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Clinical recovery after 5 level of posterior decompression spine surgeries in patients with cervical spondylotic myelopathy: A retrospective cohort study
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Asian Journal of Surgery xxx (xxxx) xxx
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ORIGINAL ARTICLE
Clinical recovery after 5 level of posterior decompression spine surgeries in patients with cervical spondylotic myelopathy: A retrospective cohort study Qiaomei Li a, Xiaoqiang Han b, Renqiang Wang a, Yuanyuan Zhang a, Puke Liu a, Qingqing Dong c,* a Department of Operating and Anesthesiology, Ankang Hospital of Traditional Chinese Medicine, Ankang, Shaanxi, 725000, China b Department of Orthopedic, Ankang Hospital of Traditional Chinese Medicine, Ankang, Shaanxi, 725000, China c Department of Outpatient, Ankang Hospital of Traditional Chinese Medicine, Ankang, Shaanxi, 725000, China
Received 13 June 2019; received in revised form 14 July 2019; accepted 5 August 2019
KEYWORDS Bone union; Cervical spondylotic myelopathy; Cervical lordotic; Posterior decompression spine surgeries; Spinal cord volume
Summary Background/Objective: The selection of surgical technique in patients with cervical spondylotic myelopathy relies on the surgeon(s) and patients’ conditions. The objectives of the study were to test the hypotheses that French-door laminoplasty recovers faster than laminectomy and has good outcome measures. Methods: Data regarding surgical, radiological, and clinical outcome measures of 330 patients with cervical spondylotic myelopathy operated under French-door laminoplasty (fdLP group, n Z 110), open-door laminoplasty (odLP group, n Z 110), or laminectomy (LC group, n Z 110) were collected from the records of institute and analyzed. Results: Patients of fdLP group (p < 0.0001, q Z 11.65) and odLP group (p < 0.0001, q Z 11.27) both had significantly improved modified Rankin scale score than those of LC group. In addition, patients of fdLP group had minimum blood loss during operations and that was maximum for patients of the LC group. Unlike patients of fdLP group (p < 0.0001, q Z 80) and LC group (p < 0.0001, q Z122), those of odLP group had lost more amount of cervical lordotic after surgery. Open-door laminoplasty had significantly reduced cervical range of motion than laminectomy (p < 0.0001, q Z 15.45) and French-door laminoplasty (p < 0.0001, q Z 13.45). After 12-months, fdLP group had higher bone union rate than odLP group (p Z 0.007,
* Corresponding author. Fax: þ0086 0915 8183608. E-mail addresses: [email protected] (Q. Li), [email protected] (X. Han), [email protected] (R. Wang), zobrqu@163. com (Y. Zhang), [email protected] (P. Liu), [email protected] (Q. Dong). https://doi.org/10.1016/j.asjsur.2019.08.003 1015-9584/ª 2019 Asian Surgical Association and Taiwan Robotic Surgery Association. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Please cite this article as: Li Q et al., Clinical recovery after 5 level of posterior decompression spine surgeries in patients with cervical spondylotic myelopathy: A retrospective cohort study, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.08.003
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Q. Li et al. q Z 3.395) and LC group (p Z 0.007, q Z 4.243). French door laminoplasty had a better postoperative quality of life. Conclusions: Among the posterior decompression spine surgeries, French-door laminoplasty is superior surgical procedure than laminectomy and could be superior surgical technique than open-door laminoplasty. ª 2019 Asian Surgical Association and Taiwan Robotic Surgery Association. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction Congenital and degenerative changes of the cervical spinal canal are responsible for cervical spondylotic myelopathy (CSM)1 and becoming one of the leading cause in old patients, affecting the physical, psychological, and social quality of life. Also, significantly increases economic burden.2 Anterior cervical discectomy and fusion,3 anterior cervical corpectomy and fusion,4 posterior decompression spine surgeries, e.g. laminoplasty,5 laminectomy with fusion,2 and laminectomy6 are available surgical treatment options for CSM. The spinal cord injury is the major risk factor associated with anterior cervical discectomy and fusion surgery, while anterior cervical corpectomy and fusion surgery is difficult spinal surgery so far.2 Laminectomy has satisfactory outcomes but has technical failures, e.g. postoperative kyphosis and worsening of neurological functions and intraoperative spinal cord injury.7 Moreover, laminoplasty has greater cervical spine stability than laminectomy.6 Single-door laminoplasty is the preferred surgical procedure.8 Apart from this, the double-door laminoplasty (e.g. French-door laminoplasty) procedure is also used by surgeons.9 There are several procedures available for singledoor laminoplasty, for example, open-door laminoplasty.10 However, laminoplasty has postoperative clinical issues, e.g. hematoma11 and C5 nerve root palsy (sensory disturbance and weakness of deltoid muscle at C5 area).7 Patients’ conditions also have a crucial role in the selection of the surgical technique by the surgeon(s). Therefore, the selection of surgical technique in CSM is required to justify. The objectives of the retrospective analysis were to outline the clinical effectiveness, radiological outcomes, and postoperative complications of patients with CSM who underwent French-door laminoplasty, open-door laminoplasty, or laminectomy in a Chinese setting.
2. Materials and methods
signed by enrolled patients or patient relatives (legally authorized person) regarding anesthesia, surgeries, and the publication of the study (including personal data) irrespective of time and language during hospitalization. As being retrospective analysis registration of the study in the Chinese clinical trial registry had been waived by the institutional review board.
2.2. Inclusion criteria Patients age 18 years and above with CSM (and degenerative indication) and planned to undergo 5 level spine surgery (laminoplasty or laminectomy) from C3 to C7 were included in the analysis.
2.3. Exclusion criteria The patients’ age below 18 years were excluded from the analysis. Patient with 5 levels of spine surgeries, who had damage to the ventral spine, those who had an unstable spine, and patients who faced surgeries for spinal code injuries was excluded from the analysis. Patients who had faced less than 5 levels of anterior decompression spinal cord surgeries were excluded from the analysis. Patients with insufficient data at institute records were also excluded from the analysis. 2.3.1. Cohort Patients who needed the removal of the bone between the spinal process and facet pedicle junction to expose the neural elements of the spine were subjected to laminectomy and patients who needed an opening of the lamina to enlarge the spinal canal during surgeries were subjected to laminoplasty. The choice of French-door laminoplasty or open-door laminoplasty was surgeon’s decision who made surgery.
2.4. Surgical techniques 2.1. Ethical consideration and consent to participate The original protocol (ATCM/CL/5/14 dated 22 December 2014) of the study had been approved by the Ankang Hospital of Traditional Chinese Medicine review board. The study had adhered to the law of China, the strengthening the reporting of observational studies in epidemiology (STROBE) statement, and Declaration of Helsinki (V2008). An informed consent form had been
2.4.1. Laminoplasty The head of patients had been placed in a neutral position in a Mayfield clamp (MIL1108, Medline Industries, Inc., San Diago, CA, USA). C3eC7 was exposed by incision and the cutting processes had been performed a by bone cutter (MDS3234720, Forcep, Cutting, Bone, Horsley, D/A, 1000 , Medline Industries, Inc., San Diago, CA, USA).12 The surrounding soft tissues were removed. C6 and C7 were used to prepare graft. A trough was drilled on the less symptomatic
Please cite this article as: Li Q et al., Clinical recovery after 5 level of posterior decompression spine surgeries in patients with cervical spondylotic myelopathy: A retrospective cohort study, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.08.003
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Posterior Decompression Spine Surgeries side at the laminaefacet joint by a MidaseRex drill/M8 cutting bit (Medline Industries, Inc., San Diago, CA, USA). The contralateral laminaefacet junction was also drilled from C3 to C7. The structured autograft was placed in space.6 Spinal canal was opened on one side, the other side was hinged, and an asymmetrical expansion of the canal was created in open-door laminoplasty. While, in the Frenchdoor laminoplasty, the spinal canal was opened from the midline and the symmetrical opening of the canal was made.10 A total of 15 spine surgeons of the institute (minimum 10-years of experience) were involved in the laminoplasty surgeries. Single surgeon approach was preferred. 2.4.2. Laminectomy The patients had been positions in the same manner as those of laminoplasty. The drilling was performed bilaterally at gutters and bones were removed completely preserving facet joints.6 A total of 15 spine surgeons (minimum 10-years of experience) of the institute were involved in the laminectomy surgeries. Single surgeon approach was preferred. All posterior decompression spine surgeries had been performed in line with the STROCSS (the strengthening the reporting of cohort studies in surgery) criteria.13
Percentage cervical range of motion Z
3 moderate disability, 2: severe disability, 3: persistent vegetative state, and 5: death.16
2.9. Karnofsky performance status It was measured to evaluate daily activity. 0: death and 100: normal without any complain.17
2.10. Cervical lordotic angle The neutral lateral x-ray (GE Healthcare, Chicago, IL, USA) view of all patients were taken in supine, sitting, and standing positions. The cervical lordotic angle was evaluated as the difference between preoperative and postoperative cervical angle.18 The cervical lordosis was calculated as the Cobb angle between the lower endplate of C7 and C2 (Fig. 1).19
2.11. Percentage cervical range of motion T2 Magnetic resonance imaging (GE Healthcare, Chicago, IL, USA) was performed in supine position of patients to check flexion rotation, extension rotation, or lateral bending to measure the cervical range of motion and percentage cervical range of motion was evaluated as per Eq. (1),20:
Preoperative angle Postoperative angle 100 Preoperative angle
ð1Þ
2.5. Clinical recovery
2.12. The quality of life
The information of patients regarding functions and disabilities (preoperative and postoperative until discharge) were collected from the Digital Imaging and Communications in Medicine (DICOM) of institutes. The medical staff (minimum 3-years of experience) of the institutes who were not involved in the surgeries had evaluated the scores.
The quality of life was evaluated by the EQ-5D questionnaire (a standardized instrument for measuring generic health status) Chinese version.21
2.6. Modified Rankin scale
T2 Magnetic resonance imaging (GE Healthcare, Chicago, IL, USA) was performed in the supine position and the neck was fixed in the central position. The sagittal sectional area of the spinal cord was measured by using a cursor to find the vertebrate profile on each slice, and the spinal cord volume was calculated by compiling the sagittal sectional area. The size measured from the foramen magnum to the inferior border of the C7 (Fig. 2).22 All outcome measures were evaluated one week after surgeries.
The degree of dependency of the patients was measured by the Modified Rankin scale. It was seven-points scale scores. 0: normal and 6: death.14
2.7. Nurick scale It was a six-point scale score. 0: normal and 5: bedridden or chair bound.15
2.13. Spinal cord volume
2.8. Glasgow outcome score
2.14. Bone union rate
It was accessed to focus on the outcome of the surgeries and was a five-point scale score. 0: good recovery, 1:
Bone union rates were evaluated from the Computed Tomography scan after 6 and 12-months of surgeries.23
Please cite this article as: Li Q et al., Clinical recovery after 5 level of posterior decompression spine surgeries in patients with cervical spondylotic myelopathy: A retrospective cohort study, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.08.003
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Q. Li et al. Medicine, Ankang, Shaanxi, China, and the referring hospitals from 1 January 2015 to 1 July 2018 who faced 5 levels of posterior decompression surgeries were reviewed. Among them 15 patients had confounded results with study evaluation parameters, 8 patients were partially ambulant (spinal cord injuries), 7 were fully ambulant (spinal cord injuries), 6 patients were planned for instrumentation procedure, and 5 patients had planned for cervical spine fusion. Therefore, data of these patients were excluded from the analysis. The data of 330 patients were included in the analysis. Patients with CSM operated under French-door laminoplasty were included into fdLP group (n Z 110), those operated under open-door laminoplasty were included into odLP group (n Z 110), and patients operated under laminectomy were included into LC group (n Z 110). Clinical effectiveness, radiological outcomes, and complications during 1-year of follow-up of all study patients were evaluated. Flow diagram of the work-up is presented in Fig. 3.
3.2. The demographic characteristics Figure 1 The x-ray view (in sitting position) for measurement of the cervical lordosis between C2 and C7.
2.15. Statistical analysis InStat, GraphPad Software, San Diego, USA was used for analysis purposes. The Chi-square Independence test6 was used for a categorical variable. A two-tailed paired t-test (between groups) or the Wilcoxon test6 (between preoperative and postoperative conditions) following the Tukey post hoc test (considering critical value [q] > 3.333 as significant)24 were used for continuous variables. The results were considered significant at 95% of confidence level.
3. Results
Most of the patients were overweight. The other demographic characteristics and clinical conditions of patients at the time of the surgeries are presented in Table 1. There was no significant difference between preoperative clinical conditions of the patients (p > 0.05 for all).
3.3. Surgical outcome measures Surgeons had taken 101.12 25.47 min, 98.45 21.42 min, and 152.47 25.47 min to perform surgeries for patients of fdLP, odLP, and LC group respectively (Fig. 4). The time required for the hospital stays for patients of fdLP, odLP, and LC group were 8.15 2.11 days, 9.15 3.14 days, and 12.14 5.15 days respectively (Fig. 5). Estimated blood loss during the operation for patients of fdLP, odLP, and LC group was 220.47 30.41 mL, 325.47 50.17 mL, and 410.12 25.47 mL respectively (Fig. 6).
3.1. Enrollment 3.4. Radiological outcome measures Data of 371 patients with CSM in at the department of spine surgery of the Ankang Hospital of Traditional Chinese
Patients of fdLP, odLP, and LC had reported 0.55 0.08 , 1.3 0.15 , and 0.15 0.02 of the reduced cervical lordotic angle after surgery respectively (Fig. 7). Patients of fdLP (34.11 7.91 vs. 27.11 5.61-degree, p < 0.0001), odLP (33.92 6.75 vs. 20.12 4.45-degree, p < 0.0001), and LC (34.51 6.79 vs. 28.15 6.15-degree, p < 0.0001) all had reported reduction in the postoperative cervical range of motion (Fig. 8).
3.5. Clinical outcome measures
Figure 2 T2 weighted magnetic resonance image of the sagittal sectional area of the spinal cord to find spinal cord volume.
After surgeries, laminectomy (p Z 0.008), French-door laminoplasty (p < 0.0001), and open-door laminoplasty (p < 0.0001) all had improved modified Rankin scale score as compared to baseline. However, French-door laminoplasty (p < 0.0001, q Z 11.65) and open-door laminoplasty (p < 0.0001, q Z 11.27) both had significantly improved modified Rankin scale score than laminectomy (Fig. 9).
Please cite this article as: Li Q et al., Clinical recovery after 5 level of posterior decompression spine surgeries in patients with cervical spondylotic myelopathy: A retrospective cohort study, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.08.003
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Posterior Decompression Spine Surgeries
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Figure 3
Flow diagram of the study.
Glasgow outcome score for fdLP, odLP, and LC groups were 1.35 0.35, 1.34 0.41, and 1.45 0.31 respectively. Bone union rate at 6-months for fdLP, odLP, and LC groups were 63 (57%), 61 (55%), and 57 (52%) respectively. While, at 12-months for fdLP, odLP, and LC groups were 90 (82%), 74 (67%), 70 (64%) respectively (Fig. 10). After 12months, fdLP group had higher bone union rate than odLP group (p Z 0.007, q Z 3.395) and LC group (p Z 0.007, q Z 4.243). As compared to baseline, French-door laminoplasty (p Z 0.03), open-door laminoplasty (p Z 0.0002), and laminectomy (p Z 0.03) all had improved Nurick scale score of patients. Also, French-door laminoplasty (p < 0.0001), open-door laminoplasty (p < 0.0001), and laminectomy (p Z 0.0002) all had improved Karnofsky performance status of patients as compared to baseline. However, after open-door laminoplasty cervical lordotic angle of the patients was significantly reduced as compared to baseline (p Z 0.034) and also as compared to French-door
laminoplasty (p Z 0.0008, q Z 4.31) and laminectomy (p Z 0.0008, q Z 4.96). All procedures were increased spinal cord volume after surgeries (p < 0.05 for all) but French-door laminoplasty had significant fewer increased spinal cord volume after surgeries than open-door laminoplasties and laminectomies (Table 2).
3.6. Postoperative complications Laminoplasties had reported postoperative hematoma (p Z 0.03). After all types of surgeries, none of the patients was suffered from clinical deterioration, permanent morbidity, or mortality. For fdLP, odLP, and LC groups, postoperative infection were reported in 3 (3%), 3 (3%), and 1 (1%) respectively. In all group, few patients had minor dehiscence after surgeries. Minor dehiscence was overcome by additional sutures. Less intravenous narcotics (morphine or morphine equivalent) was required for postoperative pain for laminoplasties than
Please cite this article as: Li Q et al., Clinical recovery after 5 level of posterior decompression spine surgeries in patients with cervical spondylotic myelopathy: A retrospective cohort study, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.08.003
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Q. Li et al. Table 1
Preoperative clinical conditions of the patients. Characteristics
Groups
Comparison between groups
fdLP
odLP
LC
French-Door Laminoplasty
Open-Door Laminoplasty
Laminectomy
Sample size (n)
110
110
110
p-value
Age
81 35 58.85 8.75 71 (65) 39 (35) 25 (23)
79 34 60.11 7.21 73 (66) 37 (34) 24 (22)
80 36 59.15 6.81 78 (70) 32 (30) 26 (23)
0.443
59 (54)
58 (53)
61 (55)
26 (23) 3.52 0.39 2.82 0.21 55.42 8.15
28 (25) 3.47 0.31 2.84 0.26 56.61 8.89
23 (22) 3.43 0.30 2.88 0.27 57.63 9.21
0.139 0.19 0.175
14.71 2.01
13.91 2.97
14.45 2.45
0.056
34.11 7.91
33.92 6.75
34.51 6.79
0.824
8.64 1.46
8.53 1.41
8.41 1.52
0.508
Types of surgery
Maximum Minimum Mean SD Gender Male Female 18.5e24.9 Body mass (Normal) index (kg/m2) 25e29.9 (Overweight) 30 (Obese) a Modified Rankin scale b Nurick scale c Karnofsky Performance Status d Preoperative cervical lordotic angle (degree) e Preoperative Cervical range of motion (degree) The spinal canal volume (cm3)
0.585 0.906
n: the numbers of patients were enrolled in the individual group. Continuous variables are represented as mean SD and constant variables are represented as number (percentage). The Chi-square independence test (for constant variables) and two-tailed paired t-test (for continuous variables) were used for statistical analysis. A p < 0.05 was considered significant. The medical staff of the institute(s) (not involved in the surgeries) was evaluated in clinical conditions. a 0: normal and 6: death. b 0: normal and 5: bedridden or chair bound. c 0: death and 100: normal without any complaint. d The neutral lateral X-ray view. e T2 Magnetic resonance imaging.
laminectomy (p Z 0.005). After discharge patients with subjective pain went to a nursing home and those with poor neurological recovery went to inpatient rehabilitation. All went home by the end of 4-months. fdLP group had 2 (2%) patients were subjected to reoperation, which was fewer than reoperations reported in odLP group (12, p Z 0.008, q Z 3.46) and LC group (14, p Z 0.008, q Z 4.15). Also, least numbers of residual neurological symptoms were reported in fdLP group than the odLP group and LC group (Table 3).
3.7. Quality of life
Figure 4 Operation time to complete the procedure. Variables are represented as mean SD. The numbers of patients were enrolled in the individual group: n: 110. Two-tailed paired t-test following the Tukey post hoc test was used for statistical analysis. A p < 0.05 and q > 3.333 were considered significant. # Significant less operation time required than a laminectomy.
There was no significant change for EQ-5D difference between laminectomy and French door laminoplasty (p < 0.0001, q Z 3.323) but significant difference between laminectomy and open door laminoplasty (p < 0.0001, q Z 67.56). Also, significant difference between French door laminoplasty and open door laminoplasty (p < 0.0001, q Z 64.24, Fig. 11).
Please cite this article as: Li Q et al., Clinical recovery after 5 level of posterior decompression spine surgeries in patients with cervical spondylotic myelopathy: A retrospective cohort study, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.08.003
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Figure 5 Hospital stays of patients. Variables are represented as mean SD. The numbers of patients were enrolled in the individual group: n: 110. Two-tailed paired t-test following the Tukey post hoc test was used for statistical analysis. A p < 0.05 and q > 3.333 were considered significant. #Significant fewer hospital stays than a laminectomy. The time required to admit the hospital prior surgery to discharge after surgery was considered as hospital stays.
4. Discussion 4.1. Surgical outcome measures The analysis reported that French-door laminoplasty and open-door laminoplasty both had required less time for operation (p < 0.0001, q Z 22.26 and p < 0.0001, q Z 23.42), less blood loss during operation (p < 0.0001, q Z 53.87 and p < 0.0001, q Z 24.04), and fewer hospital stays (p < 0.0001, q Z 11.34 and p < 0.0001, q Z 8.5), than laminectomy. The analysis results were parallel with retrospective cohort analyses.6,25e27 The laminoplasties
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Figure 7 Reduction in cervical angle. Variables are represented as mean SD. The numbers of patients were enrolled in the individual group: n: 110. Two-tailed paired t-test following the Tukey post hoc test was used for statistical analysis. A p < 0.05 and q > 3.333 were considered significant. A p < 0.05 was considered significant.# Significant greater cervical lordotic angle after surgery. The neutral lateral X-ray view.
contributed more opportunities for the muscle to reattach to the cervical bone and rapid recovery due to the preservation of bony covering of the dura. The analysis had reported that less blood loss during operation (p < 0.0001, q Z 29.82) for French-door laminoplasty than open-door laminoplasty. The opening size of laminoplasty may affect surgical outcomes.28 Symmetrical cervical lamina opening has positive surgical outcomes.8,10 Muscle dissection to expose the lamina most significantly contributes to the amount of blood loss. The way to open the lamina makes such a difference. French-door laminoplasty is found to superior to open-door laminoplasty and laminectomy.
4.2. Radiological outcome measures
Figure 6 Estimated blood loss during operation. Variables are represented as mean SD. The numbers of patients were enrolled in the individual group: n: 110. Two-tailed paired ttest following the Tukey post hoc test was used for statistical analysis. A p < 0.05 and q > 3.333 were considered significant. A p < 0.05 was considered significant. #Significant less blood loss.
Unlike French-door laminoplasty (p < 0.0001, q Z 80) and laminectomy (p < 0.0001, q Z 122), open-door laminoplasty reported significant greater reduction in cervical lordotic angle after surgery. After surgeries, open-door laminoplasty significantly reduced higher cervical range of motion than French-door laminoplasty (p < 0.0001, q Z 13.45) and laminectomy (p < 0.0001, q Z 15.45). Also, patients of fdLP group had reported the least increased in the spinal canal volume after French-door laminoplasty. The opening size of laminoplasty has a crucial role in radiological outcomes.28 The worst radiological outcomes reported by open-door laminoplasty were parallel with the available study.9,10 Cervical kyphosis is a result of the protective reaction of the body to increase the spinal canal volume.29 Kyphosis can be prevented by laminoplasty than laminectomy but French-door laminoplasty could be safe surgery than open-door laminoplasty. After surgeries, open-door laminoplasty significantly reduced the cervical range of motion among all surgeries. The analysis results were parallel with the available studies10,30 but the results of the analysis were not parallel
Please cite this article as: Li Q et al., Clinical recovery after 5 level of posterior decompression spine surgeries in patients with cervical spondylotic myelopathy: A retrospective cohort study, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.08.003
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Figure 8 Cervical range of motion (degree) analysis. Variables are represented as mean SD. The numbers of patients were enrolled in the individual group: n: 110. Two-tailed paired t-test following the Tukey post hoc test was used for statistical analysis. A p < 0.05 and q > 3.333 were considered significant. A p < 0.05 was considered significant. # Significant lower degree of cervical range of motion. T2 Magnetic resonance imaging.
Figure 9 Modified Rankin scale score analysis. Variables are represented as mean SD. The numbers of patients were enrolled in the individual group: n: 110. The Wilcoxon test was used for statistical analysis between BL and EL. A two-tailed paired t-test was used for statistical analysis between groups. The Tukey test was used for post hoc analysis. BL: before surgery, EL: after surgery. A p < 0.05 and q > 3.333 were considered significant. The medical staff of the institute(s) (not involved in the surgeries) was evaluated in clinical conditions. #Significant improvement than a laminectomy. 0: normal and 6: death.
with an experimental study.31 To maintain the cervical range of motion after surgery, it is necessary to decrease neck pain.24 Excessive opening of spinal laminae is responsible for the decrease in postoperative cervical range of motion in open-door laminoplasty.10 With respect to the radiological outcomes of the study, open-door laminoplasty is inferior surgical procedure than French-door laminoplasty surgical procedure.
4.3. Clinical outcome measures The study reported the same neurological outcome (insignificant difference for Nurick scale score (p Z 0.062), Karnofsky performance status (p Z 0.143)) and Glasgow outcome score (p Z 0.054) among all surgical procedures after the surgeries. The analysis results are parallel with available cohort studies6,10 but not parallel with the other research reports.25e27,30 The reason behind that the study was evaluated parameters during a follow-up period of 12 months only while the available studies evaluated outcome
Figure 10 The Axial Computed Tomography scan of patient 12 months after French-door laminoplasty, displays the union of bone between the split spinous process and residual laminae.
Please cite this article as: Li Q et al., Clinical recovery after 5 level of posterior decompression spine surgeries in patients with cervical spondylotic myelopathy: A retrospective cohort study, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.08.003
Clinical recovery of patients after surgeries.
Parameters
Groups fdLP
odLP
Surgery French-Door (I) BL
EL
(n)
110
110
a
2.82 0.21 55.42 8.15 14.71 2.01 8.64 1.46
2.76 0.19 65.45 15.47 14.12 2.45 9.12 1.49f
NSS KPS c CLA The spinal canal volume (cm3)
LC
Laminoplasty
Level
b
Comparison between groups at EL
Laminectomy (III) Open-Door (II)
d
p
0.03 <0.0001 0.052 0.017
BL
EL
110
110
2.84 0.26 56.61 8.89 13.91 2.97 8.53 1.41
2.71 0.25 64.68 14.48 12.71 5.11e 12.01 1.89
d
p
0.0002 <0.0001 0.034 <0.0001
BL
EL
110
110
2.88 0.27 57.63 9.21 14.45 2.45 8.41 1.52
2.79 0.31 62.12 8.01 14.31 1.49 11.42 1.66
d
p
0.03 0.0002 0.609 <0.0001
p
0.062 0.143 0.0008 <0.0001
q-value I vs. II
I vs. III
II vs. III
N/A N/A 4.31 17.957
N/A N/A 0.6 14.291
N/A N/A 4.96 3.666
Posterior Decompression Spine Surgeries
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n: Sample size: the numbers of patients were enrolled in the individual group. BL: Before surgery. EL: After surgery. Variables are represented as mean SD. Two-tailed paired t-test following Tukey post hoc test was used for statistical analysis. A p < 0.05 and q > 3.333 were considered significant. The medical staff of the institute(s) (not involved in the surgeries) was evaluated in clinical conditions. N/A: Not applicable. a NSS: Nurick scale score: 0: normal and 5: bedridden or chair bound. b KPS: Karnofsky Performance Status: 0: death and 100: normal without any complaint. c CLA: Cervical lordotic angle (degree): The neutral lateral X-ray view. d the Wilcoxon test was used for statistical analysis between BL and EL. e Significant decrease than French-door laminoplasty and laminectomy. f Significant lesser increased spinal cord volume after French-door laminoplasty than open-door laminoplasty and laminectomy.
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Please cite this article as: Li Q et al., Clinical recovery after 5 level of posterior decompression spine surgeries in patients with cervical spondylotic myelopathy: A retrospective cohort study, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.08.003
Table 2
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Surgical outcome measures. Characteristics
Types of surgery Sample size (n) Intravenous narcotics used Postoperative complications
The discharge disposition
Abnormal reflexes The weakness of the arms or legs Inability to speak Decreased sensation Loss of balance Mental function problems, such as memory loss Vision changes Walking problems Total
Comparison between groups
fdLP
odLP
LC
French-Door Laminoplasty
Open-Door Laminoplasty
Laminectomy
110
110
110
p-value 0.005
a
a
49 (45) 61 (55)a 3 (3) 5 (5) 7 (6)a 4 (4) 0 (0) 0 (0) 0 (0) 0 (0) 80 (72) 21 (19) 9 (9) 2 (2)d 2 (2) 1 (1)
47 (43) 63 (57)a 3 (3) 4 (4) 6 (5)a 3 (3) 0 (0) 0 (0) 0 (0) 0 (0) 79 (71) 22 (20) 9 (9) 12 (11) 3 (3) 2 (2)
69 (63) 41 (37) 1 (1) 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) 0 (0) 74 (67) 25 (23) 11 (10) 14 (13) 5 (5) 3 (3)
0 1 1 1
2 4 4 2
1 7 5 4
(0) (1) (1) (1)
0 (0) 1 (1) 7 (7)d
(2) (4) (4) (2)
1 (1) 3 (3) 21 (21)
0.008 <0.0001
(1) (6) (5) (4)
2 (2) 5 (4) 32 (30)
Q. Li et al.
n: the numbers of patients were enrolled in the individual group. Data are represented as a number (percentage). The Chi-square independence test was used for statistical analysis between groups. A p < 0.05 was considered significant. The medical staff of the institute(s) (not involved in the surgeries) was evaluated in clinical conditions. N/A: Not applicable. a Significant higher for laminoplasty than a laminectomy. b Patients with subjective pain. c Patients with poor neurological recovery. d Significant fewer than open-door laminoplasty than a laminectomy.
0.558 0.09 0.03 0.408 N/A N/A N/A N/A 0.921
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Re-operation Residual neurological symptoms
48 h >48 h Postoperative infection C5 nerve root palsy Hematoma Minor dehiscence Major dehiscence Clinical deterioration Permanent morbidity Mortality Home c Inpatient rehabilitation b Nursing home
Groups
+
Please cite this article as: Li Q et al., Clinical recovery after 5 level of posterior decompression spine surgeries in patients with cervical spondylotic myelopathy: A retrospective cohort study, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.08.003
Table 3
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Posterior Decompression Spine Surgeries measures during 5 years of follow-up. A randomized clinical trial is required to perform for a long follow-up period. French-door laminoplasty had higher bone union rate than open-door laminoplasty and laminectomy. The results of the study were in line with the retrospective study.23 French-door laminoplasty has higher spinal stability.
4.4. Quality of life The study reported that laminectomy and French door laminoplasty improved the quality of life. While open door laminoplasty had not a good quality of life. The results of the study were consistent with the results of retrospective analyses.6,21 The study recommended French door laminoplasty for better postoperative quality of life for 5 levels of posterior decompression.
4.5. Limitations In the limitations of the study, for examples, the neurological outcome evaluated in the study were not generally used for evaluation of posterior decompression of the spine surgeries. The neurological outcome used in the study for evaluation purposes is required to validate prior implementation.6 Lack of randomization. Experience of the surgeon(s)32 and the satisfaction of patients for the surgical procedure33 may have effects on the postoperative outcomes in the spine surgeries but the study was not carried out such analyses. Lack of follow-up data after 4 months. Posterior decompression spine surgeries also have the risk of spinal cord injury. Patients of the LC group had significant operation time, much bleeding. Normally, laminectomy procedures were not so different. Therefore, these results lead to almost the same results among the procedures. Especially, laminectomies are most simple
11 procedures than laminoplasties. The study is failed to clarify the reasons for such results.
5. Conclusion The analysis demonstrated that all posterior decompression spine surgeries (French-door laminoplasty, open-door laminoplasty, and laminectomy) were effective surgical procedures in Chinese patients with cervical spondylotic myelopathy. French-door laminoplasty may recover faster than open-door laminoplasty and laminectomy. Also, Frenchdoor laminoplasty may have good clinical, radiological, and surgical outcome measures and a better quality of life.
Availability of data and materials The datasets used and analyzed during the current study available from the corresponding author on reasonable request.
Funding support None.
Conflict of interest The authors declared that he has no conflict of interest or any the other competing interest regarding results and/or discussion reported in the research.
Authors’ contributions All authors have reviewed and approved the submitted manuscript for publication. QL was project administrator, contributed to the formal analysis, literature review, and visualization of the study. XH contributed to the conceptualization, design, and literature review of the study. RW contributed to the conceptualization, literature review, and formal analysis of the study. YZ contributed to the conceptualization, literature review, and software of the study. PL contributed to the design, formal analysis, and literature review of the study. QD contributed to literature review and software of the study, draft, review, and edited the manuscript for intellectual content. The author agrees to be accountable for all aspects of work ensuring integrity and accuracy.
Acknowledgments Figure 11 The quality of life analysis. Variables are represented as mean SD. The numbers of patients were enrolled in the individual group: n: 110. A two-tailed paired t-test was used for statistical analysis between groups. The Tukey test was used for post hoc analysis. A p < 0.05 and q > 3.333 were considered significant. The medical staff of the institute(s) (not involved in the surgeries) was evaluated EQ-5D questionnaires. The difference in EQ-5D Z postoperative EQ-5D e preoperative EQ-5D. 1: The best imaginable health. *Improvement in quality of life with respect to open door laminoplasty.
Authors are thankful to all medical and non-medical staff of the Ankang Hospital of Traditional Chinese Medicine, Ankang, Shaanxi, China.
List of abbreviations CSM Cervical spondylotic myelopathy STROBE The strengthening the reporting of observational studies in epidemiology
Please cite this article as: Li Q et al., Clinical recovery after 5 level of posterior decompression spine surgeries in patients with cervical spondylotic myelopathy: A retrospective cohort study, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.08.003
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12 DICOM
The Digital Imaging and Communications in Medicine STROCSS The strengthening the reporting of cohort studies in surgery EQ-5D questionnaire A standardized instrument for measuring generic health status
Appendix A. Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.asjsur.2019.08.003.
References 1. Kang L, Lin D, Ding Z, Liang B, Lian K. Artificial disk replacement combined with midlevel ACDF versus multilevel fusion for cervical disk disease involving 3 levels. Orthopedics. 2013;36: e88ee94. 2. Wang T, Wang H, Liu S, An HD, Liu H, Ding WY. Anterior cervical discectomy and fusion versus anterior cervical corpectomy and fusion in multilevel cervical spondylotic myelopathy: a metaanalysis. Medicine. 2016;95. https://doi.org/10.1097/MD.0000 000000005437. 3. Shen C, Shen Y, Ding W, Zhang Y, Cao J. Contrastive analysis of neck axial symptoms after hybrid surgery or traditional anterior cervical discectomy and fusion for treatment of two-level cervical disease. J Rep Reconstr Surg. 2013;27:58e61 [Article in Chinese]. 4. Vicario C, Lopez-Oliva F, Sanchez-Lorente T, et al. Anterior cervical fusion with tantalum interbody implants. Clinical and radiological results in a prospective study. Neurocirugia. 2006; 17:132e139 [Article in Spanish]. 5. Miyamoto H, Maeno K, Uno K, Kakutani K, Nishida K, Sumi M. Outcomes of surgical intervention for cervical spondylotic myelopathy accompanying local kyphosis (comparison between laminoplasty alone and posterior reconstruction surgery using the screw-rod system). Eur Spine J. 2014;23:341e346. 6. Hardman J, Graf O, Kouloumberis PE, Gao WH, Chan M, Roitberg BZ. Clinical and functional outcomes of laminoplasty and laminectomy. Neurol Res. 2010;32:416e420. 7. Ito M, Nagahama K. Laminoplasty for cervical myelopathy. Glob Spine J. 2012;2:187e194. 8. Yang XJ, Tian RJ, Su X, Hu SB, Lei W, Zhang Y. Relationship of actual laminoplasty opening size and increment of the crosssectional area based on single-door cervical laminoplasty. Medicine. 2018;97. https://doi.org/10.1097/MD.00000000000 10216. 9. Orabi M, Chibbaro S, Makiese O, Cornelius JF, George B. Double-door laminoplasty in managing multilevel myelopathy: technique description and literature review. Neurosurg Rev. 2008;31:101e110. 10. Nakashima H, Kato F, Yukawa Y, et al. Comparative effectiveness of open-door laminoplasty versus French-door laminoplasty in cervical compressive myelopathy. Spine. 2014;39: 642e647. 11. Aono H, Ohwada T, Hosono N, et al. Incidence of postoperative symptomatic epidural hematoma in spinal decompression surgery. J Neurosurg Spine. 2011;15:202e205. 12. Wang HQ. Letter: laminoplasty: A review of its role in compressive cervical myelopathy. Spine J. 2009;9:426. 13. Agha RA, Borrelli MR, Vella-Baldacchino M, Thavayogan R, Orgill DP, STROCSS Group. The STROCSS statement: strengthening the reporting of cohort studies in surgery. Int J Surg. 2017;46:198e202.
Q. Li et al. 14. Dewilde S, Annemans L, Peeters A, et al. Modified Rankin scale as a determinant of direct medical costs after stroke. Int J Stroke. 2017;12:392e400. 15. Fehlings MG, Barry S, Kopjar B, et al. Anterior versus posterior surgical approaches to treat cervical spondylotic myelopathy: outcomes of the prospective multicenter AOSpine North America CSM study in 264 patients. Spine. 2013;38:2247e2252. 16. McMillan T, Wilson L, Ponsford J, Levin H, Teasdale G, Bond M. The Glasgow outcome scale-40 years of application and refinement. Nat Rev Neurol. 2016;12:477e485. 17. Tabouret E, Gravis G, Cauvin C, Loundou A, Adetchessi T, Fuentes S. Long-term survivors after surgical management of metastatic spinal cord compression. Eur Spine J. 2015;24:209e215. 18. Hida T, Sakai Y, Ito K, et al. Collar fixation is not mandatory after cervical laminoplasty: a randomized controlled trial. Spine. 2017;42:E253eE259. 19. Lee JS, Son DW, Lee SH, Kim DH, Lee SW, Song GS. The predictable factors of the postoperative kyphotic change of sagittal alignment of the cervical spine after the laminoplasty. J Korean Neurosurg Soc. 2017;60:577e583. 20. Hou Y, Liang L, Shi GD, et al. Comparing effects of cervical anterior approach and laminoplasty in surgical management of cervical ossification of posterior longitudinal ligament by a prospective nonrandomized controlled study. Orthop Traumatol Surg Res. 2017;103:733e740. 21. Nurboja B, Kachramanoglou C, Choi D. Cervical laminectomy vs laminoplasty: is there a difference in outcome and postoperative pain? Neurosurgery. 2012;70:965e970. 22. Healy BC, Arora A, Hayden DL, et al. Approaches to normalization of spinal cord volume: application to multiple sclerosis. J Neuroimaging. 2012;22:e12ee19. 23. Kanbara S, Yukawa Y, Ito K, Machino M, Kato F. Surgical outcomes of modified lumbar spinous process-splitting laminectomy for lumbar spinal stenosis. J Neurosurg Spine. 2015; 22:353e357. 24. Yoon S, Park JY, Kuh SU, et al. Risk factors for cervical sagittal malalignment after cervical laminoplasty. Nerve. 2017;3:38e43. 25. Heller JG, Edwards 2nd CC, Murakami H, Rodts GE. Laminoplasty versus laminectomy and fusion for multilevel cervical myelopathy: an independent matched cohort analysis. Spine. 2001;26:1330e1336. 26. Woods BI, Hohl J, Lee J, Donaldson 3rd W, Kang J. Laminoplasty versus laminectomy and fusion for multilevel cervical spondylotic myelopathy. Clin Orthop Relat Res. 2011;469: 688e695. 27. Manzano GR, Casella G, Wang MY, Vanni S, Levi AD. A prospective, randomized trial comparing expansile cervical laminoplasty and cervical laminectomy and fusion for multilevel cervical myelopathy. Neurosurgery. 2012;70:264e277. 28. Gu Z, Zhang A, Shen Y, Li F, Sun X, Ding W. Relationship between the laminoplasty opening size and the laminoplasty opening angle, increased sagittal canal diameter and the prediction of spinal canal expansion following open-door cervical laminoplasty. Eur Spine J. 2015;24:1613e1620. 29. Kurokawa R, Kim P. Cervical laminoplasty: the history and the future. Neurol Med Chir. 2015;55:529e539. 30. Park JH, Roh SW, Rhim SC, Jeon SR. Long-term outcomes of 2 cervical laminoplasty methods: midline splitting versus unilateral single door. J Spinal Disord Tech. 2012;25:E224eE229. 31. Puttlitz CM, Deviren V, Smith JA, et al. Biomechanics of cervical laminoplasty: kinetic studies comparing different surgical techniques, temporal effects and the degree of level involvement. Eur Spine J. 2004;13:213e221. 32. Hale JJ, Gruson KI, Spivak JM. Laminoplasty: a review of its role in compressive cervical myelopathy. Spine J. 2006;6:289Se298S. 33. Ohya J, Oshima Y, Takeshita K, et al. Patient satisfaction with double-door laminoplasty for cervical compression myelopathy. J Orthop Sci. 2015;20:64e70.
Please cite this article as: Li Q et al., Clinical recovery after 5 level of posterior decompression spine surgeries in patients with cervical spondylotic myelopathy: A retrospective cohort study, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.08.003
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Asian Journal of Surgery xxx (xxxx) xxx
Available online at www.sciencedirect.com
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ORIGINAL ARTICLE
Clinical recovery after 5 level of posterior decompression spine surgeries in patients with cervical spondylotic myelopathy: A retrospective cohort study Qiaomei Li a, Xiaoqiang Han b, Renqiang Wang a, Yuanyuan Zhang a, Puke Liu a, Qingqing Dong c,* a Department of Operating and Anesthesiology, Ankang Hospital of Traditional Chinese Medicine, Ankang, Shaanxi, 725000, China b Department of Orthopedic, Ankang Hospital of Traditional Chinese Medicine, Ankang, Shaanxi, 725000, China c Department of Outpatient, Ankang Hospital of Traditional Chinese Medicine, Ankang, Shaanxi, 725000, China
Received 13 June 2019; received in revised form 14 July 2019; accepted 5 August 2019
KEYWORDS Bone union; Cervical spondylotic myelopathy; Cervical lordotic; Posterior decompression spine surgeries; Spinal cord volume
Summary Background/Objective: The selection of surgical technique in patients with cervical spondylotic myelopathy relies on the surgeon(s) and patients’ conditions. The objectives of the study were to test the hypotheses that French-door laminoplasty recovers faster than laminectomy and has good outcome measures. Methods: Data regarding surgical, radiological, and clinical outcome measures of 330 patients with cervical spondylotic myelopathy operated under French-door laminoplasty (fdLP group, n Z 110), open-door laminoplasty (odLP group, n Z 110), or laminectomy (LC group, n Z 110) were collected from the records of institute and analyzed. Results: Patients of fdLP group (p < 0.0001, q Z 11.65) and odLP group (p < 0.0001, q Z 11.27) both had significantly improved modified Rankin scale score than those of LC group. In addition, patients of fdLP group had minimum blood loss during operations and that was maximum for patients of the LC group. Unlike patients of fdLP group (p < 0.0001, q Z 80) and LC group (p < 0.0001, q Z122), those of odLP group had lost more amount of cervical lordotic after surgery. Open-door laminoplasty had significantly reduced cervical range of motion than laminectomy (p < 0.0001, q Z 15.45) and French-door laminoplasty (p < 0.0001, q Z 13.45). After 12-months, fdLP group had higher bone union rate than odLP group (p Z 0.007,
* Corresponding author. Fax: þ0086 0915 8183608. E-mail addresses: [email protected] (Q. Li), [email protected] (X. Han), [email protected] (R. Wang), zobrqu@163. com (Y. Zhang), [email protected] (P. Liu), [email protected] (Q. Dong). https://doi.org/10.1016/j.asjsur.2019.08.003 1015-9584/ª 2019 Asian Surgical Association and Taiwan Robotic Surgery Association. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Please cite this article as: Li Q et al., Clinical recovery after 5 level of posterior decompression spine surgeries in patients with cervical spondylotic myelopathy: A retrospective cohort study, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.08.003
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Q. Li et al. q Z 3.395) and LC group (p Z 0.007, q Z 4.243). French door laminoplasty had a better postoperative quality of life. Conclusions: Among the posterior decompression spine surgeries, French-door laminoplasty is superior surgical procedure than laminectomy and could be superior surgical technique than open-door laminoplasty. ª 2019 Asian Surgical Association and Taiwan Robotic Surgery Association. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction Congenital and degenerative changes of the cervical spinal canal are responsible for cervical spondylotic myelopathy (CSM)1 and becoming one of the leading cause in old patients, affecting the physical, psychological, and social quality of life. Also, significantly increases economic burden.2 Anterior cervical discectomy and fusion,3 anterior cervical corpectomy and fusion,4 posterior decompression spine surgeries, e.g. laminoplasty,5 laminectomy with fusion,2 and laminectomy6 are available surgical treatment options for CSM. The spinal cord injury is the major risk factor associated with anterior cervical discectomy and fusion surgery, while anterior cervical corpectomy and fusion surgery is difficult spinal surgery so far.2 Laminectomy has satisfactory outcomes but has technical failures, e.g. postoperative kyphosis and worsening of neurological functions and intraoperative spinal cord injury.7 Moreover, laminoplasty has greater cervical spine stability than laminectomy.6 Single-door laminoplasty is the preferred surgical procedure.8 Apart from this, the double-door laminoplasty (e.g. French-door laminoplasty) procedure is also used by surgeons.9 There are several procedures available for singledoor laminoplasty, for example, open-door laminoplasty.10 However, laminoplasty has postoperative clinical issues, e.g. hematoma11 and C5 nerve root palsy (sensory disturbance and weakness of deltoid muscle at C5 area).7 Patients’ conditions also have a crucial role in the selection of the surgical technique by the surgeon(s). Therefore, the selection of surgical technique in CSM is required to justify. The objectives of the retrospective analysis were to outline the clinical effectiveness, radiological outcomes, and postoperative complications of patients with CSM who underwent French-door laminoplasty, open-door laminoplasty, or laminectomy in a Chinese setting.
2. Materials and methods
signed by enrolled patients or patient relatives (legally authorized person) regarding anesthesia, surgeries, and the publication of the study (including personal data) irrespective of time and language during hospitalization. As being retrospective analysis registration of the study in the Chinese clinical trial registry had been waived by the institutional review board.
2.2. Inclusion criteria Patients age 18 years and above with CSM (and degenerative indication) and planned to undergo 5 level spine surgery (laminoplasty or laminectomy) from C3 to C7 were included in the analysis.
2.3. Exclusion criteria The patients’ age below 18 years were excluded from the analysis. Patient with 5 levels of spine surgeries, who had damage to the ventral spine, those who had an unstable spine, and patients who faced surgeries for spinal code injuries was excluded from the analysis. Patients who had faced less than 5 levels of anterior decompression spinal cord surgeries were excluded from the analysis. Patients with insufficient data at institute records were also excluded from the analysis. 2.3.1. Cohort Patients who needed the removal of the bone between the spinal process and facet pedicle junction to expose the neural elements of the spine were subjected to laminectomy and patients who needed an opening of the lamina to enlarge the spinal canal during surgeries were subjected to laminoplasty. The choice of French-door laminoplasty or open-door laminoplasty was surgeon’s decision who made surgery.
2.4. Surgical techniques 2.1. Ethical consideration and consent to participate The original protocol (ATCM/CL/5/14 dated 22 December 2014) of the study had been approved by the Ankang Hospital of Traditional Chinese Medicine review board. The study had adhered to the law of China, the strengthening the reporting of observational studies in epidemiology (STROBE) statement, and Declaration of Helsinki (V2008). An informed consent form had been
2.4.1. Laminoplasty The head of patients had been placed in a neutral position in a Mayfield clamp (MIL1108, Medline Industries, Inc., San Diago, CA, USA). C3eC7 was exposed by incision and the cutting processes had been performed a by bone cutter (MDS3234720, Forcep, Cutting, Bone, Horsley, D/A, 1000 , Medline Industries, Inc., San Diago, CA, USA).12 The surrounding soft tissues were removed. C6 and C7 were used to prepare graft. A trough was drilled on the less symptomatic
Please cite this article as: Li Q et al., Clinical recovery after 5 level of posterior decompression spine surgeries in patients with cervical spondylotic myelopathy: A retrospective cohort study, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.08.003
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Posterior Decompression Spine Surgeries side at the laminaefacet joint by a MidaseRex drill/M8 cutting bit (Medline Industries, Inc., San Diago, CA, USA). The contralateral laminaefacet junction was also drilled from C3 to C7. The structured autograft was placed in space.6 Spinal canal was opened on one side, the other side was hinged, and an asymmetrical expansion of the canal was created in open-door laminoplasty. While, in the Frenchdoor laminoplasty, the spinal canal was opened from the midline and the symmetrical opening of the canal was made.10 A total of 15 spine surgeons of the institute (minimum 10-years of experience) were involved in the laminoplasty surgeries. Single surgeon approach was preferred. 2.4.2. Laminectomy The patients had been positions in the same manner as those of laminoplasty. The drilling was performed bilaterally at gutters and bones were removed completely preserving facet joints.6 A total of 15 spine surgeons (minimum 10-years of experience) of the institute were involved in the laminectomy surgeries. Single surgeon approach was preferred. All posterior decompression spine surgeries had been performed in line with the STROCSS (the strengthening the reporting of cohort studies in surgery) criteria.13
Percentage cervical range of motion Z
3 moderate disability, 2: severe disability, 3: persistent vegetative state, and 5: death.16
2.9. Karnofsky performance status It was measured to evaluate daily activity. 0: death and 100: normal without any complain.17
2.10. Cervical lordotic angle The neutral lateral x-ray (GE Healthcare, Chicago, IL, USA) view of all patients were taken in supine, sitting, and standing positions. The cervical lordotic angle was evaluated as the difference between preoperative and postoperative cervical angle.18 The cervical lordosis was calculated as the Cobb angle between the lower endplate of C7 and C2 (Fig. 1).19
2.11. Percentage cervical range of motion T2 Magnetic resonance imaging (GE Healthcare, Chicago, IL, USA) was performed in supine position of patients to check flexion rotation, extension rotation, or lateral bending to measure the cervical range of motion and percentage cervical range of motion was evaluated as per Eq. (1),20:
Preoperative angle Postoperative angle 100 Preoperative angle
ð1Þ
2.5. Clinical recovery
2.12. The quality of life
The information of patients regarding functions and disabilities (preoperative and postoperative until discharge) were collected from the Digital Imaging and Communications in Medicine (DICOM) of institutes. The medical staff (minimum 3-years of experience) of the institutes who were not involved in the surgeries had evaluated the scores.
The quality of life was evaluated by the EQ-5D questionnaire (a standardized instrument for measuring generic health status) Chinese version.21
2.6. Modified Rankin scale
T2 Magnetic resonance imaging (GE Healthcare, Chicago, IL, USA) was performed in the supine position and the neck was fixed in the central position. The sagittal sectional area of the spinal cord was measured by using a cursor to find the vertebrate profile on each slice, and the spinal cord volume was calculated by compiling the sagittal sectional area. The size measured from the foramen magnum to the inferior border of the C7 (Fig. 2).22 All outcome measures were evaluated one week after surgeries.
The degree of dependency of the patients was measured by the Modified Rankin scale. It was seven-points scale scores. 0: normal and 6: death.14
2.7. Nurick scale It was a six-point scale score. 0: normal and 5: bedridden or chair bound.15
2.13. Spinal cord volume
2.8. Glasgow outcome score
2.14. Bone union rate
It was accessed to focus on the outcome of the surgeries and was a five-point scale score. 0: good recovery, 1:
Bone union rates were evaluated from the Computed Tomography scan after 6 and 12-months of surgeries.23
Please cite this article as: Li Q et al., Clinical recovery after 5 level of posterior decompression spine surgeries in patients with cervical spondylotic myelopathy: A retrospective cohort study, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.08.003
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Q. Li et al. Medicine, Ankang, Shaanxi, China, and the referring hospitals from 1 January 2015 to 1 July 2018 who faced 5 levels of posterior decompression surgeries were reviewed. Among them 15 patients had confounded results with study evaluation parameters, 8 patients were partially ambulant (spinal cord injuries), 7 were fully ambulant (spinal cord injuries), 6 patients were planned for instrumentation procedure, and 5 patients had planned for cervical spine fusion. Therefore, data of these patients were excluded from the analysis. The data of 330 patients were included in the analysis. Patients with CSM operated under French-door laminoplasty were included into fdLP group (n Z 110), those operated under open-door laminoplasty were included into odLP group (n Z 110), and patients operated under laminectomy were included into LC group (n Z 110). Clinical effectiveness, radiological outcomes, and complications during 1-year of follow-up of all study patients were evaluated. Flow diagram of the work-up is presented in Fig. 3.
3.2. The demographic characteristics Figure 1 The x-ray view (in sitting position) for measurement of the cervical lordosis between C2 and C7.
2.15. Statistical analysis InStat, GraphPad Software, San Diego, USA was used for analysis purposes. The Chi-square Independence test6 was used for a categorical variable. A two-tailed paired t-test (between groups) or the Wilcoxon test6 (between preoperative and postoperative conditions) following the Tukey post hoc test (considering critical value [q] > 3.333 as significant)24 were used for continuous variables. The results were considered significant at 95% of confidence level.
3. Results
Most of the patients were overweight. The other demographic characteristics and clinical conditions of patients at the time of the surgeries are presented in Table 1. There was no significant difference between preoperative clinical conditions of the patients (p > 0.05 for all).
3.3. Surgical outcome measures Surgeons had taken 101.12 25.47 min, 98.45 21.42 min, and 152.47 25.47 min to perform surgeries for patients of fdLP, odLP, and LC group respectively (Fig. 4). The time required for the hospital stays for patients of fdLP, odLP, and LC group were 8.15 2.11 days, 9.15 3.14 days, and 12.14 5.15 days respectively (Fig. 5). Estimated blood loss during the operation for patients of fdLP, odLP, and LC group was 220.47 30.41 mL, 325.47 50.17 mL, and 410.12 25.47 mL respectively (Fig. 6).
3.1. Enrollment 3.4. Radiological outcome measures Data of 371 patients with CSM in at the department of spine surgery of the Ankang Hospital of Traditional Chinese
Patients of fdLP, odLP, and LC had reported 0.55 0.08 , 1.3 0.15 , and 0.15 0.02 of the reduced cervical lordotic angle after surgery respectively (Fig. 7). Patients of fdLP (34.11 7.91 vs. 27.11 5.61-degree, p < 0.0001), odLP (33.92 6.75 vs. 20.12 4.45-degree, p < 0.0001), and LC (34.51 6.79 vs. 28.15 6.15-degree, p < 0.0001) all had reported reduction in the postoperative cervical range of motion (Fig. 8).
3.5. Clinical outcome measures
Figure 2 T2 weighted magnetic resonance image of the sagittal sectional area of the spinal cord to find spinal cord volume.
After surgeries, laminectomy (p Z 0.008), French-door laminoplasty (p < 0.0001), and open-door laminoplasty (p < 0.0001) all had improved modified Rankin scale score as compared to baseline. However, French-door laminoplasty (p < 0.0001, q Z 11.65) and open-door laminoplasty (p < 0.0001, q Z 11.27) both had significantly improved modified Rankin scale score than laminectomy (Fig. 9).
Please cite this article as: Li Q et al., Clinical recovery after 5 level of posterior decompression spine surgeries in patients with cervical spondylotic myelopathy: A retrospective cohort study, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.08.003
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Posterior Decompression Spine Surgeries
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Figure 3
Flow diagram of the study.
Glasgow outcome score for fdLP, odLP, and LC groups were 1.35 0.35, 1.34 0.41, and 1.45 0.31 respectively. Bone union rate at 6-months for fdLP, odLP, and LC groups were 63 (57%), 61 (55%), and 57 (52%) respectively. While, at 12-months for fdLP, odLP, and LC groups were 90 (82%), 74 (67%), 70 (64%) respectively (Fig. 10). After 12months, fdLP group had higher bone union rate than odLP group (p Z 0.007, q Z 3.395) and LC group (p Z 0.007, q Z 4.243). As compared to baseline, French-door laminoplasty (p Z 0.03), open-door laminoplasty (p Z 0.0002), and laminectomy (p Z 0.03) all had improved Nurick scale score of patients. Also, French-door laminoplasty (p < 0.0001), open-door laminoplasty (p < 0.0001), and laminectomy (p Z 0.0002) all had improved Karnofsky performance status of patients as compared to baseline. However, after open-door laminoplasty cervical lordotic angle of the patients was significantly reduced as compared to baseline (p Z 0.034) and also as compared to French-door
laminoplasty (p Z 0.0008, q Z 4.31) and laminectomy (p Z 0.0008, q Z 4.96). All procedures were increased spinal cord volume after surgeries (p < 0.05 for all) but French-door laminoplasty had significant fewer increased spinal cord volume after surgeries than open-door laminoplasties and laminectomies (Table 2).
3.6. Postoperative complications Laminoplasties had reported postoperative hematoma (p Z 0.03). After all types of surgeries, none of the patients was suffered from clinical deterioration, permanent morbidity, or mortality. For fdLP, odLP, and LC groups, postoperative infection were reported in 3 (3%), 3 (3%), and 1 (1%) respectively. In all group, few patients had minor dehiscence after surgeries. Minor dehiscence was overcome by additional sutures. Less intravenous narcotics (morphine or morphine equivalent) was required for postoperative pain for laminoplasties than
Please cite this article as: Li Q et al., Clinical recovery after 5 level of posterior decompression spine surgeries in patients with cervical spondylotic myelopathy: A retrospective cohort study, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.08.003
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Q. Li et al. Table 1
Preoperative clinical conditions of the patients. Characteristics
Groups
Comparison between groups
fdLP
odLP
LC
French-Door Laminoplasty
Open-Door Laminoplasty
Laminectomy
Sample size (n)
110
110
110
p-value
Age
81 35 58.85 8.75 71 (65) 39 (35) 25 (23)
79 34 60.11 7.21 73 (66) 37 (34) 24 (22)
80 36 59.15 6.81 78 (70) 32 (30) 26 (23)
0.443
59 (54)
58 (53)
61 (55)
26 (23) 3.52 0.39 2.82 0.21 55.42 8.15
28 (25) 3.47 0.31 2.84 0.26 56.61 8.89
23 (22) 3.43 0.30 2.88 0.27 57.63 9.21
0.139 0.19 0.175
14.71 2.01
13.91 2.97
14.45 2.45
0.056
34.11 7.91
33.92 6.75
34.51 6.79
0.824
8.64 1.46
8.53 1.41
8.41 1.52
0.508
Types of surgery
Maximum Minimum Mean SD Gender Male Female 18.5e24.9 Body mass (Normal) index (kg/m2) 25e29.9 (Overweight) 30 (Obese) a Modified Rankin scale b Nurick scale c Karnofsky Performance Status d Preoperative cervical lordotic angle (degree) e Preoperative Cervical range of motion (degree) The spinal canal volume (cm3)
0.585 0.906
n: the numbers of patients were enrolled in the individual group. Continuous variables are represented as mean SD and constant variables are represented as number (percentage). The Chi-square independence test (for constant variables) and two-tailed paired t-test (for continuous variables) were used for statistical analysis. A p < 0.05 was considered significant. The medical staff of the institute(s) (not involved in the surgeries) was evaluated in clinical conditions. a 0: normal and 6: death. b 0: normal and 5: bedridden or chair bound. c 0: death and 100: normal without any complaint. d The neutral lateral X-ray view. e T2 Magnetic resonance imaging.
laminectomy (p Z 0.005). After discharge patients with subjective pain went to a nursing home and those with poor neurological recovery went to inpatient rehabilitation. All went home by the end of 4-months. fdLP group had 2 (2%) patients were subjected to reoperation, which was fewer than reoperations reported in odLP group (12, p Z 0.008, q Z 3.46) and LC group (14, p Z 0.008, q Z 4.15). Also, least numbers of residual neurological symptoms were reported in fdLP group than the odLP group and LC group (Table 3).
3.7. Quality of life
Figure 4 Operation time to complete the procedure. Variables are represented as mean SD. The numbers of patients were enrolled in the individual group: n: 110. Two-tailed paired t-test following the Tukey post hoc test was used for statistical analysis. A p < 0.05 and q > 3.333 were considered significant. # Significant less operation time required than a laminectomy.
There was no significant change for EQ-5D difference between laminectomy and French door laminoplasty (p < 0.0001, q Z 3.323) but significant difference between laminectomy and open door laminoplasty (p < 0.0001, q Z 67.56). Also, significant difference between French door laminoplasty and open door laminoplasty (p < 0.0001, q Z 64.24, Fig. 11).
Please cite this article as: Li Q et al., Clinical recovery after 5 level of posterior decompression spine surgeries in patients with cervical spondylotic myelopathy: A retrospective cohort study, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.08.003
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Posterior Decompression Spine Surgeries
Figure 5 Hospital stays of patients. Variables are represented as mean SD. The numbers of patients were enrolled in the individual group: n: 110. Two-tailed paired t-test following the Tukey post hoc test was used for statistical analysis. A p < 0.05 and q > 3.333 were considered significant. #Significant fewer hospital stays than a laminectomy. The time required to admit the hospital prior surgery to discharge after surgery was considered as hospital stays.
4. Discussion 4.1. Surgical outcome measures The analysis reported that French-door laminoplasty and open-door laminoplasty both had required less time for operation (p < 0.0001, q Z 22.26 and p < 0.0001, q Z 23.42), less blood loss during operation (p < 0.0001, q Z 53.87 and p < 0.0001, q Z 24.04), and fewer hospital stays (p < 0.0001, q Z 11.34 and p < 0.0001, q Z 8.5), than laminectomy. The analysis results were parallel with retrospective cohort analyses.6,25e27 The laminoplasties
7
Figure 7 Reduction in cervical angle. Variables are represented as mean SD. The numbers of patients were enrolled in the individual group: n: 110. Two-tailed paired t-test following the Tukey post hoc test was used for statistical analysis. A p < 0.05 and q > 3.333 were considered significant. A p < 0.05 was considered significant.# Significant greater cervical lordotic angle after surgery. The neutral lateral X-ray view.
contributed more opportunities for the muscle to reattach to the cervical bone and rapid recovery due to the preservation of bony covering of the dura. The analysis had reported that less blood loss during operation (p < 0.0001, q Z 29.82) for French-door laminoplasty than open-door laminoplasty. The opening size of laminoplasty may affect surgical outcomes.28 Symmetrical cervical lamina opening has positive surgical outcomes.8,10 Muscle dissection to expose the lamina most significantly contributes to the amount of blood loss. The way to open the lamina makes such a difference. French-door laminoplasty is found to superior to open-door laminoplasty and laminectomy.
4.2. Radiological outcome measures
Figure 6 Estimated blood loss during operation. Variables are represented as mean SD. The numbers of patients were enrolled in the individual group: n: 110. Two-tailed paired ttest following the Tukey post hoc test was used for statistical analysis. A p < 0.05 and q > 3.333 were considered significant. A p < 0.05 was considered significant. #Significant less blood loss.
Unlike French-door laminoplasty (p < 0.0001, q Z 80) and laminectomy (p < 0.0001, q Z 122), open-door laminoplasty reported significant greater reduction in cervical lordotic angle after surgery. After surgeries, open-door laminoplasty significantly reduced higher cervical range of motion than French-door laminoplasty (p < 0.0001, q Z 13.45) and laminectomy (p < 0.0001, q Z 15.45). Also, patients of fdLP group had reported the least increased in the spinal canal volume after French-door laminoplasty. The opening size of laminoplasty has a crucial role in radiological outcomes.28 The worst radiological outcomes reported by open-door laminoplasty were parallel with the available study.9,10 Cervical kyphosis is a result of the protective reaction of the body to increase the spinal canal volume.29 Kyphosis can be prevented by laminoplasty than laminectomy but French-door laminoplasty could be safe surgery than open-door laminoplasty. After surgeries, open-door laminoplasty significantly reduced the cervical range of motion among all surgeries. The analysis results were parallel with the available studies10,30 but the results of the analysis were not parallel
Please cite this article as: Li Q et al., Clinical recovery after 5 level of posterior decompression spine surgeries in patients with cervical spondylotic myelopathy: A retrospective cohort study, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.08.003
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Q. Li et al.
Figure 8 Cervical range of motion (degree) analysis. Variables are represented as mean SD. The numbers of patients were enrolled in the individual group: n: 110. Two-tailed paired t-test following the Tukey post hoc test was used for statistical analysis. A p < 0.05 and q > 3.333 were considered significant. A p < 0.05 was considered significant. # Significant lower degree of cervical range of motion. T2 Magnetic resonance imaging.
Figure 9 Modified Rankin scale score analysis. Variables are represented as mean SD. The numbers of patients were enrolled in the individual group: n: 110. The Wilcoxon test was used for statistical analysis between BL and EL. A two-tailed paired t-test was used for statistical analysis between groups. The Tukey test was used for post hoc analysis. BL: before surgery, EL: after surgery. A p < 0.05 and q > 3.333 were considered significant. The medical staff of the institute(s) (not involved in the surgeries) was evaluated in clinical conditions. #Significant improvement than a laminectomy. 0: normal and 6: death.
with an experimental study.31 To maintain the cervical range of motion after surgery, it is necessary to decrease neck pain.24 Excessive opening of spinal laminae is responsible for the decrease in postoperative cervical range of motion in open-door laminoplasty.10 With respect to the radiological outcomes of the study, open-door laminoplasty is inferior surgical procedure than French-door laminoplasty surgical procedure.
4.3. Clinical outcome measures The study reported the same neurological outcome (insignificant difference for Nurick scale score (p Z 0.062), Karnofsky performance status (p Z 0.143)) and Glasgow outcome score (p Z 0.054) among all surgical procedures after the surgeries. The analysis results are parallel with available cohort studies6,10 but not parallel with the other research reports.25e27,30 The reason behind that the study was evaluated parameters during a follow-up period of 12 months only while the available studies evaluated outcome
Figure 10 The Axial Computed Tomography scan of patient 12 months after French-door laminoplasty, displays the union of bone between the split spinous process and residual laminae.
Please cite this article as: Li Q et al., Clinical recovery after 5 level of posterior decompression spine surgeries in patients with cervical spondylotic myelopathy: A retrospective cohort study, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.08.003
Clinical recovery of patients after surgeries.
Parameters
Groups fdLP
odLP
Surgery French-Door (I) BL
EL
(n)
110
110
a
2.82 0.21 55.42 8.15 14.71 2.01 8.64 1.46
2.76 0.19 65.45 15.47 14.12 2.45 9.12 1.49f
NSS KPS c CLA The spinal canal volume (cm3)
LC
Laminoplasty
Level
b
Comparison between groups at EL
Laminectomy (III) Open-Door (II)
d
p
0.03 <0.0001 0.052 0.017
BL
EL
110
110
2.84 0.26 56.61 8.89 13.91 2.97 8.53 1.41
2.71 0.25 64.68 14.48 12.71 5.11e 12.01 1.89
d
p
0.0002 <0.0001 0.034 <0.0001
BL
EL
110
110
2.88 0.27 57.63 9.21 14.45 2.45 8.41 1.52
2.79 0.31 62.12 8.01 14.31 1.49 11.42 1.66
d
p
0.03 0.0002 0.609 <0.0001
p
0.062 0.143 0.0008 <0.0001
q-value I vs. II
I vs. III
II vs. III
N/A N/A 4.31 17.957
N/A N/A 0.6 14.291
N/A N/A 4.96 3.666
Posterior Decompression Spine Surgeries
+
n: Sample size: the numbers of patients were enrolled in the individual group. BL: Before surgery. EL: After surgery. Variables are represented as mean SD. Two-tailed paired t-test following Tukey post hoc test was used for statistical analysis. A p < 0.05 and q > 3.333 were considered significant. The medical staff of the institute(s) (not involved in the surgeries) was evaluated in clinical conditions. N/A: Not applicable. a NSS: Nurick scale score: 0: normal and 5: bedridden or chair bound. b KPS: Karnofsky Performance Status: 0: death and 100: normal without any complaint. c CLA: Cervical lordotic angle (degree): The neutral lateral X-ray view. d the Wilcoxon test was used for statistical analysis between BL and EL. e Significant decrease than French-door laminoplasty and laminectomy. f Significant lesser increased spinal cord volume after French-door laminoplasty than open-door laminoplasty and laminectomy.
MODEL
9
Please cite this article as: Li Q et al., Clinical recovery after 5 level of posterior decompression spine surgeries in patients with cervical spondylotic myelopathy: A retrospective cohort study, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.08.003
Table 2
10
Surgical outcome measures. Characteristics
Types of surgery Sample size (n) Intravenous narcotics used Postoperative complications
The discharge disposition
Abnormal reflexes The weakness of the arms or legs Inability to speak Decreased sensation Loss of balance Mental function problems, such as memory loss Vision changes Walking problems Total
Comparison between groups
fdLP
odLP
LC
French-Door Laminoplasty
Open-Door Laminoplasty
Laminectomy
110
110
110
p-value 0.005
a
a
49 (45) 61 (55)a 3 (3) 5 (5) 7 (6)a 4 (4) 0 (0) 0 (0) 0 (0) 0 (0) 80 (72) 21 (19) 9 (9) 2 (2)d 2 (2) 1 (1)
47 (43) 63 (57)a 3 (3) 4 (4) 6 (5)a 3 (3) 0 (0) 0 (0) 0 (0) 0 (0) 79 (71) 22 (20) 9 (9) 12 (11) 3 (3) 2 (2)
69 (63) 41 (37) 1 (1) 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) 0 (0) 74 (67) 25 (23) 11 (10) 14 (13) 5 (5) 3 (3)
0 1 1 1
2 4 4 2
1 7 5 4
(0) (1) (1) (1)
0 (0) 1 (1) 7 (7)d
(2) (4) (4) (2)
1 (1) 3 (3) 21 (21)
0.008 <0.0001
(1) (6) (5) (4)
2 (2) 5 (4) 32 (30)
Q. Li et al.
n: the numbers of patients were enrolled in the individual group. Data are represented as a number (percentage). The Chi-square independence test was used for statistical analysis between groups. A p < 0.05 was considered significant. The medical staff of the institute(s) (not involved in the surgeries) was evaluated in clinical conditions. N/A: Not applicable. a Significant higher for laminoplasty than a laminectomy. b Patients with subjective pain. c Patients with poor neurological recovery. d Significant fewer than open-door laminoplasty than a laminectomy.
0.558 0.09 0.03 0.408 N/A N/A N/A N/A 0.921
MODEL
Re-operation Residual neurological symptoms
48 h >48 h Postoperative infection C5 nerve root palsy Hematoma Minor dehiscence Major dehiscence Clinical deterioration Permanent morbidity Mortality Home c Inpatient rehabilitation b Nursing home
Groups
+
Please cite this article as: Li Q et al., Clinical recovery after 5 level of posterior decompression spine surgeries in patients with cervical spondylotic myelopathy: A retrospective cohort study, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.08.003
Table 3
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Posterior Decompression Spine Surgeries measures during 5 years of follow-up. A randomized clinical trial is required to perform for a long follow-up period. French-door laminoplasty had higher bone union rate than open-door laminoplasty and laminectomy. The results of the study were in line with the retrospective study.23 French-door laminoplasty has higher spinal stability.
4.4. Quality of life The study reported that laminectomy and French door laminoplasty improved the quality of life. While open door laminoplasty had not a good quality of life. The results of the study were consistent with the results of retrospective analyses.6,21 The study recommended French door laminoplasty for better postoperative quality of life for 5 levels of posterior decompression.
4.5. Limitations In the limitations of the study, for examples, the neurological outcome evaluated in the study were not generally used for evaluation of posterior decompression of the spine surgeries. The neurological outcome used in the study for evaluation purposes is required to validate prior implementation.6 Lack of randomization. Experience of the surgeon(s)32 and the satisfaction of patients for the surgical procedure33 may have effects on the postoperative outcomes in the spine surgeries but the study was not carried out such analyses. Lack of follow-up data after 4 months. Posterior decompression spine surgeries also have the risk of spinal cord injury. Patients of the LC group had significant operation time, much bleeding. Normally, laminectomy procedures were not so different. Therefore, these results lead to almost the same results among the procedures. Especially, laminectomies are most simple
11 procedures than laminoplasties. The study is failed to clarify the reasons for such results.
5. Conclusion The analysis demonstrated that all posterior decompression spine surgeries (French-door laminoplasty, open-door laminoplasty, and laminectomy) were effective surgical procedures in Chinese patients with cervical spondylotic myelopathy. French-door laminoplasty may recover faster than open-door laminoplasty and laminectomy. Also, Frenchdoor laminoplasty may have good clinical, radiological, and surgical outcome measures and a better quality of life.
Availability of data and materials The datasets used and analyzed during the current study available from the corresponding author on reasonable request.
Funding support None.
Conflict of interest The authors declared that he has no conflict of interest or any the other competing interest regarding results and/or discussion reported in the research.
Authors’ contributions All authors have reviewed and approved the submitted manuscript for publication. QL was project administrator, contributed to the formal analysis, literature review, and visualization of the study. XH contributed to the conceptualization, design, and literature review of the study. RW contributed to the conceptualization, literature review, and formal analysis of the study. YZ contributed to the conceptualization, literature review, and software of the study. PL contributed to the design, formal analysis, and literature review of the study. QD contributed to literature review and software of the study, draft, review, and edited the manuscript for intellectual content. The author agrees to be accountable for all aspects of work ensuring integrity and accuracy.
Acknowledgments Figure 11 The quality of life analysis. Variables are represented as mean SD. The numbers of patients were enrolled in the individual group: n: 110. A two-tailed paired t-test was used for statistical analysis between groups. The Tukey test was used for post hoc analysis. A p < 0.05 and q > 3.333 were considered significant. The medical staff of the institute(s) (not involved in the surgeries) was evaluated EQ-5D questionnaires. The difference in EQ-5D Z postoperative EQ-5D e preoperative EQ-5D. 1: The best imaginable health. *Improvement in quality of life with respect to open door laminoplasty.
Authors are thankful to all medical and non-medical staff of the Ankang Hospital of Traditional Chinese Medicine, Ankang, Shaanxi, China.
List of abbreviations CSM Cervical spondylotic myelopathy STROBE The strengthening the reporting of observational studies in epidemiology
Please cite this article as: Li Q et al., Clinical recovery after 5 level of posterior decompression spine surgeries in patients with cervical spondylotic myelopathy: A retrospective cohort study, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.08.003
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The Digital Imaging and Communications in Medicine STROCSS The strengthening the reporting of cohort studies in surgery EQ-5D questionnaire A standardized instrument for measuring generic health status
Appendix A. Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.asjsur.2019.08.003.
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Please cite this article as: Li Q et al., Clinical recovery after 5 level of posterior decompression spine surgeries in patients with cervical spondylotic myelopathy: A retrospective cohort study, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.08.003