Laminectomy and fusion for the treatment of cervical degenerative myelopathy

2009 ◽  
Vol 11 (2) ◽  
pp. 150-156 ◽  
Author(s):  
Paul A. Anderson ◽  
Paul G. Matz ◽  
Michael W. Groff ◽  
Robert F. Heary ◽  
Langston T. Holly ◽  
...  
Keyword(s):  
Functional Outcome ◽  
Posterior Longitudinal Ligament ◽  
Consensus Conference ◽  
Functional Improvement ◽  
Class Iii ◽  
Level Of Evidence ◽  
Cervical Laminectomy ◽  
Cochrane Database ◽  
Laminectomy And Fusion ◽  
Based Medicine

Object The objective of this systematic review was to use evidence-based medicine to examine the efficacy of cervical laminectomy and fusion for the treatment of cervical spondylotic myelopathy (CSM). Methods The National Library of Medicine and Cochrane Database were queried using MeSH headings and keywords relevant to cervical laminectomy, fusion, and CSM. Abstracts were reviewed, after which studies that met the inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Class I–III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations which contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer-review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons. Results Cervical laminectomy with fusion (arthrodesis) improves functional outcome in patients with CSM and ossification of the posterior longitudinal ligament (OPLL). Functional improvement is similar to laminectomy or laminoplasty for patients with CSM and OPLL. In contrast to laminectomy, cervical laminectomy with fusion it is not associated with late deformity (Class III). Conclusions Laminectomy with fusion (arthrodesis) is an effective strategy to improve functional outcome in CSM and OPLL.

Cervical laminectomy for the treatment of cervical degenerative myelopathy

2009 ◽  
Vol 11 (2) ◽  
pp. 142-149 ◽  
Author(s):  
Timothy C. Ryken ◽  
Robert F. Heary ◽  
Paul G. Matz ◽  
Paul A. Anderson ◽  
Michael W. Groff ◽  
...  
Keyword(s):  
Consensus Conference ◽  
Functional Improvement ◽  
Class Iii ◽  
Level Of Evidence ◽  
Cervical Laminectomy ◽  
Cochrane Database ◽  
Increased Risk ◽  
Strength Based ◽  
Near Term ◽  
Based Medicine

Object The objective of this systematic review was to use evidence-based medicine to examine the efficacy of cervical laminectomy for the treatment of cervical spondylotic myelopathy (CSM). Methods The National Library of Medicine and Cochrane Database were queried using MeSH headings and keywords relevant to cervical laminectomy and CSM. Abstracts were reviewed after which studies meeting inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I–III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons. Results Laminectomy has improved functional outcome for symptomatic cervical myelopathy (Class III). The limitations of the technique are an increased risk of postoperative kyphosis compared to anterior techniques or laminoplasty or laminectomy with fusion (Class III). However, the development of kyphosis may not necessarily to diminish the clinical outcome (Class III). Conclusions Laminectomy is an acceptable therapy for near-term functional improvement of CSM (Class III). It is associated with development of kyphosis, however.

Cervical laminoplasty for the treatment of cervical degenerative myelopathy

2009 ◽  
Vol 11 (2) ◽  
pp. 157-169 ◽  
Author(s):  
Paul G. Matz ◽  
Paul A. Anderson ◽  
Michael W. Groff ◽  
Robert F. Heary ◽  
Langston T. Holly ◽  
...  
Keyword(s):  
Japanese Orthopaedic Association ◽  
Posterior Longitudinal Ligament ◽  
Consensus Conference ◽  
Functional Improvement ◽  
Cervical Laminoplasty ◽  
Class Iii ◽  
Level Of Evidence ◽  
Duration Of Symptoms ◽  
Cochrane Database ◽  
Stenosis Severity

Object The objective of this systematic review was to use evidence-based medicine to examine the efficacy of cervical laminoplasty in the treatment of cervical spondylotic myelopathy (CSM). Methods The National Library of Medicine and Cochrane Database were queried using MeSH headings and keywords relevant to cervical laminoplasty and CSM. Abstracts were reviewed and studies meeting the inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I–III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons and Congress of Neurological Surgeons. Results Cervical laminoplasty has improved functional outcome in the setting of CSM or ossification of the posterior longitudinal ligament. Using the Japanese Orthopaedic Association scale score, ~ 55–60% average recovery rate has been observed (Class III). The functional improvement observed after laminoplasty may be limited by duration of symptoms, severity of stenosis, severity of myelopathy, and poorly controlled diabetes as negative risk factors (Class II). There is conflicting evidence regarding age, with 1 study citing it as a negative risk factor, and another not demonstrating this result. Conclusions Cervical laminoplasty is recommended for the treatment of CSM or ossification of the posterior longitudinal ligament (Class III).

Management of anterior cervical pseudarthrosis

2009 ◽  
Vol 11 (2) ◽  
pp. 228-237 ◽  
Author(s):  
Michael G. Kaiser ◽  
Praveen V. Mummaneni ◽  
Paul G. Matz ◽  
Paul A. Anderson ◽  
Michael W. Groff ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Consensus Conference ◽  
Class Iii ◽  
Inclusion Criteria ◽  
Level Of Evidence ◽  
Cervical Spine Surgery ◽  
Cochrane Database ◽  
Strength Based ◽  
Based Medicine

Object The objective of this systematic review was to use evidence-based medicine to identify the best methodology for diagnosis and treatment of anterior pseudarthrosis. Methods The National Library of Medicine and Cochrane Database were queried using MeSH headings and key words relevant to pseudarthrosis and cervical spine surgery. Abstracts were reviewed, after which studies meeting inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I–III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons. Results Evaluation for pseudarthrosis is warranted, as there may be an association between clinical outcome and pseudarthrosis. The strength of this association cannot be accurately determined because of the variable incidence of symptomatic and asymptomatic pseudarthroses (Class III). Revision of a symptomatic pseudarthrosis may be considered because arthrodesis is associated with improved clinical outcome (Class III). Both posterior and anterior approaches have proven successful for surgical correction of an anterior pseudarthrosis. Posterior approaches may be associated with higher fusion rates following repair of an anterior pseudarthrosis (Class III). Conclusions If suspected, pseudarthrosis should be investigated because there may be an association between arthrodesis and outcome. However, the strength of this association cannot be accurately determined. Anterior and posterior approaches have been successful.

Cervical laminoforaminotomy for the treatment of cervical degenerative radiculopathy

2009 ◽  
Vol 11 (2) ◽  
pp. 198-202 ◽  
Author(s):  
Robert F. Heary ◽  
Timothy C. Ryken ◽  
Paul G. Matz ◽  
Paul A. Anderson ◽  
Michael W. Groff ◽  
...  
Keyword(s):  
Cervical Radiculopathy ◽  
Consensus Conference ◽  
Cervical Disc ◽  
Class Iii ◽  
Level Of Evidence ◽  
Outcomes Measures ◽  
Cochrane Database ◽  
Strength Based ◽  
Based Medicine

Object The objective of this systematic review was to use evidence-based medicine to examine the efficacy of posterior laminoforaminotomy in the treatment of cervical radiculopathy. Methods The National Library of Medicine and Cochrane Database were queried using MeSH headings and key words relevant to posterior laminoforaminotomy and cervical radiculopathy. Abstracts were reviewed, and studies meeting inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I–III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations which contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons. Results Posterior laminoforaminotomy improves clinical outcome in the treatment of cervical radiculopathy resulting from soft lateral cervical disc displacement or cervical spondylosis with resulting narrowing of the lateral recess. All studies were Class III. The most frequent design flaw involved the lack of utilization of validated outcomes measures. In addition, few historical studies included a detailed preoperative analysis of the patients. As such, the vast majority of studies that included both pre- and postoperative assessments with legitimate outcomes measures have been performed since 1990. Conclusions Posterior laminoforaminotomy is an effective treatment for cervical radiculopathy.

The natural history of cervical spondylotic myelopathy

2009 ◽  
Vol 11 (2) ◽  
pp. 104-111 ◽  
Author(s):  
Paul G. Matz ◽  
Paul A. Anderson ◽  
Langston T. Holly ◽  
Michael W. Groff ◽  
Robert F. Heary ◽  
...  
Keyword(s):  
Natural History ◽  
Cervical Spondylotic Myelopathy ◽  
Japanese Orthopaedic Association ◽  
Consensus Conference ◽  
Class I ◽  
Class Iii ◽  
Level Of Evidence ◽  
Cochrane Database ◽  
History Of ◽  
Based Medicine

Object The objective of this systematic review was to use evidence-based medicine to delineate the natural history of cervical spondylotic myelopathy (CSM) and identify factors associated with clinical deterioration. Methods The National Library of Medicine and Cochrane Database were queried using MeSH headings and keywords relevant to the natural history of CSM. Abstracts were reviewed and studies meeting the inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I–III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons. Results The natural history of CSM is mixed: it may manifest as a slow, stepwise decline or there may be a long period of quiescence (Class III). Long periods of severe stenosis are associated with demyelination and may result in necrosis of both gray and white matter. With severe and/or long lasting CSM symptoms, the likelihood of improvement with nonoperative measures is low. Objectively measurable deterioration is rarely seen acutely in patients younger than 75 years of age with mild CSM (modified Japanese Orthopaedic Association scale score > 12; Class I). In patients with cervical stenosis without myelopathy, the presence of abnormal electromyography findings or the presence of clinical radiculopathy is associated with the development of symptomatic CSM in this patient population (Class I). Conclusions The natural history of CSM is variable, which may affect treatment decisions.

Radiographic assessment of cervical subaxial fusion

2009 ◽  
Vol 11 (2) ◽  
pp. 221-227 ◽  
Author(s):  
Michael G. Kaiser ◽  
Praveen V. Mummaneni ◽  
Paul G. Matz ◽  
Paul A. Anderson ◽  
Michael W. Groff ◽  
...  
Keyword(s):  
Class Ii ◽  
Consensus Conference ◽  
Reliable Indicator ◽  
Class Iii ◽  
Radiographic Assessment ◽  
Distance Measurements ◽  
Level Of Evidence ◽  
Angle Measurements ◽  
Cochrane Database ◽  
Based Medicine

Object The objective of this systematic review was to use evidence-based medicine to identify the best methodology for radiographic assessment of cervical subaxial fusion. Methods The National Library of Medicine and Cochrane Database were queried using MeSH headings and keywords relevant to cervical fusion. Abstracts were reviewed and studies meeting inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I–III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons. Results Pseudarthrosis is best assessed through the absence of motion detected between the spinous processes on dynamic radiographs (Class II). The measurement of interspinous distance on dynamic radiographs of ≥ 2 mm is a more reliable indicator for pseudarthrosis than angular motion of 2° based on Cobb angle measurements (Class II). Similarly, it is also understood that the pseudarthrosis rate will increase as the threshold for allowable motion on dynamic radiographs decreases. The combination of interspinous distance measurements and identification of bone trabeculation is unreliable when performed by the treating surgeon (Class II). Identification of bone trabeculation on static radiographs should be considered a less reliable indicator of cervical arthrodesis than dynamic films (Class III). Conclusions Consideration should be given to dynamic radiographs and interspinous distance when assessing for pseudarthrosis.

Techniques for cervical interbody grafting

2009 ◽  
Vol 11 (2) ◽  
pp. 203-220 ◽  
Author(s):  
Timothy C. Ryken ◽  
Robert F. Heary ◽  
Paul G. Matz ◽  
Paul A. Anderson ◽  
Michael W. Groff ◽  
...  
Keyword(s):  
Iliac Crest ◽  
Class Ii ◽  
Consensus Conference ◽  
Anterior Cervical Discectomy ◽  
Current Evidence ◽  
Class Iii ◽  
Level Of Evidence ◽  
Cervical Discectomy ◽  
Cochrane Database ◽  
Titanium Cages

Object The objective of this systematic review was to use evidence-based medicine to determine the efficacy of interbody graft techniques. Methods The National Library of Medicine and Cochrane Database were queried using MeSH headings and keywords relevant to cervical interbody grafting. Abstracts were reviewed and studies that met the inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I–III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgerons/Congress of Neurological Surgeons. Results Autograft bone harvested from the iliac crest, allograft bone from either cadaveric iliac crest or fibula, or titanium cages and rectangular fusion devices, with or without the use of autologous graft or substitute, have been successful in creating arthrodesis after 1- or 2-level anterior cervical discectomy with fusion (Class II). Alternatives to autograft, allograft, or titanium cages include polyetheretherketone cages and carbon fiber cages (Class III). Polyetheretherketone cages have been used successfully with or without hydroxyapatite for anterior cervical discectomy with fusion. Importantly, recombinant human bone morphogenic protein-2 carries a complication rate of up to 23–27% (especially local edema) compared with 3% for a standard approach. Conclusions Current evidence does not support the routine use of interbody grafting for cervical arthrodesis. Multiple strategies for interbody grafting have been successful with Class II evidence supporting the use of autograft, allograft, and titanium cages.

Electrophysiological monitoring during surgery for cervical degenerative myelopathy and radiculopathy

2009 ◽  
Vol 11 (2) ◽  
pp. 245-252 ◽  
Author(s):  
Daniel K. Resnick ◽  
Paul A. Anderson ◽  
Michael G. Kaiser ◽  
Michael W. Groff ◽  
Robert F. Heary ◽  
...  
Keyword(s):  
Cervical Spondylotic Myelopathy ◽  
Cervical Radiculopathy ◽  
Study Data ◽  
Neurological Injury ◽  
Class Iii ◽  
Cervical Spine Surgery ◽  
Cochrane Database ◽  
Strength Based ◽  
Cervical Degenerative Disease ◽  
Based Medicine

Object The objective of this systematic review was to use evidence-based medicine to examine the diagnostic and therapeutic utility of intraoperative electrophysiological (EP) monitoring in the surgical treatment of cervical degenerative disease. Methods The National Library of Medicine and Cochrane Database were queried using MeSH headings and key words relevant to cervical spine surgery and EP monitoring. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I–III). The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons. Results The reliance on changes in EP monitoring as an indication to alter a surgical plan or administer steroids has not been observed to reduce the incidence of neurological injury during routine surgery for cervical spondylotic myelopathy or cervical radiculopathy (Class III). However, there is an absence of study data examining the benefit of altering a surgical plan due to EP changes. Conclusions Although the use of EP monitoring may serve as a sensitive means to diagnose potential neurological injury during anterior spinal surgery for cervical spondylotic myelopathy, the practitioner must understand that intraoperative EP worsening is not specific—it may not represent clinical worsening and its recognition does not necessarily prevent neurological injury, nor does it result in improved outcome (Class II). Intraoperative improvement in EP parameters/indices does not appear to forecast outcome with reliability (conflicting Class I data).

Functional Outcome after Central Corpectomy in Poor-grade Patients with Cervical Spondylotic Myelopathy or Ossified Posterior Longitudinal Ligament

Neurosurgery ◽  
2005 ◽  
Vol 56 (6) ◽  
pp. 1279-1285 ◽  
Author(s):  
Vedantam Rajshekhar ◽  
G Samson Sujith Kumar
Keyword(s):  
Functional Outcome ◽  
Cervical Spondylotic Myelopathy ◽  
Posterior Longitudinal Ligament ◽  
Outcome Data ◽  
Functional Improvement ◽  
Prognostic Indicators ◽  
Poor Grade ◽  
Grade 5 ◽  
Ossified Posterior Longitudinal Ligament

Abstract OBJECTIVE: We studied the long-term functional outcome in poor-grade patients (Nurick Grades 4 and 5) with cervical spondylotic myelopathy (CSM) or ossified posterior longitudinal ligament after central corpectomy (CC). We sought to determine whether there were any prognostic factors that could predict functional outcome in these patients. METHODS: Functional outcome data were collected for 72 patients (68 men and 4 women; mean age, 49.7 yr; range, 30–67 yr) with CSM (60 patients) or OPLL (12 patients) of Nurick Grades 4 (55 patients) and 5 (17 patients). Uninstrumented CC was performed at 1 level in 12 patients, at 1 level combined with a discoidectomy at another level in 4 patients, at 2 levels in 50 patients, and at 2 levels plus a discoidectomy in 5 patients. The age at presentation (≤50 yr or >50 yr), grade before surgery (4 or 5), the number of levels operated (1 or >1), diagnosis (CSM or ossified posterior longitudinal ligament), and duration of myelopathic symptoms (≤12 mo or >12 mo) were studied for their effect on the functional outcome noted at the last follow-up. Functional outcome was graded as poor (no change in Nurick grade), fair (improvement of one Nurick grade), good (improvement of two Nurick grades), and cure (follow-up Nurick grade of 0 or 1). RESULTS: The follow-up ranged from 9 to 104 months (mean, 36.3 mo). One patient died 3 weeks after CC after surgery for a perforated duodenal ulcer. There was transient operative morbidity in 12 patients (16.9%). The mean Nurick score improved from 4.24 to 2.47 (P < 0.001). Of the 54 patients (76%) who improved in their Nurick grade, the functional outcome was graded as fair in 13 patients (18.3%), good in 24 patients (33.8%), and cure in 17 patients (23.9%). The functional outcome was poor in 17 patients (23.9%). Functional improvement after CC was uniformly correlated with myelopathic symptoms of 12 months' duration or shorter. The other favorable prognostic indicators for improvement after CC were a diagnosis of CSM and preoperative Nurick Grade 5; however, patients with a preoperative Nurick grade of 4 were more likely to experience a cure. CONCLUSION: More than three-fourths of patients with poor-grade CSM improve in their functional status after CC, with nearly 24% of patients obtaining a cure. Because patients with a duration of myelopathic symptoms of 12 months or less had the best functional outcome, early decompressive surgery should be offered to patients with poor-grade CSM.

Anterior cervical surgery for the treatment of cervical degenerative myelopathy

2009 ◽  
Vol 11 (2) ◽  
pp. 170-173 ◽  
Author(s):  
Paul G. Matz ◽  
Langston T. Holly ◽  
Praveen V. Mummaneni ◽  
Paul A. Anderson ◽  
Michael W. Groff ◽  
...  
Keyword(s):  
Systematic Review ◽  
Scale Score ◽  
Japanese Orthopaedic Association ◽  
Consensus Conference ◽  
Surgical Decompression ◽  
Class Iii ◽  
Level Of Evidence ◽  
Nonoperative Therapy ◽  
Cervical Surgery ◽  
Anterior Cervical Surgery

Object The objective of this systematic review was to use evidence-based medicine to examine the efficacy of anterior cervical surgery for the treatment of cervical spondylotic myelopathy (CSM). Methods The National Library of Medicine and Cochrane Database were queried using MeSH headings and key words relevant to anterior cervical surgery and CSM. Abstracts were reviewed, and studies meeting inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I–III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons. Results Mild CSM (modified Japanese Orthopaedic Association [mJOA] scale scores > 12) responds in the short term (3 years) to either surgical decompression or nonoperative therapy (prolonged immobilization in a stiff cervical collar, “low-risk” activity modification or bed rest, and antiinflammatory medications) (Class II). More severe CSM responds to surgical decompression with benefits being maintained a minimum of 5 years and as long as 15 years postoperatively (Class III). Conclusions Treatment of mild CSM may involve surgical decompression or nonoperative therapy for the first 3 years after diagnosis. More severe CSM (mJOA scale score ≤ 12) should be considered for surgery depending upon the individual case. The shortcomings of this systematic review are that the group was not able to determine whether an mJOA scale score of 12 was indicative of a more severe CSM disease course, and whether patients who received nonsurgical treatment for 3 years had a significant probability for clinical deterioration after that time point.

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