Anterior cervical discectomy and fusion versus posterior laminoplasty for multilevel cervical myelopathy: A meta-analysis

Accepted Manuscript Anterior cervical discectomy and Fusion versus posterior laminoplasty for multilevel cervical myelopathy: A meta-analysis Liping Xu, Hong Sun, Zhenhuan Li, Xiaodong Liu, Guanghui Xu PII:

S1743-9191(17)30491-0

DOI:

10.1016/j.ijsu.2017.06.030

Reference:

IJSU 3896

To appear in:

International Journal of Surgery

Received Date: 10 February 2017 Revised Date:

26 May 2017

Accepted Date: 12 June 2017

Please cite this article as: Xu L, Sun H, Li Z, Liu X, Xu G, Anterior Cervical discectomy and Fusion versus posterior laminoplasty for multilevel cervical myelopathy: a meta-analysis, International Journal of Surgery (2017), doi: 10.1016/j.ijsu.2017.06.030. 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.

ACCEPTED MANUSCRIPT

Anterior Cervical Discectomy and Fusion versus posterior laminoplasty for multilevel cervical myelopathy: a

Liping Xu1,2 Hong Sun1 Zhenhuan Li3

RI PT

meta-analysis Xiaodong Liu3 Guanghui

SC

Xu3*

1. University of Shanghai for Science & Technology, 516, Jungong Road

M AN U

Shanghai, 200093

2. Shanghai Publishing and Printing College, 100, Yongfeng Road Shanghai, 200093

3. Orthopedic surgery department, Zhabei central hospital of Jingan District,Shanghai, 619 Zhonghuaxin Road,200070

TE D

* Correspondence Author:

E-mail: [email protected]

AC C

EP

Funded by The Natural Science Foundation of Shanghai (15411970400).

ACCEPTED MANUSCRIPT

Anterior Cervical Discectomy and Fusion versus posterior laminoplasty for multilevel cervical myelopathy: a

RI PT

meta-analysis

Abstract

Object: Anterior cervical discectomy with fusion (ACDF) and laminoplasty (LAMP)

SC

are used for the treatment of multilevel cervical myelopathy. Despite their widespread applications certain differences are noted between the ACDF and LAMP procedures.

M AN U

A meta-analysis was conducted in order to compare the clinical outcomes, complications, and surgical trauma between ACDF and LAMP for the treatment of multilevel cervical myelopathy.

Methods: Medline, EMBASE, Google Scholar, and Cochrane databases were used for the search of relevant studies until September 2016. The studies aimed to compare

TE D

the ACDF and LAMP procedures for the treatment of multilevel cervical myelopathy. Title and abstract screening was carried out concomitantly, whereas full text screening was carried out independently. A random effect model was used for heterogeneous data. The data that did not follow heterogeneous pattern were pooled by a fixed effect

EP

model in order to examine the mean difference (MD) for continuous outcomes and the odds ratio (OR) for dichotomous outcomes, respectively.

AC C

Results: A total of 6 articles out of 1,351 citations (379 participants) were eligible. Significant differences were noted between the two groups in the cobb angle of C2– C7 (MD =4.00, 95%, CI=0.83 to 7.17; p=0.01) and with regard to the incidence of associated complications (OR =3.61, 95%, CI=1.72 to 7.59; p=0.0007). However, no apparent differences were noted in the variables blood loss (MD=-24.16, 95% CI=-174.47 to 126.15; p=0.75), operation time ((MD=32.81, 95% CI=-26.76 to 92.38; p=0.28), recovery rate of JOA score (MD =4.00, 95%, CI=0.83 to 7.17; p=0.01) and incidence of associated complications (OR =3.61, 95%, CI=1.72 to 7.59). Conclusions: The present meta-analysis demonstrates that the rate of complications is 1

ACCEPTED MANUSCRIPT lower in the laminoplasty. However, the cobb angle of C2–C7 was decreased in the ACDF group at the final follow-up period compared with the baseline. The outcomes of the variables blood loss, operation time, range of motion and recovery rate of JOA score, were similar in the two groups.

RI PT

Introduction Multilevel cervical myelopathy is an age-related clinical change that frequently compresses the spinal cord due to the development of degenerative disorders of the intervertebral discs and adjacent vertebrae [1-4]. Cervical myelopathy is a common

SC

cause of neurologic morbidity, which can lead to direct alteration and/or neurological injury. The disease can cause pathophysiological changes similar to traumatic spinal

M AN U

cord injury that may substantially decrease the quality of life [5-6]. The progression of cervical myelopathy involves deterioration of the spinal cord and the natural course in the absence of surgical treatment is often poor. Surgical intervention would be required eventually as a result of significant neurological impairment for the majority of the patients, whereas certain cases may obtain a stabilization of the neurological

TE D

deficit and/or even a recovery of the disease with surgical decompression [7]. Despite these findings, the selection of the optimal surgical approach for the treatment of patients with cervical myelopathy remains controversial. In general, surgical

EP

approaches can be divided into anterior, posterior and anterior and posterior cervical canal decompression approaches. Each approach is supplemented by additional fusion.

AC C

The anterior approach typically comprises anterior cervical discectomy with fusion and anterior cervical corpectomy with fusion, whereas laminectomy in the presence and/or absence of instrumentation and/or laminoplasty is included in the posterior approach. The anterior cervical discectomy with fusion (ACDF) that was developed by Smith [8] and Cloward [9] in the 1950s, is a conventional surgical procedure used for cervical myelopathy caused by soft-disc herniation and/or spondylosis with favorable outcomes. Nevertheless, certain reports have indicated that various complications are associated with ACDF namely, incomplete decompression, recurrence of myelopathy due to adjacent segment degeneration and dislodgement, 2

ACCEPTED MANUSCRIPT fracture and nonunion of the grafted bone [10-19]. Notably, two methods are applied in the posterior approach namely, laminectomy and laminoplasty. An increasing number of surgeons seem to perform laminoplasty instead of laminectomy recently. The process is used as the standard posterior approach for the treatment of multilevel

RI PT

cervical myelopathy, due to the prevention of postoperative segmental instability, kyphosis, perineural adhesion and late neurological deterioration, which were often noted following laminectomy [20-23]. Laminoplasty (LAMP) is a less demanding technical process that was first described by Tsuji [24]. The procedure includes certain

SC

complications regarding the postoperative cervical management and the axial pain symptoms that remain unresolved [25-26].

M AN U

Several authors have reported the clinical effects of ACDF and LAMP procedures for the treatment of cervical myelopathy, although certain differences between the two procedures are apparent. Therefore, a meta-analysis was conducted in the present study in order to compare the ACDF with the LAMP for the treatment of cervical

Methods

TE D

myelopathy.

Inclusion and exclusion criteria

The studies that were included reported information which adhered to the following

EP

criteria: (1) Adult patients of both genders with cervical myelopathy, (2) randomized and/or non-randomized controlled clinical studies of ACDF compared with LAMP for

AC C

the treatment of cervical myelopathy, (3) Patients with cervical myelopathy caused by multi-segmental spinal stenosis (C2 segments); (4) Patients who underwent surgical treatment; (5): Outcome assessment based on the primary outcome and the secondary outcome. The primary outcome included major surgical complications, radiographic outcomes, and patient-related outcome measures with regard to the variables pain and quality of life, such as the Japanese Orthopedic Association scores (JOA). The secondary outcome included surgical data, such as the operation time and blood loss. The studies that were excluded fulfilled the following criteria: (1) Non-controlled; (2) Description of case reports and/or systematic review; (3) Combined anterior and 3

ACCEPTED MANUSCRIPT posterior surgery.

Search strategy Electronic searches were conducted using electronic databases provided by Google Scholar [1966 to September 2016], Medline [1966 to September 2016], EMBASE

RI PT

[1974 to September 2016], and Cochrane Controlled Trial Register [Cochrane library 2016]. A total of two independent researchers conducted literature searches using the following search terms: cervical spondylotic myelopathy, cervical spine, discectomy, spinal fusion, and laminoplasty with various combinations of the operators “AND”,

SC

“NOT”, and “OR”. The full search strategy was available upon request from the corresponding authors. The references of the retrieved articles and relevant overview

M AN U

articles were assessed in order to identify additional studies.

The quality of the studies was independently assessed by two researchers and the level of agreement between reviewers was recorded. The inclusion of the resultant titles was determined by screening of manual titles and abstracts, followed by full-text screening. The screen was conducted by the same reviewers. The disagreements

TE D

between reviewers were resolved by discussion.

Data extraction and management

Independently, data were extracted by two researchers, whereas the following

EP

information was collected from each study. This included: (1) The characteristics of the selected papers, including authors, publish year, sample size, age, gender, duration

AC C

of follow-up, duration of symptoms and anteroposterior canal diameter (Table 1); (2) The details of the clinical outcome measurement, including blood loss, operation time, recovery rate of JOA, cobb angles of C2–C7, range of motion and complications (Table 2).

Statistical analysis All statistical tests were performed using RevMan v.5.1 software (Cochrane Collaboration, Copenhagen, Denmark). The value of I2 would be considered to result in substantial heterogeneity, at a percentage higher than 50%. The results were 4

ACCEPTED MANUSCRIPT expressed in terms of mean difference (MD) and 95% CI for continuous outcomes, and in terms of odds ratio (OR) and 95% confidence interval (95% CI) for dichotomous outcomes. Random-effects and/or fixed-effects models were used, depending on the heterogeneity of the studies included. Meta-analysis of pooled risk

RI PT

ratios was carried out. P-values of less than 0.05 were considered to be statistically significant (P < 0.05).

Results

SC

Literature search

Initial electronic databases search yielded 1,351 relevant titles, of which 1,086 were

M AN U

excluded due to failure to meet the inclusion criteria. The remaining 226 articles were subsequently excluded due to failure to meet the inclusion criteria, following review of the full text that was notably attributed to inappropriate comparison methods. In addition, 33 articles were excluded due to insufficient follow-up, duplicate reports and/or other interventions. The detail selection process is shown in Figure 1. The

[27-32].

TE D

remaining 6 studies were used for the present systematic review and meta-analysis

Demographic characteristics and quality assessment

EP

The demographic characteristics of the studies included, are presented in Table 1-2. The six retrospective cohort studies included a total of 379 patients. A total of 188 patients

underwent ACDF, whereas 191 underwent LAMP. The median follow-up

AC C

time periods for each study ranged from 10 months to 60 months. The publication dates ranged from 2005 to 2016. Quality assessments revealed average Newcastle Ottawa Quality Assessment Scale (NOQAS) scores from the two reviewers. A total of four studies scored 8 points, whereas two scored 7 points, indicating that all 6 included studies were of moderate quality (Table 3).

Clinical outcome analysis Blood loss and operation time A total of 5 studies that reported assessment of the parameters intraoperative blood 5

ACCEPTED MANUSCRIPT loss and operation time, included a total of 346 patients (173 patients for ACDF and 173 patients for LAMP). The blood loss in the ACDF group was similar with that in the LAMP group (MD=-24.16, 95% CI=-174.47 to 126.15; p=0.75; Fig. 3). No significant difference in the operation time between the two treatment groups was

RI PT

observed (MD=32.81, 95% CI=-26.76 to 92.38; p=0.28; Fig. 4). However, significant heterogeneity in the variables blood loss and operation time was noted in the two groups (heterogeneity: I2= 98% and 99%), which could not be explained by our predefined subgroup analysis. Therefore, the quality of the evidence for this outcome

SC

was low (Fig. 2, 3).

Recovery rate of JOA, cobb angle of C2–C7, range of motion and complications.

M AN U

A total of 379 patients from six studies used the recovery rate of JOA score to assess the clinical outcome (188 in the ACDF group and 191 in the LAMP group).

No

significant differences were noted in the final follow-up JOA score between the two groups (MD =-7.80, 95%, CI=-16.13 to 0.52; p=0.07) with moderate heterogeneity (I2=53%) (Fig. 4). A total of 4 trials reported the variable cobb angle of C2–C7 (109

TE D

in the ACDF group and 121 in the LAMP group), while 4 trials reported the variable range of motion (104 in the ACDF group and 117 in the LAMP group). Statistical analysis indicated that significant differences occurred in the changes of the angle of

EP

C2–C7 (MD =4.00, 95%, CI=0.83 to 7.17; p=0.01; I2= 34%) (Fig. 5), whereas with regard to the variable range of motion, the results were similar between the two groups (MD =0.88, 95%, CI=-2.71 to 4.48; p=0.63; I2= 31%) (Fig. 6). A total of 5

AC C

studies reported the parameter complications (n = 329 patients, 163 in the ACDF group and 166 in the LAMP group). The incidence of complications was significantly higher in the ACDF group compared with that noted in the LAMP group (OR =3.61, 95%, CI=1.72 to 7.59; p=0.0007) with no heterogeneity (I2= 0%) (Fig. 7).

Discussion Cervical myelopathy can substantially decrease the quality of life of patients, and the patient’s history of the disease is possibly one of the main contributing factors responsible for its deterioration. Eventually, the majority of patients 6

require surgical

ACCEPTED MANUSCRIPT intervention as a result of severe neurological impairment. The principal indication for surgery in the case of cervical myelopathy is the development of progressive spinal cord type symptoms and signs [33]. A vast number of studies have proposed the application of surgical treatment for cervical myelopathy, although the optimal

RI PT

selection of the surgical approach remains controversial. ACDF is considered more radical than posterior surgery in removing the compressive pathology due to the immediate spinal stability that can be achieved by reconstruction of the alignment of the cervical spine. This procedure yields optimal clinical results and several surgeons

SC

have widely accepted ACDF as a reliable and effective operative procedure. However, due to the degeneration of the adjacent segments that progresses with age, secondary

M AN U

myelopathy manifests in a high number of patients, irrespective of the effects of ACDF and the complications related to bone grafting. Several authors demonstrated that the incidence of nonunion and other complications ranged from 17% to 53% in the ACDF, notably for the cases of multilevel cervical myelopathy. Currently, an increasing number of surgeons conduct laminoplasty as a routine procedure in order

TE D

to provide extensive posterior decompression of the spinal cord. The compression occurs at several levels of the spinal cord as a result of spondylosis and/or developmental spinal canal stenosis [34]. Since laminoplasty invades muscles and

EP

ligaments in and behind the posterior elements of the cervical spine, several patients will suffer from postoperative neck pain [35]. Due to the indirect decompression of

AC C

the nerve tissue by laminoplasty, the ‘‘total decompression effect’’ that resulted from the posterior shift of the spinal cord should be carefully assessed [36]. Therefore, we conducted a meta-analysis to determine whether ACDF is associated with optimal clinical outcomes compared with LAMP. In the present meta- analysis, strict eligibility criteria were used. Although no RCT studies were included in the current study, all selected studies were of high quality, as determined by the NOQAS and the baseline variables were similar, indicating that the included reports were considered suitable for meta-analysis. Clinical (the recovery rate of JOA), surgical (operation time, blood loss, and complications), and radiographic outcomes (cobb angle of C2– 7

ACCEPTED MANUSCRIPT C7 and range of motion) were assessed in the current meta-analysis. In the present meta-analysis, the variables operation time and blood loss were selected for evaluation of surgical trauma and no significant difference was noted for these two parameters between the ACDF and the LAMP groups. A number of studies

RI PT

demonstrated that the blood loss was higher in the ACDF group of spondylotic myelopathy patients, which is opposite to the findings reported by Liu and Seng that blood loss was higher in the the corresponding LAMP group [28, 30, Hiari, and Sakai]. Posterior laminoplasty required extensive dissection, which resulted in a

SC

higher amount of blood loss in the LAMP compared with the ACDF groups. Koakutsu, Hiari, and Sakai have shown that the operation time was longer in the

M AN U

ACDF group of spondylotic myelopathy patients, due to reconstruction of the spinal column and careful resection of the cervical disc herniation that was associated with ossification of posterior longitudinal ligament (OPLL) in the ACDF. Although, the recovery rate of the JOA score was similar in the two surgical methods during the final follow up period, all of the studies reported that the JOA score exhibited a

TE D

significant difference following operation, which indicated that both ACDF and LAMP procedures could achieve sufficient decompression. In addition, the 2 methods could significantly increase lordosis of C2-C7. The increase level was higher in the

EP

ACDF group compared with the LAMP group (P=0.01, I2=37%). Previous studies have reported that ACDF could restore alignment and provide multiple points of distraction and fixation, in addition to the graft and interbody space shaping, by

AC C

pulling the involved vertebral bodies. In contrast to these findings, LAMP required additional dissection of the vertebral structure and possessed certain limitations in terms of the stabilization of the cervical spine and the prevention of the development of kyphosis, which could exert a deteriorating effect during long-term progression. The range of motion was greatly decreased in the 2 groups and no significant differences were noted between the 2 groups. This decrease occurred due to the dissection of soft tissues and the reduced ROM achievement compared with the preoperative level. We selected the parameter “total complications” for meta-analysis 8

ACCEPTED MANUSCRIPT in order to evaluate the complication-related outcomes. The types of complications were different in the anterior and posterior approach, and a higher incidence of complications was noted in the ACDF compared with the LAMP groups (P=0.0007). The main complications in the ACDF group included relation to graft, adjacent

RI PT

degeneration, and postoperative hematoma, while, in the posterior group the complications C5 palsy and posterior arch collapse were often encountered. A limited number of studies have additionally reported the incidence of laminoplasty at a range of 8% to 13% in the populations examined [37-40].

SC

Nonetheless, several limitations are evident within the present meta-analysis. Firstly, despite the high NOQAS scores (7 to 8) reported in all of the studies

M AN U

examined, none of studies included in the meta- analysis was RCTs. Secondly, the length of the follow-up period in the studies investigated was variable. Finally, the clinical heterogeneity might have been caused by different surgical methodologies.

Conclusion

In conclusion, the present study demonstrated that the outcomes of the parameters

TE D

blood loss, operation time, range of motion and recovery rate of JOA score were similar between the ACDF and LAMP groups. The incidence of complications was lower in the laminoplasty, whereas the cobb angle of C2–C7 was decreased in the

EP

LAMP compared with the ACDF groups. Although the present meta-analysis compared the clinical outcomes between ACDF and LAMP procedures, the surgeons

AC C

should take into consideration the actual conditions of patients, irrespective of the type of operation used.

References

1. Ferguson RJL, Caplan LR (1985) Cervical spondylitic myelopathy. Neurol Clin 3:373–382 2. Bernhardt M, Hynes RA, Blume HW et al (1993) Cervical spondylotic myelopathy. J Bone Joint Surg Am 75:119–128 3. Ogino H, Tada K, Okada K et al (1983) Canal diameter, anter oposterior compression ratio, and spondylotic myelopathy of the cervical spine. Spine. 8:1–15 4. Edwards CC 2nd, Riew KD, Anderson PA, Hilibrand AS, Vaccaro AF (2003) Cervical myelopathy. Current diagnostic and treatment strategies. Spine J 3(1):68–81 9

ACCEPTED MANUSCRIPT

AC C

EP

TE D

M AN U

SC

RI PT

5. Baptiste DC, Fehlings MG. Pathophysiology of cervical myelopathy. Spine J 2006;6(6 Suppl):190S–7S. 6. Young, W.F., Cervical spondylotic myelopathy: a common cause of spinal cord dysfunction in older persons. Am Fam Physician, 2000. 62(5): p. 1064-70, 1073. 7. Clarke E, Robinson PK. Cervical myelopathy: a complication of cervical spondylosis. Brain 1956;79:483. 8. Smith, G.W. and R.A. Robinson, The treatment of certain cervical-spine disorders by anterior removal of the intervertebral disc and interbody fusion. J Bone Joint Surg Am, 1958. 40-A(3): p. 607-24. 9. Cloward, R.B., The anterior approach for removal of ruptured cervical disks. J Neurosurg, 1958. 15(6): p. 602-17. 10. Bernard TN Jr, Whitecloud TS 3rd. Cervical spondylotic myelopathy and myeloradiculopathy: anterior decompression and stabilization with autogenous fi bula strut graft. Clin Orthop 1987;221:149–60. 11. Yonenobu K, Fuji T, Ono K, Okada K, Yamamoto T, Harada N. Choice of surgical treatment for multisegmental cervical spondylotic myelopathy. Spine 1985;10:710–6 12. Yang KC, Lu XS, Cai QL, Ye LX, Lu WQ. Cervical spondylotic myelopathy treated by anterior multilevel decompression and fusion: follow-up report of 214 cases. Clin Orthop 1987;221: 161–4. 13. Emery SE, Bohlman HH, Bolesta MJ, Jones PK. Anterior cervical decompression and arthrodesis for the treatment of cervical spondylotic myelopathy: two to seventeen-year follow-up. J Bone Joint Surg Am 1998;80:941–51. 14. Okada K, Shirasaki N, Hayashi H, Oka S, Hosoya T. Treatment of cervical spondylotic myelopathy by enlargement of the spinal canal anteriorly, followed by arthrodesis. J Bone Joint Surg Am 1991;73:352–64. 15. Baba H, Furusawa N, Imura S, Kawahara N, Tsuchiya H, Tomita K. Late radiographic fi ndings after anterior cervical fusion for spondylotic myeloradiculopathy. Spine 1993;18:2167–73. 16. Ebersold MJ, Pare MC, Quast LM. Surgical treatment for cervical spondylotic myelopathy. J Neurosurg 1995;82:745–51 17. Yonenobu K, Okada K, Fuji T, Fujiwara K, Yamashita K, Ono K. Cause of neurological deterioration following surgical treatment of cervical myelopathy. Spine 1986;11:181–23. 18. Saunders RL, Bernini PM, Shirretts TG Jr, Reeves AG. Central corpectomy for cervical spondylotic myelopathy: a consecutive series with long-term follow-up evaluation. J Neurosurg 1991;74:163–70 19. Teramoto T, Ohmori K, Takatsu T, Inoue H, Ishida Y, Suzuki K. Long-term results of the anterior cervical spondylodesis. Neurosurgery 1994;35:64–8. 20. CybulskiGR,D’AngeloCM.Neurological deterioration after laminectomy for spondylotic cervical myeloradiculopathy: the putative role of spinal cord ischaemia. J Neurol Neurosurg Psychiatry 1988;51:717–8. 21. Guigui P, Lefevre C, Lassale B, et al. Static, dynamic changes of the cervical spine after laminectomy for cervical spondylotic myelopathy. Rev Chir Orthop Reparatrice Appar Mot 1998;84:17–25. 22. Morimoto T, Okuno S, Nakase H, et al. Cervical myelopathy due to dynamic compression by the laminectomy membrane: dynamic MR imaging study. J Spinal Disord 1999;12:172–3. 10

ACCEPTED MANUSCRIPT

AC C

EP

TE D

M AN U

SC

RI PT

23. Herkowitz HN. A comparison of anterior cervical fusion, cervical laminectomy, and cervical laminoplasty for the surgical management of multiple level spondylotic radiculopathy. Spine 1988;13:774–80. 25. Hosono N, Yonenobu K, Ono K (1996) Neck and shoulder pain after laminoplasty. A noticeable complication. Spine (Phila Pa1976) 21:1969–1973 26. Chen Y, Guo Y, Lu X, Chen D, Song D, Shi J, Yuan W (2011) Surgical strategy for multilevel severe ossification of posterior longitudinal ligament in the cervical spine. J Spinal Disord Tech.24:24–30 27. Long-term outcome of laminoplasty for cervical myelopathy due to disc herniation: a comparative study of laminoplasty and anterior spinal fusion. Sakaura H, Hosono N, Mukai Y, Ishii T, Iwasaki M, Yoshikawa H. Spine (Phila Pa 1976). 2005 Apr 1;30(7):756-9 28. Anterior decompression and fusion versus laminoplasty for cervical myelopathy caused by soft disc herniation: a prospective multicenter study TOMOAKI KOAKUTSU1 , NAOKI MOROZUMI1, YUSHIN ISHII1, FUMIO KASAMA2, TETSURO SATO3, YASUHISA TANAKA4 , SHOICHI KOKUBUN4, and SHIN YAMAZAKI5 29. Middle-Term Results of a Prospective Comparative Study of Anterior Decompression With Fusion and Posterior Decompression With Laminoplasty for the Treatment of Cervical Spondylotic Myelopathy 30. ACDF With the PCB Cage-Plate System Versus Laminoplasty for Multilevel Cervical Spondylotic Myelopathy Tao Liu, MD, Hui-Lin Yang, MD, PhD, Yao-Zeng Xu, MD, Rong-Fu Qi, MD, and Hua-Qing Guan, MD 31. Five-year Follow-up Evaluation of Surgical Treatment for Cervical Myelopathy Caused by Ossifi cation of the Posterior Longitudinal Ligament A Prospective Comparative Study of Anterior Decompression and Fusion With Floating Method Versus Laminoplasty 32. Surgically treated cervical myelopathy: a functional outcome comparison study between multilevel anterior cervical decompression fusion withinstrumentation and posterior laminoplasty 33. Sypert, G.W. and H.O. Cole, Management of multilevel cervical spondylosis with myelopathy. Surg Neurol, 1999. 51(1): p. 4-5. 34. Kokubun S, Sato T. Cervical myelopathy and its management. Curr Orthop 1998;12:7–12 35. Hosono N, Yonenobu K, Ono K. Neck and shoulder pain after laminoplasty: a noticeable complication. Spine 1996; 21:1969–73. 36. Hirabayashi K, Bohlman H. Controversy multilevel cervical spondylosis: laminoplasty versus anterior decompression. Spine. 1995; 20:1732–1734. 37. Edwards CC II, Heller JG, Murakami H. Corpectomy versus laminoplasty for multilevel cervical myelopathy: an independent matchedcohort analysis. Spine 2002; 27:1168–75. 38. Edwards CC, Heller JG, Silcox DH III. ‘‘T-saw’’ laminoplasty for the management of cervical spondylotic myelopathy: clinical and radiographic outcome. Spine 2000; 25:1788–94. 39. Edwards CC, Riew KD, Anderson PA, et al. Cervical myelopathy: current diagnostic and treatment strategies. Spine J 2003; 3:68–81. 40. Tomita K, Kawahara N, Toribatake Y, et al. Expansive midline T-saw laminoplasty (modified spinous process-splitting) for the management of cervical myelopathy. Spine 1998; 23:32–7

11

ACCEPTED MANUSCRIPT 1.

Study

Publition year

Sample Size

Meanage(years)

ACDF

LAMP

ACDF

LAMP

Sex(male/female) ACDF

LAMP

2005

15

18

44.7±8.6

51.6±11.2

NR

NR

Koakutsu et al.

2010

25

25

59.4±10.2

55.7±11.6

14M/19F

10M/25F

Hiari et al.

2011

39

47

67(57-74)

Liu et al.

2011

25

27

48.0±8.1

Sakai et al.

2012

20

22

57.1±8.1

Seng et al.

2013

64

52

53.5(18-77)

Study

65.5(58-76)

19M/24F

20M/22F

52.0±7.2

16M/12F

18M/14F

58.2±7.6

17M/20F

18M/25F

20M/26F

20M/36F

SC

M AN U

2.

RI PT

Sakaura et al.

Operating time

55.7(26-82)

Blood loss

Recovery rate of JOA

LAMP

ACDF

LAMP

Sakaura et al.

NR

NR

NR

NR

72.0±22.5

70.8±22.4

Koakutsu et al.

122±24

122±24

128±107

63±48

66.8±25.3

73.2±20.6

211±55.3

149±38.7

340±287

188±92.1

50.2±26.6

72.9±28.3

115.92± 24.14

187.78± 25.01

118.48±27.62

361.11±57.80

59.79±23.43

59.54±29.37

Sakai et al.

300.3± 78.6

183.2± 41.1

292.8±192.8

289.6±215.8

55.3±29.6

71.4±26.0

Seng et al.

186±38

123±28

101±54

183±141

51.9±30.9

53.1±42.3

AC C

Liu et al.

EP

Hiari et al.

TE D

ACDF

ACDF

3. Table 3 Quality assessment according to the Newcastle–Ottawa scale Study

Selection

Comparability 12

Exposure

Total score

LAMP

1

ACCEPTED MANUSCRIPT 2 3 3 3 3 2

2 2 2 2 2 2

3 3 3 3 3 3

7 8 8 8 8 7

EP

4.

TE D

M AN U

SC

RI PT

Sakaura et al. Koakutsu et al. Hiari et al. Liu et al. Sakai et al. Seng et al.

AC C

Potentially relevant reports after identified initial literature review N=1351 Studies excluded after

review of the abstract and title. N=1086

Studies were included in full text reviewing. N=265 Studies excluded due to failure to meet the inclusion criteria. N=226

Potential relevant studies included in the mata-analysis. 13 N=39

ACCEPTED MANUSCRIPT

Studies excluded due to insufficient follow-up, duplicate report,other intervention. N=33

Figure1

RI PT

6 studies were included in the meta-analysis. N=6

Flow diagram detailing study inclusion.

EP

TE D

Figure3. Operation Time

M AN U

SC

Figure2. Blood Loss

AC C

Figure4. Recovery rate of JOA

Figure5. C2–C7 angle

14

ACCEPTED MANUSCRIPT

RI PT

Figure6. ROM

AC C

EP

TE D

M AN U

SC

Figure7. Complications

15

ACCEPTED MANUSCRIPT

Study

Publition year

Sample Size

Meanage(years)

ACDF

LAMP

ACDF

LAMP

Sex(male/female) ACDF

LAMP

2005

15

18

44.7±8.6

51.6±11.2

NR

NR

Koakutsu et al.

2010

25

25

59.4±10.2

55.7±11.6

14M/19F

10M/25F

Hiari et al.

2011

39

47

67(57-74)

65.5(58-76)

19M/24F

20M/22F

Liu et al.

2011

25

27

48.0±8.1

52.0±7.2

16M/12F

18M/14F

Sakai et al.

2012

20

22

57.1±8.1

58.2±7.6

17M/20F

18M/25F

Seng et al.

2013

64

52

53.5(18-77)

55.7(26-82)

20M/26F

20M/36F

AC C

EP

TE D

M AN U

SC

RI PT

Sakaura et al.

1

ACCEPTED MANUSCRIPT

Study

Operating time

Blood loss

Recovery rate of JOA

LAMP

ACDF

LAMP

Sakaura et al.

NR

NR

NR

NR

Koakutsu et al.

122±24

122±24

128±107

Hiari et al.

211±55.3

149±38.7

340±287

Liu et al.

115.92± 24.14

187.78± 25.01

Sakai et al.

300.3±78.6

Seng et al.

186±38

72.0±22.5

LAMP

70.8±22.4

66.8±25.3

73.2±20.6

188±92.1

50.2±26.6

72.9±28.3

118.48±27.62

361.11±57.80

59.79±23.43

59.54±29.37

183.2± 41.1

292.8±192.8

289.6±215.8

55.3±29.6

71.4±26.0

123±28

101±54

51.9±30.9

53.1±42.3

M AN U

SC

63±48

TE D EP AC C

ACDF

RI PT

ACDF

183±141

ACCEPTED MANUSCRIPT Table 3 Quality assessment according to the Newcastle–Ottawa scale Selection

Comparability

Exposure

Total score

2 3 3 3 3 2

2 2 2 2 2 2

3 3 3 3 3 3

7 8 8 8 8 7

AC C

EP

TE D

M AN U

SC

Sakaura et al. Koakutsu et al. Hiari et al. Liu et al. Sakai et al. Seng et al.

RI PT

Study

ACCEPTED MANUSCRIPT

Potentially relevant reports after identified initial literature review N=1351 Studies excluded after

Studies were included in full text reviewing. N=265

RI PT

review of the abstract and title. N=1086

M AN U

Potential relevant studies included in the mata-analysis. N=39

SC

Studies excluded due to failure to meet the inclusion criteria. N=226

TE D

6 studies were included in the meta-analysis. N=6

Flow diagram detailing study inclusion.

AC C

EP

Figure 1

Studies excluded due to insufficient follow-up, duplicate report,other intervention. N=33

AC C

EP

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT

AC C

EP

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT

AC C

EP

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT

AC C

EP

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT

AC C

EP

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT

AC C

EP

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT

ACCEPTED MANUSCRIPT 1. Many studies have advocated for surgical treatment for cervical myelopathy, however, the optimal surgical approach remains to be controversial. 2. We conducted a meta-analysis to determine whether ACDF is associated with better clinical outcomes compared with LAMP. 3. Based on this study, the outcomes of blood loss, operation time, range of motion

RI PT

and recovery rate of JOA score are similar in these two groups. The incidence of complications is lower in the laminoplasty; however, the cobb angle of C2–C7 is

AC C

EP

TE D

M AN U

SC

better in the ACDF group.