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Postoperative three-dimensional cervical range of motion and neurological outcomes in patients with cervical ossification of the posterior longitudinal ligament: Cervical laminoplasty versus laminectomy with fusion
Accepted Manuscript Title: Postoperative three-dimensional cervical range of motion and neurological outcomes in patients with cervical ossification of the posterior longitudinal ligament: cervical laminoplasty versus laminectomy with fusion Author: Wei Yuan Yue Zhu Xinchun Liu Haitao Zhu Xiaoshu Zhou Renyi Zhou Cui Cui Jie Li PII: DOI: Reference:
S0303-8467(15)00126-2 http://dx.doi.org/doi:10.1016/j.clineuro.2015.04.004 CLINEU 4035
To appear in:
Clinical Neurology and Neurosurgery
Received date: Revised date: Accepted date:
29-1-2015 30-3-2015 5-4-2015
Please cite this article as: Yuan W, Zhu Y, Liu X, Zhu H, Zhou X, Zhou R, Cui C, Li J, Postoperative three-dimensional cervical range of motion and neurological outcomes in patients with cervical ossification of the posterior longitudinal ligament: cervical laminoplasty versus laminectomy with fusion, Clinical Neurology and Neurosurgery (2015), http://dx.doi.org/10.1016/j.clineuro.2015.04.004 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1. Laminoplasty preserved more ROM than laminectomy with fusion in all directions except bilateral rotations. 2. Major ROM reduction was observed in extension in both groups. 3. The most preserved ROM was witnessed in rotation in both groups. 4. Both Laminoplasty and laminectomy with fusion provided significant neurologic improvement to
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patients.
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Postoperative three-dimensional cervical range of motion and neurological outcomes in patients with cervical ossification of the posterior longitudinal ligament: cervical laminoplasty versus laminectomy with fusion Abstract Objective
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Laminoplasty (LP) and laminectomy with fusion (LCF) are acceptable surgical options for cervical myelopathy caused by ossification of the posterior longitudinal ligament (OPLL). This study focused
on evaluating cervical range of motion (ROM) on a three-dimensional basis as well as neurological
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outcomes after LP and LCF. Methods
This prospective cohort study consisted of 38 patients undergoing LP (n = 20) or LCF ( n = 18) from
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December 2010 to December 2012. Before surgery and at the 3rd, 6th, 12th month follow-up, patients were assessed with three-dimensional cervical ROM, Japanese Orthopaedic Association (JOA) scores, visual analogue scale (VAS) and complications.
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Results
The patients in both groups had significant ROM loss after surgery in six directions of motion. At the 12th month follow-up, the LP group preserved more ROM than LCF in all directions except bilateral rotations. Major reduction was observed in extension, as with only 59.8% and 54.3% ROM preserved
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in LP and LCF groups. However, the most preserved ROM was witnessed in rotation, especially in the LP group (90.8%). For JOA and VAS, both groups showed significant improvements postoperatively, Conclusions
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and the difference between the two groups was not statistically significant. Patients with OPLL had an obvious reduction in active cervical ROM following LP and LCF. Major
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reduction was observed in extension, and less impact was detected on rotation. Compared with LCF, LP had better ROM preserved. Both LP and LCF provided patients with significant neurological
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improvement.
Key words: cervical range of motion; ossification of the posterior longitudinal ligament; laminoplasty; laminectomy; fusion
1. Introduction
Cervical ossification of the posterior longitudinal ligament (OPLL) is an ectopic ossification, which could exert significant chronic pressure on the spinal cord and lead to myelopathy. Patients with severe progressive myelopathy due to OPLL are generally considered as definitive candidates for surgical treatment[1]. However, with more than three levels involved, increasing complications associated with the anterior surgical approaches, such as fusion failure, adjacent level degeneration, instrumentation failure and dysphagia have been observed[2], yielding the posterior approaches preferable. Posterior approaches, such as laminoplasty (LP) and laminectomy with fusion (LCF), are popular surgical options for cervical OPLL without cervical kyphosis. Laminectomy featured with extensive decompression was initially regarded as the gold standard in treating multilevel cervical myelopathy. However, loss of cervical stability and cervical lordosis after laminectomy has prompted prophylactic fusion of decompressed cervical levels to gain popularity [3].
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LP has been offered as an alternative to these approaches, which could maintain postoperative spine stability by preserving the bony arch and the posterior tension band, hence reducing the incidence of postoperative kyphosis without subjecting the patients to the risks of instrumentation[4]. Satisfactory results from the patients with LP or LCF have been reported throughout the literature[5]. However, the above-mentioned approaches will cause subjective discomfort owing to the limitation of cervical range of motion (ROM) [6,5]. In this case, cervical ROM shall be an important parameter in evaluating the
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effect of surgical treatment.
A number of studies have compared the cervical ROM after LP and LCF focusing on
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two-dimensional motions. However, few studies have analyzed cervical ROM on a three-dimensional
basis. In addition, though several studies have demonstrated favorable neurological recoveries after LP and LCF, the superiority of one over the other is still a subject of controversy. The primary purpose of
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this study was to assess cervical ROM on a three-dimensional basis and to examine the neurological outcomes after LP and LCF.
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2. Materials and Methods 2.1. Patients
This study was a prospective, cohort study of two surgical procedures (LP, LCF) for treating cervical myelopathy caused by OPLL. Inclusion criteria included the following: (1) symptoms of cervical
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myelopathy (mainly manifested with cervical discomfort, restricted cervical ROM, various degrees of limb numbness, decreased muscle tone, impaired fine motor function, unsteady gait, etc.); (2) failed conventional treatments; (3) lordotic sagittal alignment; (4) at least 3 levels of cervical compression
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caused by OPLL with radiographic confirmation. Patients were excluded with the following conditions: (1) myelopathy caused by cervical disc herniation or spondylosis; (2) history of cervical surgery or
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injury; (3) cervical kyphosis; (4) C2 vertebrae involved; (5) neurodegenerative diseases like Parkinson's disease; (6) unstable medical conditions. Consecutive patients who met the above criteria
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and admitted to our hospital between December 2010 and December 2012 were included in this study. Approval has been obtained from the institutional review board of our hospital. 2.2. Surgical Intervention
All operations were performed by the same surgical team. Patients were allocated into two groups (LP, LCF) by the same surgeon by experience: relative indications for LCF included transverse CT scan indicating transverse diameter of heterotopic ossification larger than 1/2 transverse diameter of vertebral posterior edge. LP procedure was performed at C3-C7 levels in our institution. After the spinous processes and laminae of C3-C7 were exposed, a trough was drilled at the junction of the lateral mass and the lamina on the less symptomatic side with a high-speed drill. The contralateral lamina-facet junction was drilled from C3 to C7 down to the ligamentum flavum. The left lamina was conventionally opened and fixed to the contralateral articular capsule with a tread. LCF started with the similar procedure to the LP, but drilling at the gutters was performed bilaterally and the bone was removed completely. Lateral mass screws were placed bilaterally to C3, C5, C7, and were fixed with rods. The autograft was placed posterolaterally. The postoperative cervical collar period was 4 weeks for all the patients. 2.3. ROM Measurement
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The CROM device (Performance Attainment Associates, MN, USA), which has been reported to have good intra-tester and inter-tester reliability, was applied for active cervical ROM measurement [7,8]. It could measure the cervical ROM of flexion, extension, lateral flexion, and rotation with separate inclinometers (Fig. 1). The measurement protocol was set under the CROM device manual (Performance Attainments
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Associates TM). Each patient was asked to sit in a neutral pelvic position with knees vertical to the
floor, feet flat on the floor, and arms resting in lap. The CROM device was placed on the head. For
active movements, the patient was asked to move his head at a steady pace as much as possible, whilst
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keeping back and shoulder still. Movement degrees were recorded when the ROM was stopped by muscle tightness, pain or any substitution movement. Each measurement was performed 3 times and the average data was calculated by one single surgeon before surgery as well as at the 3rd, 6th, and 12th
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month follow-up. 2.4. Neurological Assessment
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Patients were evaluated with Visual Analog Scale score (VAS, score range 0 to 10, with 10 indicating the worst pain), Japanese Orthopedic Association score (JOA), and complications before surgery and at the 3rd, 6th, 12th month follow-up.
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2.5. Statistical methods
SPSS Version 12.0 software (SPSS Inc., Chicago, IL, USA) was applied for statistical analysis. The one-way analysis of variance (ANOVA) was performed to compare ROM, JOA, VAS between LP and
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LCF group, paired t-test was used to compare ROM, JOA, VAS within groups before and after surgery.
3. Results
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3.1. General data
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P value < 0.05 was considered statistically significant.
A total of 38 patients underwent LP or LCF with an average age of 52, among whom 20 patients had continuous OPLL and 13 patients had mixed OPLL. In LP group, there were 20 patients with 14 males and 6 females, with the mean age of 59 and the mean disease duration of 22 months. In LCF group, there were 11 males and 7 females, with the mean age of 62 and the mean disease duration of 18 months. There was no significant difference between groups. The characteristics of the patients were summarized in Table 1. Until the 12th month follow-up, no cervical kyphosis has been observed. The
examples of pre- and post-operative radiological images for each procedure were shown in Fig. 2 and Fig. 3.
3.2. Cervical ROM data The mean ROM decreased significantly in the six directions of motion in both groups at the 12th month follow-up. Significant differences between two groups have been witnessed in all directions except bilateral rotations. The mean ROM increased significantly between the 3rd month and the 12th month after operation in the LP group; while the cervical ROM remained unchanged in the LCF group (Fig. 4). The most preserved ROM was rotation, especially in the LP group (90.8%); while the most lost ROM was extension, as with only 59.8% and 54.3% ROM preserved in LP and LCF groups. The mean values of the preoperative, postoperative cervical ROM and significant difference were listed in Table 2.
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3.3. Neurological outcomes Both groups (LP and CLF) showed significant improvements in their JOA score postoperatively (Fig. 4). In the LP group, the mean JOA score improved from 10.6 before surgery to 13.4 at the 12th month follow-up with a mean recovery rate of 43.7%; while in the LCF group, the mean JOA score improved from 10.6 before surgery to 13.4 at the 12th month follow-up with a mean recovery rate of 50.8%. The
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calculation method of recovery rate is [(postoperative JOA score- preoperative JOA score)/ (17-
preoperative JOA score)]*100%[9].The difference in the postoperative JOA score between the two
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groups was not statistically significant.
Patients reported reduced pain after both procedures. The mean VAS score of the LP group decreased from 4.8 to 1.7, and that of the LCF group decreased from 4.5 to 2.5 twelve months after surgery (Fig.
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5). The difference in the mean VAS score change between the two groups was not statistically significant.
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For both procedures, no death has been observed, and the main complications included C5 palsy and axial symptoms. C5 palsy has been defined as loss of motor strength in the deltoid and/or biceps brachii, sensory deficit or increased pain in the C5 nerve distribution [10]. Axial symptoms have been defined as pain from the nuchal to the periscapular or shoulder region [11]. After surgery, in the LP
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group, we observed one case of post-operative C5 palsy (5%) and three cases of axial symptoms (15%); while in the LCF group, we observed two cases of C5 palsy (11.1%) and four cases of axial symptoms(22.2%). At the 12th month follow-up, all the cases with C5 palsy fully recovered, however,
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only one case of axial symptoms in LCF group showed improvement. The complication rate showed no
4. Discussion
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significant difference between two groups.
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The goals of any treatment of cervical disorders are to restore original living ability, to relieve residual pain, to decrease neurological deficits, to avoid residual deformity and to prevent further disability [12]. Posterior approaches (CLP or LCF) have shown significant neurological outcomes in progressive CSM caused by OPLL with continuous or mixed levels [13,1]. However, complications like decreased ROM, C5 palsy, and axial pain still exist. As an important indicator of cervical disease treatment and postoperative life quality, cervical ROM shall never be overlooked. In the current study, we examined ROM changes on a three-dimensional basis and analyzed neurological function improvement after LP or LCF.
4.1. Cervical ROM
It is particularly challenging to assess cervical ROM accurately due to the complex anatomical structures[14]. So far, cervical ROM can be assessed with a variety of methods, such as visual estimation, tape measurement, CROM device, X-ray, and complex 3-dimensional electromagnetic or audiovisual technologies, which may be more appropriate for pure research purposes [8]. Some researchers believed radiological evaluations to be the gold standard, but it is confined by its two-dimensional measurement. The CROM device has been evaluated with high reliability and validity of three-dimensional cervical ROM measurement and has demonstrated favorable results [8,7]. Furthermore, the CROM device is convenient for clinical application and the patients will not be
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exposed to radiation. Considering the above merits, our clinic chose CROM device to measure three-dimensional cervical ROM. Some authors demonstrated that patients with cervical disorders had less cervical ROM than the normal controls [15,16]. In this study, before surgery, the patients had a lower active cervical ROM compared with the normal controls (Table 3). A possible explanation for this loss of ROM might be that flexion and extension were the mostly affected motions compared with the others.
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multilevel vertebral fusion caused by OPLL would adversely affect intervertebral motion, thus the
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There have been several reports on LP or LCF for OPLL with reduction of ROM in flexion and extension plane. Ratliff and Cooper[17] meta-analyzed more than 2000 patients who were treated with LP, and demonstrated that ROM of the cervical spine decreased by approximately 50% (range,
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20%-70%) compared with the preoperative ROM. In Heller’s study, when compared with LP, LCF achieved intervertebral stability at the expense of losing a greater ROM [18]. In this study, subjects with LP or LCF shared significant ROM loss 3 months after surgery. Although laminoplasty preserved
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more posterior elements than laminectomy with fusion, we believed that it would cause paravertebral muscle dysfunction and neck pain. At the 12th month follow-up, the cervical ROM in the LP group increased significantly compared with the 3rd month, which could facilitate neck muscle recovery and pain relief. In contrary, LCF group remained unchanged due to the bony fusion and posterior
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instrument fixation. Hence, compared with LCF, LP presented more ROM preserved. The most ROM loss was observed in extension; 59.8% and 54.3% of ROM was preserved in LP and LCF group, respectively (Table 2). The ROM loss in LP may be explained by the postoperative bony fusion of the
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laminae, ligment and facet joint[19]. The reason for at least 50% ROM preserved in LCF might be
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attributed to the compensation of occiput-C1-C2 [20]. Fortunately, with regard to the loss of neck motion after LP or LCF, patients might not experience
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difficulties in performing activities of daily living (ADL) as only a proportion (less than 50%) of the full ROM was involved during ADL[21,22]. 4.2. Neurological outcomes
There have been several retrospective compared studies on LP and LCF focusing on neurological
outcomes. Highsmith et al.[23] reported LP with similar improvement in JOA score but significantly lower improvement in VAS score comparing with LCF group. Du et al.[24] reported that JOA score and recovery rate were similar in both groups, but LP group (66.7%) showed higher axial symptom incidence than LCF group (37.5%). Heller et al[18] reported similar Nurick score changes in both groups, but when considering strength, dexterity, sensation, pain, gait and complications, they found that LP might be preferable to LCF. According to a randomized control study[4], improvements in the mJOA, VAS, complications were similar in both groups, while Nurick grade for the LP group was statistically significant. But the limited number of patients in each treatment arm might weaken the strength of the study. In this study, both LP and LCF were proved to be safe and effective options. Improvements in JOA and VAS score were observed similarly in both groups. LCF group showed higher JOA recovery rate (50.8%) than LP (43.7%) at the last follow-up, and we proposed that LCF could yield larger
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postoperative spinal cord area, which was conductive to JOA recovery. Furthermore, some authors found a positive correlation between spinal cord area and the JOA scale[25]. C5 palsy (5% in LP vs 11.1% in LCF) and axial symptoms (15% in LP vs 16.7% in LCF) were the main complications in this study. The incidence of C5 palsy was higher in LCF group presumably because laminectomy would provide an excessive space for the spinal cord to shift posteriorly. The patients with C5 palsy showed significant recovery with conservative treatment at the 12th month follow-up. By contrast, axial
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symptoms showed no obvious improvement, possibly due to the ROM reduction caused by the damage of the cervical structure and posterior muscles[26] through LP and LCF procedures. However, the
primary cause of postoperative axial symptoms and the exact mechanism have been unclear and need
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further research.
There were several limitations in this study. Although a standardized cervical ROM measurement
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protocol was applied, the results might be influenced by movement of the upper thoracic spine. Since the number of participants was limited within one single institute, we could not take factors like age and gender into consideration, which may also affect the cervical ROM[27], thus influencing its
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statistical power. Furthermore, longer follow-up studies shall be conducted in the future to observe the changes with time. 5. Conclusion
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This study demonstrated that patients with OPLL had an obvious reduction in active cervical ROM following LP and LCF. Major reduction was observed in extension, and less impact was detected on rotation. Compared with LCF, LP had better ROM preserved. Both LP and LCF provided patients with
References
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Conflict of interest: None
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significant neurological improvement.
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1. Mochizuki M, Aiba A, Hashimoto M, Fujiyoshi T, Yamazaki M (2009) Cervical myelopathy in patients with ossification of the posterior longitudinal ligament. J Neurosurg Spine 10 (2):122-128. doi:10.3171/2008.10.SPI08480
2. 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 3. Kumar VG, Rea GL, Mervis LJ, McGregor JM (1999) Cervical spondylotic myelopathy: functional and radiographic long-term outcome after laminectomy and posterior fusion. Neurosurgery 44 (4):771-777; discussion 777-778
4. Manzano GR, Casella G, Wang MY, Vanni S, Levi AD (2012) A prospective, randomized trial comparing expansile cervical laminoplasty and cervical laminectomy and fusion for multilevel cervical myelopathy. Neurosurgery 70 (2):264-277. doi:10.1227/NEU.0b013e3182305669 5. Lee CH, Jahng TA, Hyun SJ, Kim KJ, Kim HJ (2014) Expansive Laminoplasty Versus Laminectomy Alone Versus Laminectomy and Fusion for Cervical Ossification of the Posterior Longitudinal Ligament: Is There a Difference in the Clinical Outcome and Sagittal Alignment? J Spinal Disord Tech. doi:10.1097/BSD.0000000000000058 6. Yuan W, Zhu Y, Liu X, Zhou X, Cui C (2014) Laminoplasty versus skip laminectomy for the treatment
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of multilevel cervical spondylotic myelopathy: a systematic review. Arch Orthop Trauma Surg 134 (1):1-7. doi:10.1007/s00402-013-1881-8 7. de Koning CH, van den Heuvel SP, Staal JB, Smits-Engelsman BC, Hendriks EJ (2008) Clinimetric evaluation of active range of motion measures in patients with non-specific neck pain: a systematic review. Eur Spine J 17 (7):905-921. doi:10.1007/s00586-008-0656-3 8. Williams MA, McCarthy CJ, Chorti A, Cooke MW, Gates S (2010) A systematic review of reliability
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9. Hirabayashi K, Miyakawa J, Satomi K, Maruyama T, Wakano K (1981) Operative results and
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palsy after multilevel cervical decompression procedures: a review of 750 consecutive cases. Spine (Phila Pa 1976) 37 (3):174-178. doi:10.1097/BRS.0b013e318219cfe9
11. Kawaguchi Y, Matsui H, Ishihara H, Gejo R, Yoshino O (1999) Axial symptoms after en bloc cervical
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laminoplasty. J Spinal Disord 12 (5):392-395
12. Aebi M (2010) Surgical treatment of upper, middle and lower cervical injuries and non-unions by anterior procedures. Eur Spine J 19 Suppl 1:S33-39. doi:10.1007/s00586-009-1120-8 13. Smith ZA, Buchanan CC, Raphael D, Khoo LT (2011) Ossification of the posterior longitudinal (3):E10. doi:10.3171/2011.1.FOCUS10256
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ligament: pathogenesis, management, and current surgical approaches. A review. Neurosurg Focus 30 14. McDonald CP, Bachison CC, Chang V, Bartol SW, Bey MJ (2010) Three-dimensional dynamic in vivo
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motion of the cervical spine: assessment of measurement accuracy and preliminary findings. Spine J 10 (6):497-504. doi:10.1016/j.spinee.2010.02.024
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15. Dvir Z, Gal-Eshel N, Shamir B, Prushansky T, Pevzner E, Peretz C (2006) Cervical motion in patients with chronic disorders of the cervical spine: a reproducibility study. Spine (Phila Pa 1976) 31 (13):E394-399. doi:10.1097/01.brs.0000219951.79922.df
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16. Simpson AK, Biswas D, Emerson JW, Lawrence BD, Grauer JN (2008) Quantifying the effects of age, gender, degeneration, and adjacent level degeneration on cervical spine range of motion using multivariate analyses. Spine (Phila Pa 1976) 33 (2):183-186. doi:10.1097/BRS.0b013e31816044e8 17. Ratliff JK, Cooper PR (2003) Cervical laminoplasty: a critical review. J Neurosurg 98 (3 Suppl):230-238
18. Heller JG, Edwards CC, 2nd, Murakami H, Rodts GE (2001) Laminoplasty versus laminectomy and fusion for multilevel cervical myelopathy: an independent matched cohort analysis. Spine (Phila Pa 1976) 26 (12):1330-1336
19. Hyun SJ, Riew KD, Rhim SC (2013) Range of motion loss after cervical laminoplasty: a prospective study with minimum 5-year follow-up data. Spine J 13 (4):384-390. doi:10.1016/j.spinee.2012.10.037 20. Park MS, Mesfin A, Stoker GE, Song KS, Kennedy C, Riew KD (2014) Sagittal range of motion after extensive cervical fusion. Spine J 14 (2):338-343. doi:10.1016/j.spinee.2013.06.072 21. Bennett SE, Schenk RJ, Simmons ED (2002) Active range of motion utilized in the cervical spine to perform daily functional tasks. J Spinal Disord Tech 15 (4):307-311 22. Bible JE, Biswas D, Miller CP, Whang PG, Grauer JN (2010) Normal functional range of motion of the cervical spine during 15 activities of daily living. J Spinal Disord Tech 23 (1):15-21. doi:10.1097/BSD.0b013e3181981632
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23. Highsmith JM, Dhall SS, Haid RW, Jr., Rodts GE, Jr., Mummaneni PV (2011) Treatment of cervical stenotic myelopathy: a cost and outcome comparison of laminoplasty versus laminectomy and lateral mass fusion. J Neurosurg Spine 14 (5):619-625. doi:10.3171/2011.1.SPINE10206 24. Du W, Wang L, Shen Y, Zhang Y, Ding W, Ren L (2013) Long-term impacts of different posterior operations on curvature, neurological recovery and axial symptoms for multilevel cervical degenerative myelopathy. Eur Spine J 22 (7):1594-1602. doi:10.1007/s00586-013-2741-5
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25. Houten JK, Cooper PR (2003) Laminectomy and posterior cervical plating for multilevel cervical
spondylotic myelopathy and ossification of the posterior longitudinal ligament: effects on cervical
alignment, spinal cord compression, and neurological outcome. Neurosurgery 52 (5):1081-1087;
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discussion 1087-1088
26. Wang SJ, Jiang SD, Jiang LS, Dai LY (2011) Axial pain after posterior cervical spine surgery: a systematic review. Eur Spine J 20 (2):185-194. doi:10.1007/s00586-010-1600-x
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27. Lansade C, Laporte S, Thoreux P, Rousseau MA, Skalli W, Lavaste F (2009) Three-dimensional analysis of the cervical spine kinematics: effect of age and gender in healthy subjects. Spine (Phila Pa
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1976) 34 (26):2900-2906. doi:10.1097/BRS.0b013e3181b4f667
Figure legends
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Fig. 1 The CROM device with magnetic yoke
Fig. 2 Radiological images of LP procedure. The sagittal CT scan showed continuous type of OPLL(a), and the sagittal MRI scan showed compression of spinal cord(b). The postoperative 3D-CT scan
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showed open door of LP(c), the postoperative sagittal MRI scan showed posterior shift of spinal cord.
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Fig. 3 Radiological images of LCF procedure. The X-ray and sagittal CT scan showed mixed type of OPLL(a), and the sagittal MRI scan showed compression of spinal cord(b). The postoperative X-ray
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showed instrumentation fixation of LCF(c), the postoperative sagittal MRI scan showed posterior shift of spinal cord.
Fig. 4 The mean cervical ROM decreased significantly after surgery in the six directions of motion in both groups at the 12th month follow-up. Compared with the LP group, the cervical ROM remained
unchanged in the LCF group between the 3rd month and the 12th month after operation; LP preserved
more ROM than LCF (a-f). ROM lost most in extension (b), and ROM preserved most in rotation (e, f). Fig. 5 JOA score was significantly improved in both groups (LP and CLF). Fig. 6 VAS was significantly improved in both groups (LP and CLF), and LP group showed better recovery.
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Table 1. General data LP
LCF
P value
Number
20
18
Age(year SD)
59(11.6)
62(13.1)
Gender
14M/6F
11M/7F
Disease duration
22(12.4)
18(9.3)
P<0.05
P<0.05 10 continuous(55.6%)
7 mixed(35%)
6 mixed(33.3%)
3 segmental(15%)
2 segmental(11.1%)
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10 continuous(50%)
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OPLL type
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P<0.05
(month SD)
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Table 2 The mean values and the standard deviations of the preoperative and postoperative cervical ROM data Flexion
Extension
Left
Right
Left
Right
flexion
flexion
rotation
rotation
39.4±6.8
50.8±8.3
40.9±5.3
42.3±3.9
56.4±8.6
57.6±5.9
LCF
40.7±5.8
48.4±8.9
43.1±4
43.5±5.6
58.5±8.5
59.6±7.5
Posto3m
LP
24.7±5.5
22.9±3.7
27.8±6.7
26.3±6.2
48.3±6.6
47.3±5.5
LCF
20.6±3.5
23.5±5.8
26.1±6.8
26.8±6.9
45.3±7.1
46.1±8.3
Posto6m
LP
28.1±4.5
31.1±5.3
29.6±5.1
30.1±6.1
45.9±6.1
49.2±5.8
LCF
19.5±3.3
24.6±5.2
26.7±6
28±5.6
46.4±5.9
47.9±8.1
LP
29.6±7.1*#
30.4±5.9*#
33.1±5.2*#
32.2±4.5*#
LCF
52.3±4.8*
47.1±6.8*
48.9±7.1*
22.9±5.6*△
26.3±5.2*△
27.5±5.8*△
26.9±4.2*△
LP
75.1%
59.8%
80.9%
76.1%
89.4%
90.8%
LCF
56.2%
54.3%
63.8%
61.8%
81.1%
82.0%
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%
50.4±6.5*
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ROM preservation
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Posto12m
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LP
Preop
ROM preservation %= Posto12m ROM/Preo ROM.
*p<0.05 present the significant between 12th month follow up and preoperation.
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#p<0.05 present the significant between 12th month follow up and 3rd month follow up.
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△p<0.05 present the significant between LP group and LCF group at 12th month follow up.
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Table 3 The cervical ROM data of OPLL patients in this study and normal data in previous study Flexion
Extension
Left
Right
Left
Right
flexion
flexion
rotation
rotation
OPLL
40.1±6.2
49.7±8.5
42.1±4.5
42.9±4.2
57.5±8.6
58.6±6.6
Normal
49.1±5.8
62.7±10.6
45.5±5.6
46.1±7.6
63.7±7.4
63.5±6.5
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The normal data were quoted from the paper by *[ ].
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Figure 1
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Our reference: CLINEU 4035 Editorial reference: CLINEU_CNN-D-15-126 To be published in: Clinical Neurology and Neurosurgery Postoperative three-dimensional cervical range of motion and neurological outcomes in patients with cervical ossification of the posterior longitudinal ligament: cervical laminoplasty versus laminectomy
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with fusion
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List of Authors： Wei Yuan, Yue Zhu, Xinchun Liu, Haitao Zhu, Xiaoshu Zhou, Renyi Zhou, Cui Cui, Jie Li Affiliations:
Department of Orthopedics, First Hospital of China Medical University.
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No. 155 Nanjing Bei Street, Heping District, Shenyang City, Liaoning Province, China.
Correspondence author:
Email: [email protected] Tel: +86-02483283360
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Fax: +86-02483282772
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Mobile phone: +86-13940227775
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Yue Zhu, M.D., Ph D
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S0303-8467(15)00126-2 http://dx.doi.org/doi:10.1016/j.clineuro.2015.04.004 CLINEU 4035
To appear in:
Clinical Neurology and Neurosurgery
Received date: Revised date: Accepted date:
29-1-2015 30-3-2015 5-4-2015
Please cite this article as: Yuan W, Zhu Y, Liu X, Zhu H, Zhou X, Zhou R, Cui C, Li J, Postoperative three-dimensional cervical range of motion and neurological outcomes in patients with cervical ossification of the posterior longitudinal ligament: cervical laminoplasty versus laminectomy with fusion, Clinical Neurology and Neurosurgery (2015), http://dx.doi.org/10.1016/j.clineuro.2015.04.004 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1. Laminoplasty preserved more ROM than laminectomy with fusion in all directions except bilateral rotations. 2. Major ROM reduction was observed in extension in both groups. 3. The most preserved ROM was witnessed in rotation in both groups. 4. Both Laminoplasty and laminectomy with fusion provided significant neurologic improvement to
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patients.
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Postoperative three-dimensional cervical range of motion and neurological outcomes in patients with cervical ossification of the posterior longitudinal ligament: cervical laminoplasty versus laminectomy with fusion Abstract Objective
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Laminoplasty (LP) and laminectomy with fusion (LCF) are acceptable surgical options for cervical myelopathy caused by ossification of the posterior longitudinal ligament (OPLL). This study focused
on evaluating cervical range of motion (ROM) on a three-dimensional basis as well as neurological
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outcomes after LP and LCF. Methods
This prospective cohort study consisted of 38 patients undergoing LP (n = 20) or LCF ( n = 18) from
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December 2010 to December 2012. Before surgery and at the 3rd, 6th, 12th month follow-up, patients were assessed with three-dimensional cervical ROM, Japanese Orthopaedic Association (JOA) scores, visual analogue scale (VAS) and complications.
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Results
The patients in both groups had significant ROM loss after surgery in six directions of motion. At the 12th month follow-up, the LP group preserved more ROM than LCF in all directions except bilateral rotations. Major reduction was observed in extension, as with only 59.8% and 54.3% ROM preserved
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in LP and LCF groups. However, the most preserved ROM was witnessed in rotation, especially in the LP group (90.8%). For JOA and VAS, both groups showed significant improvements postoperatively, Conclusions
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and the difference between the two groups was not statistically significant. Patients with OPLL had an obvious reduction in active cervical ROM following LP and LCF. Major
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reduction was observed in extension, and less impact was detected on rotation. Compared with LCF, LP had better ROM preserved. Both LP and LCF provided patients with significant neurological
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improvement.
Key words: cervical range of motion; ossification of the posterior longitudinal ligament; laminoplasty; laminectomy; fusion
1. Introduction
Cervical ossification of the posterior longitudinal ligament (OPLL) is an ectopic ossification, which could exert significant chronic pressure on the spinal cord and lead to myelopathy. Patients with severe progressive myelopathy due to OPLL are generally considered as definitive candidates for surgical treatment[1]. However, with more than three levels involved, increasing complications associated with the anterior surgical approaches, such as fusion failure, adjacent level degeneration, instrumentation failure and dysphagia have been observed[2], yielding the posterior approaches preferable. Posterior approaches, such as laminoplasty (LP) and laminectomy with fusion (LCF), are popular surgical options for cervical OPLL without cervical kyphosis. Laminectomy featured with extensive decompression was initially regarded as the gold standard in treating multilevel cervical myelopathy. However, loss of cervical stability and cervical lordosis after laminectomy has prompted prophylactic fusion of decompressed cervical levels to gain popularity [3].
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LP has been offered as an alternative to these approaches, which could maintain postoperative spine stability by preserving the bony arch and the posterior tension band, hence reducing the incidence of postoperative kyphosis without subjecting the patients to the risks of instrumentation[4]. Satisfactory results from the patients with LP or LCF have been reported throughout the literature[5]. However, the above-mentioned approaches will cause subjective discomfort owing to the limitation of cervical range of motion (ROM) [6,5]. In this case, cervical ROM shall be an important parameter in evaluating the
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effect of surgical treatment.
A number of studies have compared the cervical ROM after LP and LCF focusing on
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two-dimensional motions. However, few studies have analyzed cervical ROM on a three-dimensional
basis. In addition, though several studies have demonstrated favorable neurological recoveries after LP and LCF, the superiority of one over the other is still a subject of controversy. The primary purpose of
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this study was to assess cervical ROM on a three-dimensional basis and to examine the neurological outcomes after LP and LCF.
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2. Materials and Methods 2.1. Patients
This study was a prospective, cohort study of two surgical procedures (LP, LCF) for treating cervical myelopathy caused by OPLL. Inclusion criteria included the following: (1) symptoms of cervical
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myelopathy (mainly manifested with cervical discomfort, restricted cervical ROM, various degrees of limb numbness, decreased muscle tone, impaired fine motor function, unsteady gait, etc.); (2) failed conventional treatments; (3) lordotic sagittal alignment; (4) at least 3 levels of cervical compression
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caused by OPLL with radiographic confirmation. Patients were excluded with the following conditions: (1) myelopathy caused by cervical disc herniation or spondylosis; (2) history of cervical surgery or
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injury; (3) cervical kyphosis; (4) C2 vertebrae involved; (5) neurodegenerative diseases like Parkinson's disease; (6) unstable medical conditions. Consecutive patients who met the above criteria
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and admitted to our hospital between December 2010 and December 2012 were included in this study. Approval has been obtained from the institutional review board of our hospital. 2.2. Surgical Intervention
All operations were performed by the same surgical team. Patients were allocated into two groups (LP, LCF) by the same surgeon by experience: relative indications for LCF included transverse CT scan indicating transverse diameter of heterotopic ossification larger than 1/2 transverse diameter of vertebral posterior edge. LP procedure was performed at C3-C7 levels in our institution. After the spinous processes and laminae of C3-C7 were exposed, a trough was drilled at the junction of the lateral mass and the lamina on the less symptomatic side with a high-speed drill. The contralateral lamina-facet junction was drilled from C3 to C7 down to the ligamentum flavum. The left lamina was conventionally opened and fixed to the contralateral articular capsule with a tread. LCF started with the similar procedure to the LP, but drilling at the gutters was performed bilaterally and the bone was removed completely. Lateral mass screws were placed bilaterally to C3, C5, C7, and were fixed with rods. The autograft was placed posterolaterally. The postoperative cervical collar period was 4 weeks for all the patients. 2.3. ROM Measurement
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The CROM device (Performance Attainment Associates, MN, USA), which has been reported to have good intra-tester and inter-tester reliability, was applied for active cervical ROM measurement [7,8]. It could measure the cervical ROM of flexion, extension, lateral flexion, and rotation with separate inclinometers (Fig. 1). The measurement protocol was set under the CROM device manual (Performance Attainments
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Associates TM). Each patient was asked to sit in a neutral pelvic position with knees vertical to the
floor, feet flat on the floor, and arms resting in lap. The CROM device was placed on the head. For
active movements, the patient was asked to move his head at a steady pace as much as possible, whilst
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keeping back and shoulder still. Movement degrees were recorded when the ROM was stopped by muscle tightness, pain or any substitution movement. Each measurement was performed 3 times and the average data was calculated by one single surgeon before surgery as well as at the 3rd, 6th, and 12th
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month follow-up. 2.4. Neurological Assessment
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Patients were evaluated with Visual Analog Scale score (VAS, score range 0 to 10, with 10 indicating the worst pain), Japanese Orthopedic Association score (JOA), and complications before surgery and at the 3rd, 6th, 12th month follow-up.
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2.5. Statistical methods
SPSS Version 12.0 software (SPSS Inc., Chicago, IL, USA) was applied for statistical analysis. The one-way analysis of variance (ANOVA) was performed to compare ROM, JOA, VAS between LP and
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LCF group, paired t-test was used to compare ROM, JOA, VAS within groups before and after surgery.
3. Results
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3.1. General data
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P value < 0.05 was considered statistically significant.
A total of 38 patients underwent LP or LCF with an average age of 52, among whom 20 patients had continuous OPLL and 13 patients had mixed OPLL. In LP group, there were 20 patients with 14 males and 6 females, with the mean age of 59 and the mean disease duration of 22 months. In LCF group, there were 11 males and 7 females, with the mean age of 62 and the mean disease duration of 18 months. There was no significant difference between groups. The characteristics of the patients were summarized in Table 1. Until the 12th month follow-up, no cervical kyphosis has been observed. The
examples of pre- and post-operative radiological images for each procedure were shown in Fig. 2 and Fig. 3.
3.2. Cervical ROM data The mean ROM decreased significantly in the six directions of motion in both groups at the 12th month follow-up. Significant differences between two groups have been witnessed in all directions except bilateral rotations. The mean ROM increased significantly between the 3rd month and the 12th month after operation in the LP group; while the cervical ROM remained unchanged in the LCF group (Fig. 4). The most preserved ROM was rotation, especially in the LP group (90.8%); while the most lost ROM was extension, as with only 59.8% and 54.3% ROM preserved in LP and LCF groups. The mean values of the preoperative, postoperative cervical ROM and significant difference were listed in Table 2.
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3.3. Neurological outcomes Both groups (LP and CLF) showed significant improvements in their JOA score postoperatively (Fig. 4). In the LP group, the mean JOA score improved from 10.6 before surgery to 13.4 at the 12th month follow-up with a mean recovery rate of 43.7%; while in the LCF group, the mean JOA score improved from 10.6 before surgery to 13.4 at the 12th month follow-up with a mean recovery rate of 50.8%. The
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calculation method of recovery rate is [(postoperative JOA score- preoperative JOA score)/ (17-
preoperative JOA score)]*100%[9].The difference in the postoperative JOA score between the two
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groups was not statistically significant.
Patients reported reduced pain after both procedures. The mean VAS score of the LP group decreased from 4.8 to 1.7, and that of the LCF group decreased from 4.5 to 2.5 twelve months after surgery (Fig.
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5). The difference in the mean VAS score change between the two groups was not statistically significant.
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For both procedures, no death has been observed, and the main complications included C5 palsy and axial symptoms. C5 palsy has been defined as loss of motor strength in the deltoid and/or biceps brachii, sensory deficit or increased pain in the C5 nerve distribution [10]. Axial symptoms have been defined as pain from the nuchal to the periscapular or shoulder region [11]. After surgery, in the LP
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group, we observed one case of post-operative C5 palsy (5%) and three cases of axial symptoms (15%); while in the LCF group, we observed two cases of C5 palsy (11.1%) and four cases of axial symptoms(22.2%). At the 12th month follow-up, all the cases with C5 palsy fully recovered, however,
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only one case of axial symptoms in LCF group showed improvement. The complication rate showed no
4. Discussion
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significant difference between two groups.
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The goals of any treatment of cervical disorders are to restore original living ability, to relieve residual pain, to decrease neurological deficits, to avoid residual deformity and to prevent further disability [12]. Posterior approaches (CLP or LCF) have shown significant neurological outcomes in progressive CSM caused by OPLL with continuous or mixed levels [13,1]. However, complications like decreased ROM, C5 palsy, and axial pain still exist. As an important indicator of cervical disease treatment and postoperative life quality, cervical ROM shall never be overlooked. In the current study, we examined ROM changes on a three-dimensional basis and analyzed neurological function improvement after LP or LCF.
4.1. Cervical ROM
It is particularly challenging to assess cervical ROM accurately due to the complex anatomical structures[14]. So far, cervical ROM can be assessed with a variety of methods, such as visual estimation, tape measurement, CROM device, X-ray, and complex 3-dimensional electromagnetic or audiovisual technologies, which may be more appropriate for pure research purposes [8]. Some researchers believed radiological evaluations to be the gold standard, but it is confined by its two-dimensional measurement. The CROM device has been evaluated with high reliability and validity of three-dimensional cervical ROM measurement and has demonstrated favorable results [8,7]. Furthermore, the CROM device is convenient for clinical application and the patients will not be
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exposed to radiation. Considering the above merits, our clinic chose CROM device to measure three-dimensional cervical ROM. Some authors demonstrated that patients with cervical disorders had less cervical ROM than the normal controls [15,16]. In this study, before surgery, the patients had a lower active cervical ROM compared with the normal controls (Table 3). A possible explanation for this loss of ROM might be that flexion and extension were the mostly affected motions compared with the others.
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multilevel vertebral fusion caused by OPLL would adversely affect intervertebral motion, thus the
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There have been several reports on LP or LCF for OPLL with reduction of ROM in flexion and extension plane. Ratliff and Cooper[17] meta-analyzed more than 2000 patients who were treated with LP, and demonstrated that ROM of the cervical spine decreased by approximately 50% (range,
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20%-70%) compared with the preoperative ROM. In Heller’s study, when compared with LP, LCF achieved intervertebral stability at the expense of losing a greater ROM [18]. In this study, subjects with LP or LCF shared significant ROM loss 3 months after surgery. Although laminoplasty preserved
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more posterior elements than laminectomy with fusion, we believed that it would cause paravertebral muscle dysfunction and neck pain. At the 12th month follow-up, the cervical ROM in the LP group increased significantly compared with the 3rd month, which could facilitate neck muscle recovery and pain relief. In contrary, LCF group remained unchanged due to the bony fusion and posterior
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instrument fixation. Hence, compared with LCF, LP presented more ROM preserved. The most ROM loss was observed in extension; 59.8% and 54.3% of ROM was preserved in LP and LCF group, respectively (Table 2). The ROM loss in LP may be explained by the postoperative bony fusion of the
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laminae, ligment and facet joint[19]. The reason for at least 50% ROM preserved in LCF might be
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attributed to the compensation of occiput-C1-C2 [20]. Fortunately, with regard to the loss of neck motion after LP or LCF, patients might not experience
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difficulties in performing activities of daily living (ADL) as only a proportion (less than 50%) of the full ROM was involved during ADL[21,22]. 4.2. Neurological outcomes
There have been several retrospective compared studies on LP and LCF focusing on neurological
outcomes. Highsmith et al.[23] reported LP with similar improvement in JOA score but significantly lower improvement in VAS score comparing with LCF group. Du et al.[24] reported that JOA score and recovery rate were similar in both groups, but LP group (66.7%) showed higher axial symptom incidence than LCF group (37.5%). Heller et al[18] reported similar Nurick score changes in both groups, but when considering strength, dexterity, sensation, pain, gait and complications, they found that LP might be preferable to LCF. According to a randomized control study[4], improvements in the mJOA, VAS, complications were similar in both groups, while Nurick grade for the LP group was statistically significant. But the limited number of patients in each treatment arm might weaken the strength of the study. In this study, both LP and LCF were proved to be safe and effective options. Improvements in JOA and VAS score were observed similarly in both groups. LCF group showed higher JOA recovery rate (50.8%) than LP (43.7%) at the last follow-up, and we proposed that LCF could yield larger
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postoperative spinal cord area, which was conductive to JOA recovery. Furthermore, some authors found a positive correlation between spinal cord area and the JOA scale[25]. C5 palsy (5% in LP vs 11.1% in LCF) and axial symptoms (15% in LP vs 16.7% in LCF) were the main complications in this study. The incidence of C5 palsy was higher in LCF group presumably because laminectomy would provide an excessive space for the spinal cord to shift posteriorly. The patients with C5 palsy showed significant recovery with conservative treatment at the 12th month follow-up. By contrast, axial
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symptoms showed no obvious improvement, possibly due to the ROM reduction caused by the damage of the cervical structure and posterior muscles[26] through LP and LCF procedures. However, the
primary cause of postoperative axial symptoms and the exact mechanism have been unclear and need
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further research.
There were several limitations in this study. Although a standardized cervical ROM measurement
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protocol was applied, the results might be influenced by movement of the upper thoracic spine. Since the number of participants was limited within one single institute, we could not take factors like age and gender into consideration, which may also affect the cervical ROM[27], thus influencing its
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statistical power. Furthermore, longer follow-up studies shall be conducted in the future to observe the changes with time. 5. Conclusion
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This study demonstrated that patients with OPLL had an obvious reduction in active cervical ROM following LP and LCF. Major reduction was observed in extension, and less impact was detected on rotation. Compared with LCF, LP had better ROM preserved. Both LP and LCF provided patients with
References
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Conflict of interest: None
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significant neurological improvement.
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1. Mochizuki M, Aiba A, Hashimoto M, Fujiyoshi T, Yamazaki M (2009) Cervical myelopathy in patients with ossification of the posterior longitudinal ligament. J Neurosurg Spine 10 (2):122-128. doi:10.3171/2008.10.SPI08480
2. 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 3. Kumar VG, Rea GL, Mervis LJ, McGregor JM (1999) Cervical spondylotic myelopathy: functional and radiographic long-term outcome after laminectomy and posterior fusion. Neurosurgery 44 (4):771-777; discussion 777-778
4. Manzano GR, Casella G, Wang MY, Vanni S, Levi AD (2012) A prospective, randomized trial comparing expansile cervical laminoplasty and cervical laminectomy and fusion for multilevel cervical myelopathy. Neurosurgery 70 (2):264-277. doi:10.1227/NEU.0b013e3182305669 5. Lee CH, Jahng TA, Hyun SJ, Kim KJ, Kim HJ (2014) Expansive Laminoplasty Versus Laminectomy Alone Versus Laminectomy and Fusion for Cervical Ossification of the Posterior Longitudinal Ligament: Is There a Difference in the Clinical Outcome and Sagittal Alignment? J Spinal Disord Tech. doi:10.1097/BSD.0000000000000058 6. Yuan W, Zhu Y, Liu X, Zhou X, Cui C (2014) Laminoplasty versus skip laminectomy for the treatment
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of multilevel cervical spondylotic myelopathy: a systematic review. Arch Orthop Trauma Surg 134 (1):1-7. doi:10.1007/s00402-013-1881-8 7. de Koning CH, van den Heuvel SP, Staal JB, Smits-Engelsman BC, Hendriks EJ (2008) Clinimetric evaluation of active range of motion measures in patients with non-specific neck pain: a systematic review. Eur Spine J 17 (7):905-921. doi:10.1007/s00586-008-0656-3 8. Williams MA, McCarthy CJ, Chorti A, Cooke MW, Gates S (2010) A systematic review of reliability
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9. Hirabayashi K, Miyakawa J, Satomi K, Maruyama T, Wakano K (1981) Operative results and
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postoperative progression of ossification among patients with ossification of cervical posterior longitudinal ligament. Spine (Phila Pa 1976) 6 (4):354-364
10. Nassr A, Eck JC, Ponnappan RK, Zanoun RR, Donaldson WF, 3rd, Kang JD (2012) The incidence of C5
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palsy after multilevel cervical decompression procedures: a review of 750 consecutive cases. Spine (Phila Pa 1976) 37 (3):174-178. doi:10.1097/BRS.0b013e318219cfe9
11. Kawaguchi Y, Matsui H, Ishihara H, Gejo R, Yoshino O (1999) Axial symptoms after en bloc cervical
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laminoplasty. J Spinal Disord 12 (5):392-395
12. Aebi M (2010) Surgical treatment of upper, middle and lower cervical injuries and non-unions by anterior procedures. Eur Spine J 19 Suppl 1:S33-39. doi:10.1007/s00586-009-1120-8 13. Smith ZA, Buchanan CC, Raphael D, Khoo LT (2011) Ossification of the posterior longitudinal (3):E10. doi:10.3171/2011.1.FOCUS10256
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ligament: pathogenesis, management, and current surgical approaches. A review. Neurosurg Focus 30 14. McDonald CP, Bachison CC, Chang V, Bartol SW, Bey MJ (2010) Three-dimensional dynamic in vivo
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motion of the cervical spine: assessment of measurement accuracy and preliminary findings. Spine J 10 (6):497-504. doi:10.1016/j.spinee.2010.02.024
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15. Dvir Z, Gal-Eshel N, Shamir B, Prushansky T, Pevzner E, Peretz C (2006) Cervical motion in patients with chronic disorders of the cervical spine: a reproducibility study. Spine (Phila Pa 1976) 31 (13):E394-399. doi:10.1097/01.brs.0000219951.79922.df
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16. Simpson AK, Biswas D, Emerson JW, Lawrence BD, Grauer JN (2008) Quantifying the effects of age, gender, degeneration, and adjacent level degeneration on cervical spine range of motion using multivariate analyses. Spine (Phila Pa 1976) 33 (2):183-186. doi:10.1097/BRS.0b013e31816044e8 17. Ratliff JK, Cooper PR (2003) Cervical laminoplasty: a critical review. J Neurosurg 98 (3 Suppl):230-238
18. Heller JG, Edwards CC, 2nd, Murakami H, Rodts GE (2001) Laminoplasty versus laminectomy and fusion for multilevel cervical myelopathy: an independent matched cohort analysis. Spine (Phila Pa 1976) 26 (12):1330-1336
19. Hyun SJ, Riew KD, Rhim SC (2013) Range of motion loss after cervical laminoplasty: a prospective study with minimum 5-year follow-up data. Spine J 13 (4):384-390. doi:10.1016/j.spinee.2012.10.037 20. Park MS, Mesfin A, Stoker GE, Song KS, Kennedy C, Riew KD (2014) Sagittal range of motion after extensive cervical fusion. Spine J 14 (2):338-343. doi:10.1016/j.spinee.2013.06.072 21. Bennett SE, Schenk RJ, Simmons ED (2002) Active range of motion utilized in the cervical spine to perform daily functional tasks. J Spinal Disord Tech 15 (4):307-311 22. Bible JE, Biswas D, Miller CP, Whang PG, Grauer JN (2010) Normal functional range of motion of the cervical spine during 15 activities of daily living. J Spinal Disord Tech 23 (1):15-21. doi:10.1097/BSD.0b013e3181981632
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23. Highsmith JM, Dhall SS, Haid RW, Jr., Rodts GE, Jr., Mummaneni PV (2011) Treatment of cervical stenotic myelopathy: a cost and outcome comparison of laminoplasty versus laminectomy and lateral mass fusion. J Neurosurg Spine 14 (5):619-625. doi:10.3171/2011.1.SPINE10206 24. Du W, Wang L, Shen Y, Zhang Y, Ding W, Ren L (2013) Long-term impacts of different posterior operations on curvature, neurological recovery and axial symptoms for multilevel cervical degenerative myelopathy. Eur Spine J 22 (7):1594-1602. doi:10.1007/s00586-013-2741-5
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25. Houten JK, Cooper PR (2003) Laminectomy and posterior cervical plating for multilevel cervical
spondylotic myelopathy and ossification of the posterior longitudinal ligament: effects on cervical
alignment, spinal cord compression, and neurological outcome. Neurosurgery 52 (5):1081-1087;
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discussion 1087-1088
26. Wang SJ, Jiang SD, Jiang LS, Dai LY (2011) Axial pain after posterior cervical spine surgery: a systematic review. Eur Spine J 20 (2):185-194. doi:10.1007/s00586-010-1600-x
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27. Lansade C, Laporte S, Thoreux P, Rousseau MA, Skalli W, Lavaste F (2009) Three-dimensional analysis of the cervical spine kinematics: effect of age and gender in healthy subjects. Spine (Phila Pa
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1976) 34 (26):2900-2906. doi:10.1097/BRS.0b013e3181b4f667
Figure legends
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Fig. 1 The CROM device with magnetic yoke
Fig. 2 Radiological images of LP procedure. The sagittal CT scan showed continuous type of OPLL(a), and the sagittal MRI scan showed compression of spinal cord(b). The postoperative 3D-CT scan
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showed open door of LP(c), the postoperative sagittal MRI scan showed posterior shift of spinal cord.
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Fig. 3 Radiological images of LCF procedure. The X-ray and sagittal CT scan showed mixed type of OPLL(a), and the sagittal MRI scan showed compression of spinal cord(b). The postoperative X-ray
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showed instrumentation fixation of LCF(c), the postoperative sagittal MRI scan showed posterior shift of spinal cord.
Fig. 4 The mean cervical ROM decreased significantly after surgery in the six directions of motion in both groups at the 12th month follow-up. Compared with the LP group, the cervical ROM remained
unchanged in the LCF group between the 3rd month and the 12th month after operation; LP preserved
more ROM than LCF (a-f). ROM lost most in extension (b), and ROM preserved most in rotation (e, f). Fig. 5 JOA score was significantly improved in both groups (LP and CLF). Fig. 6 VAS was significantly improved in both groups (LP and CLF), and LP group showed better recovery.
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Table 1. General data LP
LCF
P value
Number
20
18
Age(year SD)
59(11.6)
62(13.1)
Gender
14M/6F
11M/7F
Disease duration
22(12.4)
18(9.3)
P<0.05
P<0.05 10 continuous(55.6%)
7 mixed(35%)
6 mixed(33.3%)
3 segmental(15%)
2 segmental(11.1%)
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10 continuous(50%)
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OPLL type
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P<0.05
(month SD)
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Table 2 The mean values and the standard deviations of the preoperative and postoperative cervical ROM data Flexion
Extension
Left
Right
Left
Right
flexion
flexion
rotation
rotation
39.4±6.8
50.8±8.3
40.9±5.3
42.3±3.9
56.4±8.6
57.6±5.9
LCF
40.7±5.8
48.4±8.9
43.1±4
43.5±5.6
58.5±8.5
59.6±7.5
Posto3m
LP
24.7±5.5
22.9±3.7
27.8±6.7
26.3±6.2
48.3±6.6
47.3±5.5
LCF
20.6±3.5
23.5±5.8
26.1±6.8
26.8±6.9
45.3±7.1
46.1±8.3
Posto6m
LP
28.1±4.5
31.1±5.3
29.6±5.1
30.1±6.1
45.9±6.1
49.2±5.8
LCF
19.5±3.3
24.6±5.2
26.7±6
28±5.6
46.4±5.9
47.9±8.1
LP
29.6±7.1*#
30.4±5.9*#
33.1±5.2*#
32.2±4.5*#
LCF
52.3±4.8*
47.1±6.8*
48.9±7.1*
22.9±5.6*△
26.3±5.2*△
27.5±5.8*△
26.9±4.2*△
LP
75.1%
59.8%
80.9%
76.1%
89.4%
90.8%
LCF
56.2%
54.3%
63.8%
61.8%
81.1%
82.0%
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%
50.4±6.5*
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ROM preservation
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Posto12m
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LP
Preop
ROM preservation %= Posto12m ROM/Preo ROM.
*p<0.05 present the significant between 12th month follow up and preoperation.
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#p<0.05 present the significant between 12th month follow up and 3rd month follow up.
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△p<0.05 present the significant between LP group and LCF group at 12th month follow up.
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Table 3 The cervical ROM data of OPLL patients in this study and normal data in previous study Flexion
Extension
Left
Right
Left
Right
flexion
flexion
rotation
rotation
OPLL
40.1±6.2
49.7±8.5
42.1±4.5
42.9±4.2
57.5±8.6
58.6±6.6
Normal
49.1±5.8
62.7±10.6
45.5±5.6
46.1±7.6
63.7±7.4
63.5±6.5
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The normal data were quoted from the paper by *[ ].
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Figure 6
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Our reference: CLINEU 4035 Editorial reference: CLINEU_CNN-D-15-126 To be published in: Clinical Neurology and Neurosurgery Postoperative three-dimensional cervical range of motion and neurological outcomes in patients with cervical ossification of the posterior longitudinal ligament: cervical laminoplasty versus laminectomy
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List of Authors： Wei Yuan, Yue Zhu, Xinchun Liu, Haitao Zhu, Xiaoshu Zhou, Renyi Zhou, Cui Cui, Jie Li Affiliations:
Department of Orthopedics, First Hospital of China Medical University.
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No. 155 Nanjing Bei Street, Heping District, Shenyang City, Liaoning Province, China.
Correspondence author:
Email: [email protected] Tel: +86-02483283360
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Fax: +86-02483282772
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Mobile phone: +86-13940227775
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Yue Zhu, M.D., Ph D
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