
- All 142 patients who underwent LP were free of radiographic contraindications for the procedure
- Thus, 228/250 patients (91%) were radiographically candidates for LP
An Underutilized Procedure
LP has theoretical advantages of motion preservation and decreased risk of adjacent segment degeneration and nonunion, as well as the clinical advantages already documented in the literature. LP warrants consideration for patients with CSM who fit the radiographic criteria.
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