A Retrospective study comparing the outcomes of

Laminoplasty, Laminectomy and Laminectomy with

lateral mass fixation for Multilevel Degenerative

Cervical Spine Disease

Submitted for MCh Neurosurgery

By

Dr. Debabrata Sahana

2014

DEPARTMENT OF NEUROSURGERY

SREE CHITRA TIRUNAL INSTITUTE FOR MEDICAL SCIENCES

& TECHNOLOGY

THIRUVANANTHPURAM, INDIA- 695011

A Retrospective study comparing the outcomes of

Laminoplasty, Laminectomy and Laminectomy with

lateral mass fixation for Multilevel Degenerative

Cervical Spine Disease

Submitted by : Dr. Debabrata Sahana

Programme : Mch Neurosurgery

Month & Year of submission : October 2014

CERTIFICATE

This is to certify that the thesis entitled “A Retrospective study comparing the

outcomes of Laminoplasty, Laminectomy and Laminectomy with lateral mass

fixation for Multilevel Degenerative Cervical Spine Disease” is a bonafide work of

Dr. Debabrata Sahana and was conducted in the Department of Neurosurgery, Sree

Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthpuram, under

my guidance and supervision.

Prof. Suresh Nair N.

Head

Department of Neurosurgery

SCTIMST, Thiruvananthpuram

DECLARATION

The thesis entitled “A Retrospective study comparing the outcomes of

Laminoplasty, Laminectomy and Laminectomy with lateral mass fixation for

Multilevel Degenerative Cervical Spine Disease” is a consolidated report based on a

bonafide study of the period from January 2000 to June 2013, done by me under the

Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and

Technology, Thiruvananthpuram.

This thesis is submitted to SCTIMST in partial fulfillment of rule and regulations of MCh

Neurosurgery examination.

Dr. Debabrata Sahana

Department of Neurosurgery

SCTIMST, Thiruvananthpuram

ACKNOWLEDGEMENT

This project has been a result of combined efforts of not just me, but a lot of people working with

me and the guidance of my teachers. I grab this opportunity to express my indebtedness to them.

Prof. Suresh Nair N, Head of Department, Neurosurgery, SCTIMST, besides being a great

surgeon, is a wonderful person, whose guidance, expert supervision and untiring help throughout

the period of this study has made it possible for this work take its present form. Without his

knowledge and foresight it was impossible to complete this project. His remarkable sense of

humour has kept us cheerful throughout and helped me steer through times of darkness and

gloom. I take great pride in addressing myself as his student. He was more of a father figure than

a guide to me. His teachings would light the long and tedious roads towards success.

Dr. Krishna Kumar K., Associate Professor, Neurosurgery has been my principal guide for this

project. Without his expertise in this field, it would have been extremely difficult to find my way

through the long lists of references and patient profiles. He has stood by me at each and every

step of this project. His constant encouragement and guidance was essential for completion of

this study.

mI am highly indebted to Prof. Girish Menon R,. Professor Neurosurgery, for providing all the

resources and every possible help and encouragement needed for completion of this project.

His constant reminders and deadlines were invaluable for the progress of this work. I am

thankful to him for all his efforts.

I take this opportunity to express my deep sense of gratitude and regards for my teachers

Dr. Mathew Abraham, Dr. George C. Vilanilam and Dr. Jayanand Sudhir B. for their kind

help, consistent encouragement and healthy suggestions.. Their vast knowledge, acute perception

and critical analysis aided me in innumerable ways. Their cooperation and assistance was

indispensible.

I also express my gratitude for my friends and colleagues Dr Amit Upadhyay, Dr.

Bhaumik Thakur and Dr. Sanjeev Kumar, who have always been there at times of need. Dr.

Adam Kamrudeen, Dr. Chandra Tavishetty, Dr. Vishal Dabre, Dr. Varun Agarwal, Dr. Ranjit

Rangnekar, Dr.Vishal Thakur, Dr. Sridutt and Dr. Vihang Sali have provided me with enough

assistance whenever required. I am indebted to all of them.

I owe my gratitude to all those patients who made it possible for me to bring forth this

study. I thank them for giving me the privilege to serve them.

October 2014 Debabrata Sahana

INDEX

1. Introduction …………………………………………………………………………………….. 1

2. Review of literature……………………………………………………………………………3

3. Aims and objectives…………………………………………………………………………..40

4. Material and methods……………………………………………………………………….41

5. Results………………………………………………………………………………………………..45

6. Discussion …………………………………………………………………………………………86

7. Conclusions……………………………………………………………………………………….96

8. References…………………………………………………………………………………………97

9. Annexures

i. Patient proforma

ii. Pain score questionnaire

1. INTRODUCTION

Controversy exists as to the best posterior operative procedure to treat multilevel

compressive cervical spondylotic myelopathy (CSM). Multilevel (>2) anterior cervical

decompression and instrumented fusion is a treatment option that was very popular

throughout the 1990s. Because high rates of pseudoarthrosis, adjacent-level disease,

dysphagia, and instrumentation failure are seen when these constructs span multiple

levels, this technique started falling out of fashion.

Posterior decompressive approaches are coming back in vogue. Multilevel cervical

laminectomies had been the posterior decompressive procedure of choice in the

treatment of CSM. A high incidence of post-laminectomy kyphosis, segmental

instability, and associated postoperative neurological deterioration has been cited for

the reduction in the use of the procedure.

Expansile laminoplasty and multilevel laminectomies with instrumented fusion have

since become more popular means of relieving multilevel spinal stenosis with

myelopathy. Laminoplasty avoids the risk of neurological injury from the violation of

the spinal canal with surgical instruments and provides postoperative spine stability by

preserving the bony arch and the posterior tension band, thereby reducing the incidence

of postoperative kyphosis.

Proponents of multilevel laminectomies with instrumented fusion contend that it deals

most optimally with the pathophysiology responsible for spondylotic myelopathy. Both

static and dynamic factors responsible in the pathophysiology of CSM are addressed by

decompression and instrumentation respectively, halting the progression of disease. It

2

also offers immediate spine stability, thus reducing the risk of postoperative kyphosis

more effectively than laminoplasty.

The study was thus designed to identify the best posterior approach for degenerative

cervical spine disease.

REVIEW OF LITERATURE

3

2. REVIEW OF LITERATURE

Spondylosis defined as “vertebral osteophytosis secondary to degenerative disc

disease” 1 is considered the most common progressive cervical spine disorder in the

elderly 2,3,4

. It should be differentiated arthritis which are a group of inflammatory

disorders, classically involving the synovial membranes of diarthrodial joints, lined

with synovium. The osteophytes seen in spondylosis, a disease of the amphiarthrodial

joint without a synovial membrane are associated with degeneration of the

intervertebral disc5.

Spondylosis is a natural process of aging and is therefore seen in 10% of individuals by

the age of 25 years and in 95% by the age of 65 years6.

Most people with degenerative changes of the cervical spine remain asymptomatic.

Symptomatic patients are usually older than 40 years of age7. Three main symptom

complexes are usually seen: neck pain, cervical radiculopathy, and cervical

myelopathy8.

Neck pain can be acute or chronic and occurs from degenerative disc than from

degenerative facet changes. The facets are innervated by branches of the posterior

primary ramus 9. Neck pain can be associated with abnormalities in the structures

innervated by the sinuvertebral nerve-posterior longitudinal ligament, epidural

vasculature, dura, and spinal periosteum 8.

Cervical radiculopathy can be acute, subacute, or chronic. Radiculopathy caused by

herniated nucleus pulposus more commonly affects patients younger than 55 years

whereas patients older than 55 years are more likely to have canal or foraminal stenosis

caused by osteophyte formation7. Radicular symptoms, in a dermatomal distribution,

may be caused by intraforaminal herniation. A soft herniated disc produces motor

4

findings of weakness and atrophy whereas a hard disc degeneration produces more of

sensory symptoms like paresthesias, hyperesthesias, or hyperalgesias. Motor and reflex

changes are often associated with a chronic condition 8.

Cervical myelopathy may be rapidly progressive or become static, with relatively minor

symptoms 8

and develops in only a fraction of patients with spondylosis 10,11

who are

usually beyond the fifth decade. Long-tract signs are a hallmark. Men are more

commonly affected, with labourers being affected the most 10,11

. Pain was located over

neck pain, subscapular or shoulder region. A shock-like sensations in the limbs, with

rapid flexion or extension of the neck (Lhermitte‟s sign) is also common. Ascending

numbness in the lower extremities with neck extension, and gradual signs of spinal cord

dysfunction with spasticity are also commonly seen12, 10, 13, 11

. Some early subtle

findings include hyperreflexia, and/or Babinski‟s sign, and/or Hoffman‟s reflex, and/or

clonus in an asymptomatic patient 15,14

. The characteristic signs and symptoms include

spastic weakness of the hands and forearms earlier than other muscle groups, hand

numbness, loss of dexterity, and painful paresthesias 3, 11, 12, 13, 26,

lower extremity

weakness, spastic gait, stooped, wide-based, somewhat jerky gait, dorsal column

function loss3, 14, 23

. Atrophy or fasciculation in the distal upper extremities and

sphincter dysfunction 16, 26, 30

occur late and are associated with a poor prognosis26

.

Some of the signs masked by a superimposed upper extremity radiculopathy are

worsened with head compression (Spurling‟s maneuver) 12, 28, 30

. The combined

syndrome of radiculopathy and myelopathy produces motor findings that are

characterized by lower motor neuron involvement at the level of the lesion and upper

motor neuron signs below the level of the lesion 11

5

Anatomy and pathophysiology

Pathophysiology of Spondylosis

Cervical spondylosis results from progressive biomechanical stress and strain and can

be compounded by repetitive trauma. The process involves noninflammatory disk

degeneration (amphiarthrodial joint without a synovial membrane) and is

accompanied by facet joint osteoarthritis (zygapophyseal diarthrodial joint lined with a

synovial membrane), as well as pathologic changes of the posterior longitudinal

ligament and ligamentum flavum such as hypertrophy, laxity, ossification. A normal

disk is composed of the nucleus pulposus, which is a water-rich gel (as a result of

proteoglycan aggrecan molecules that attract and entrap water) in the center of the disk,

and the annulus fibrosus, which is the fibrous outer portion of the disk. The annulus

fibrosus is made of type I collagen and is organized into individual sheets called

lamellae that are oriented at a 60-degree angle. The very outer lamellae, also called

Sharpey‟s fibers, are anchored directly into the bony matrix at the periphery of each

vertebral body, just outside the cartilaginous vertebral end plate. Also of note, in a

healthy cervical spine, the height of the vertebral body is slightly greater

anteriorly. Such a vertebral body angle, in addition to the flexible disk, ensures

the naturally lordotic sagittal curvature with the center of the axial loading plane within

the middle column. As part of normal aging, degenerative biochemical changes

occur in hydrophilic proteoglycan molecules that result in loss of adsorbed water. This

eventually leads to a decrease in viscoelasticity of the nucleus pulposus and a reduction

in its overall volume and disk height. As a result, the stress under an axial load

is translated to the annulus fibrosus and it bulges, with eventual wear and tear

causing thinning and further fibrosis. The weakened lamellae allow the fibrotic

nuclear material to dissect through the fibers and disrupt the attachment of Sharpey‟s

6

fibers to the edges of the vertebral body bone. Subsequently, this process

stimulates reactive bony growth and is the origin of early osteophyte formation. In a

more acute scenario, dissection of nuclear material through the weakened annulus

causes disk herniation. The recent literature shows that the delamination process of the

annulus during progressive cervical disk herniation occurs within the lamellae rather

than between them, without evidence of any annulus rupture or failure.16

Early reactive

bone growth ultimately causes osteophyte spur and ridge formation, which leads to

infolding and peeling of the posterior longitudinal ligament the bone and secondary

hypertrophy and ossification. In addition, the loss of disk space height causes initial

straightening of the normally lordotic sagittal curvature of the cervical spine. As the

center of axial loading shifts anteriorly, a cycle of further degeneration contributes

to the chronic compressive vertebral body changes that eventually result in a kyphotic

deformity.17

These changes lead to abnormal cervical spine biomechanics and

subsequently to hypertrophy or laxity of the facet joint and ligamentum flavum.

The cervical spine hypermobility or instability is pathologically stabilized by

osteophyte bar formation and uncovertebral joint degeneration. Multiple studie have

demonstrated a significant decrease in mobility with advanced age.18

In a more recent

study by Miyazaki and colleagues, magnetic resonance imaging (MRI) was

performed on patients with degrees of spondylosis ranging from very mild to very

severe.19

The early degenerative process affected the mobility of the functional spinal

unit, which changed from a normal disk to a more unstable phase with increased

mobility. As the degeneration entered later phases, the motion segment stabilized

and became more ankylosed. The C4-5 and C5-6 segments were shown to

contribute most of the total angular mobility, but their contribution to total

7

angular mobility decreased significantly after severe degeneration. This degenerative

cascade eventually leads to neuroforaminal or spinal canal stenosis, or both.

Pathophysiology of Pain

Patients can have clinically significant neurological symptoms or objective findings

during any of the aforementioned stages. Symptoms can range from mild axial neck

pain to severe cervical myelopathy. Even though the actual source of pain in

cervical spondylosis is controversial, there is consensus that it originates from

degeneration of the cervical disk or facet joint (or both).20

Multiple studies have

demonstrated very rich innervation, both somatic and autonomic, of the cervical

intervertebral disk and facet joint. As the cervical nerve root exits the

neuroforamina, it splits into ventral and dorsal rami, which are the source of

somatic, proprioceptive, and nociceptive input. The small branches (somatic root) of

the ventral ramus join the vertebral nerve (autonomic root) to form the sinuvertebral

nerve. The vertebral nerves are formed by the gray rami communicantes, which are

branches of the sympathetic trunk and the stellate ganglion. The sinuvertebral nerve

arborizes superiorly and inferiorly as it enters the cervical canal through a

neuroforamen and supplies the posterior aspect of the annulus (up to the posterior

third), the posterior longitudinal ligament, and the dura. The anterior longitudinal

ligament and anterior annulus are innervated by the sympathetic trunk and recurrent

branches of the gray rami communicantes. It is reasonable to conclude that an

annular tear can cause increased afferent output that can be the source of axial neck

pain. Moreover, Bogduk and coworkers have proposed that intervertebral disks,

especially when under significant stress, can be the source of pain even without obvious

annular rupture or herniation.21

An internal annular rupture would suffice because

it can cause enough inflammatory changes as it encroaches on the deep and rich

8

innervation of the annulus fibrosus. In addition to the cervical disk being a source of

axial neck pain, the cervical facet joint can also be an important source. The dorsal rami

of the cervical nerve roots supply most of the innervation to the facet joints, which are

rich in mechanoreceptors and nociceptive nerve endings. Studies by Dwyer and

associates have confirmed that stimulation of the facet joint produces a clinically

distinguishable, characteristic pattern of pain that enables the construction of pain

charts.22

Practitioners can use these charts to isolate the symptomatic joint in patients

with cervical zygapophyseal pain. Some authors believe that facet joint pain could be of

primary importance, especially in neck pain associated with whiplash injury.

Pathophysiology of Radiculopathy

The pathologic changes in patients with cervical radiculopathy can be divided into

acute and chronic. Acute radiculopathy is usually secondary to soft disk herniation

and occurs in a younger patient group. The inflammatory process, which involves

acytokine-mediated response, leads to a decrease in the number of large-diameter

myelinated axons. This finding can be seen within the first week23

and results in

relatively more prominent motor findings. Chronic radiculopathy, in contrast, usually

causes predominantly sensory complaints and is more commonly seen in an older

patient group. Chronic radiculopathy is associated with cervical spondylosis.

Jancalek and Dubovy showed that changes include thickening of the dura mater

and arachnoid membrane around the affected nerve root with associated alteration of

the blood-nerve barrier, which eventually leads to nerve root dysfunction as a result of

chronic compression.24

Pathophysiology of Myelopathy

Multiple pathologic processes that eventually lead to similar pathologic cervical

cord changes in the white and gray matter can cause cervical myelopathy. Even acute

9

cervical cord injury (despite representing a different mechanism and manifestation) has

been shown to result in similar pathologic cord findings as those of indolent

cervical spondylosis.25

The pathogenesis of myelopathy in patients with cervical spondylosis should be

subdivided into three main components that are responsible for the final cord

changes.26

The first consists of static factors, which are processes that lead to cervical

canal stenosis and cord compression. The second consists of dynamic factors caused by

repetitive movement of the compressed cord, which is associated with decreased

elasticity and susceptibility to stretch-associated injury. The third component is the

final cord changes that are seen histopathologically and include vascular

rearrangement, arterial- or venous-induced ischemia and infarction (or both),

oligodendrocyte apoptosis, and other cytotoxic cell changes. The static factors that

contribute to decreased canal diameter include acquired spondylosis of the disk, facet,

vertebral bodies, and ligaments and subsequent loss of the lordotic curvature. In

addition, other less common conditions can contribute, such as congenital cervical

stenosis, ossification of the posterior longitudinal ligament, and ossification of the

ligamentum flavum. Patients with congenital cervical stenosis are initially

symptomatic but eventually progress to severe cord compression and usually

become symptomatic by the third decade. The normal sagittal cervical canal

diameter has been identified as being approximately 17 to 18 mm. Based on multiple

studies, the canal is considered stenotic when smaller than 13 mm, which is associated

with a high risk for the development of cord compression with myelopathic changes.

The dynamic factors resulting in cervical cord injury are multifactorial. First, the

movements of a severely compressed cord are restricted. Second, flexion of the spine

results in overstretching of the cord. This effect is more severe in the setting of

10

a prominent ventral osteophyte complex or with a kyphotic deformity. Conversely,

extension causes posterior cord compression by buckling of the ligamentum flavum and

shingling of the laminae. Some studies, including MRI, show both flexion- and

extension induced compression, with extension-associated injury causing more

severe compression. Panjabi and White27

showed that axial rotation and lateral

bending do not cause as significant cord indentations as do sagittal movements. As

mentioned earlier, the spondylotic spine can become unstable and result in

repetitive cord injury during flexion-extension movements. Furthermore, the spinal

cord‟s ability to tolerate stretch decreases with age, and thus older adults become

extremely susceptible to stretch injury.28

In animal studies, Shi and Pryor confirmed

three types of conduction block resulting from and correlating with the extent of stretch

injury in the absence of pathologic variables related to vascular damage29

: an

immediate, spontaneously reversible component that may result from a transient

increase in membrane permeability that affects ionic distribution; a second component

that may be due to perturbation of the myelin sheath and was reversible with the

use of a potassium channel blocker; and a third component that was irreversible and

resulted from profound axolemmal disruption. Finally, the last well-described

pathogenesis of myelopathy is cord ischemia. Spondylotic cord compression causes the

pathologic butterfly pattern of cord ischemia that affects the gray and medial white

matter. This pattern is also consistent with a vascular hypoperfusion injury. The

compression probably affects flow in the small pial and intramedullary arterioles,

as well as the larger anterior spinal artery. Venous congestion may also play a role

and lead to venous infarction. All these processes can result in cord cavitation and

delayed syringomyelia and are probably similar to traumatic syrinx formation. In

11

further support of this ischemic theory, oligodendrocytes have been shown to undergo

apoptosis, similar to the pathologic changes in traumatic cord injury.

Clinical features –

The clinical manifestations of cervical spondylosis can vary from minor to disabling

and include one or any combination of axial cervical pain, radiculopathy, and

myelopathy.

Cervical Pain

Patients with chronic pain as a result of a degenerated cervical disk usually complain of

axial neck pain that is exaggerated with flexion. As a consequence of facet

degeneration or instability, or both, any movement of the sensitive joint can cause pain

that has a reproducible regional pattern.

Cervical Radiculopathy

When radiculopathy is suspected, a thorough examination is needed. As mentioned

earlier, younger patients generally exhibit greater motor involvement from acute soft

disk herniation. In contrast, older patients with extensive spondylosis usually have

primarily sensory and fine motor problems. Moreover, their disease tends to be

multilevel. The Spurling and abduction relief signs also help confirm the radicular

nature of the disease.

Radiculopathy is usually characterized by level-specific clinical findings, as outlined in

the following list:

C3: The C3 nerve exits at the C2-3 foramen. There is no clinically significant motor

component. Occipital and posterior upper neck pain is the only identifiable symptom.

C4: The C4 nerve exits at the C3-4 foramen. The usual manifestation includes lower

neck, medial shoulder, and medial scapular pain. This pain pattern may be confused

12

with axial cervical pain. When C4 radiculopathy is suspected, MRI can confirm the

diagnosis.

C5: The C5 nerve exits at the C4-5 foramen. The pain usually involves the lateral

aspect of the shoulder and upper part of the arm. Because the deltoid muscle is

innervated by the fifth cervical nerve, deltoid weakness is the primary motor deficit.

In addition, biceps weakness can be ascertained by decreased biceps reflex.

Infraspinatus and supraspinatus weakness, although frequently present, is harder to

assess.

C6: The C6 nerve exits at the C5-6 foramen. Radiculopathy is most common at the

C6 level. The pain radiates from the neck, down to the lateral aspect of the arm and

forearm, and extends to the thumb and index finger. Biceps weakness is typical.

The biceps and brachioradialis reflexes are diminished. Other muscles involved

include the supinator and extensor pollicis. The extensor carpi radialis (wrist

extension) is solely innervated by the C6 nerve root.

C7: The C7 nerve exits at the C6-7 foramen. Triceps weakness with diminished triceps

reflex is a hallmark of C7 radiculopathy. In addition, the pronator, latissimus dorsi, and

flexor carpi radialis are primarily supplied by C7. The pain can radiate from the

posterior portion of the shoulder, along the posterolateral aspect of the forearm/arm,

down to the middle digits.

C8: The C8 nerve exits at the C7-T1 foramen. C8 sensory deficits are primarily located

on the ulnar side of the forearm and extend into the fourth and fifth digits. The C8

nerve innervates the small muscles of the hand, primarily the interossei.

Additionally, wrist flexion and extension are affected, which causes decreased

hand grip. At this level, the exiting nerve also carries sympathetic fibers. Horner‟s

13

syndrome should be looked for because of compression of second-order

sympathetic neurons.

T1: The T1 nerve exits at the T1-2 foramen. T1 radiculopathy is very rare as a result

of degenerative disease. On sensory examination, ulnar arm/forearm numbness is the

usual finding. The intrinsic muscles of the hand are also supplied by T1.

Cervical Myelopathy

Identifying signs of cervical myelopathy is critical in evaluating any patient with

spondylosis because it can affect the treatment strategy. Because the etiology of cord

compression is primarily chronic degeneration, patients rarely have acute signs as

they would in a traumatic setting.

Cervical myelopathy is most commonly seen in the setting of progressive chronic

spondylosis causing cord compression. Symptoms can be subdivided on the basis

of upper or lower motor neuron injury. Lower motor neuron injury is secondary to

alpha motor neuron or exiting nerve root compression (or both).

Patients complain of dermatomal weakness, tingling, numbness, and decreased fine

motor coordination. Examination reveals atrophy and weakness of the arms or hands,

diminished pinprick sensation in the fingers, and decreased deep tendon reflexes.

Upper motor neuron injury is secondary to long tract compression and subsequent

dysfunction. The primary tracts responsible for symptoms in patients with cervical

compression myelopathy are the corticospinal (motor), spinothalamic (pain and

temperature), dorsal column (vibration and proprioception), and spinocerebellar (motor

tone and coordination) tracts. The usual complaints are unsteady/clumsy gait, leg

rigidity, altered sensation, and bowel and bladder dysfunction (in the late stages).

14

Physical examination reveals lower extremity spasticity and diffuse hyperreflexia

with the possible presence of the Babinski, clonus, or Hoffman reflexes, or any

combination of these reflexes (Hoffman‟s sign is present if the cord compression is

higher than C7/C8 and is causing long tract injury). The deterioration in gait is

generally the result of overall lower extremity spasticity rather than weakness.

Diagnostic studies

The diagnostic workup often includes static or dynamic plain cervical x-rays, computed

tomography(CT), magnetic resonance imaging (MRI), and myelography.

MRI is useful for evaluating the spinal canal diameter, spinal cord, intervertebral discs,

and vertebral ligaments 1,2, 3, 12, 19, 20, 22, 31, 35.

Signal changes on T2-weighted MRI scans

at the level of spinal compression are often increased in patients with cervical

spondylotic myelopathy. This represents edema, inflammation, ischemia,

myelomalacia, or gliosis 31

.However, bone quality assessment on MRI scans is not as

good as with CT 22

.

Myelography has been widely replaced by MRI. However, some authors think that

postmyelography CT is superior to MRI for distinguishing a bony spondylotic spur

from a “succulent cartilaginous precursor to a hard spur, or afrank soft disc

extrusion”3,21.

It is of note that radiological findings have not been well correlated with

clinical symptoms 2,

18

, and that electromyography, nerve conduction studies, and

somatosensory evoked potential findings have been shown to delineate myelopathy and

radiculopathy in cervical spondylosis 3, 20

Roentgenography

Cervical x-rays still have an important role in imaging the cervical spine in patients

with spondylosis. Plain radiographs provide a detailed rendering of the bony anatomy.

15

Fractures of the vertebral body, pedicle, and lamina can be diagnosed. Pathologic

bone changes such as spondylosis (osteophytes), erosive lesions (infection, tumors), or

trauma (fractures) can easily be seen. Sagittal canal diameter can be measured. The

anteroposterior and lateral views provide important information on the overall

alignment in any posture. Flexion and extension lateral radiographs are still the

primary means of identifying instability.

Computed Tomography (CT)

CT is useful for evaluating the transverse foramina, size and shape of the spinal canal,

facet, and uncovertebral joints 1, 20

. Axial images alone can be very misleading with

regard to sagittal neural element and extrinsic mass relationships. This is particularly

true if sagittal-plane spinal deformation is present and if thick axial CT cuts are used-

With sagittal, coronal, and three-dimensional reconstructions, computed

tomography (CT) is a very useful way of looking at normal and abnormal cervical

spine bony anatomy. The hyperdense signal of bone algorithm CT allows

visualization of the vertebral body, pedicle, lateral mass, laminae, and spinous process

in exquisite detail. Fractures are seen as radiolucencies that (along with distortions in

surrounding soft tissue anatomy) allow a more

specific diagnosis and decrease the risk of missing pathology. Any abnormal bone

growth (osteophyte, ligament ossification), erosions, and distortion are easily seen. The

hypodense appearance of the neuroforamina and canal allow more accurate

visualization and correlation with the bony anatomy than possible with plain

radiography. Unfortunately, CT alone is of little value in assessing the soft tissues,

but CT-myelography (CTM) (with water-soluble intrathecal contrast material injected

before CT), however, is invaluable in evaluating either cord or nerve root

compression. Instillation of contrast material into the subarachnoid space around the

16

spinal cord and nerve roots allows very high sensitivity regardless of the cause of

the compression. CTM can actually be superior to MRI in some patients, especially

those with postoperative scars or instrumentation or those who are claustrophobic

or cannot undergo MRI for other reasons (e.g., indwelling pacemaker). With the

technique of double-contrast CTM, in which an intravenous contrast agent is given in

addition to intrathecal contrast, one can significantly increase both sensitivity and

specificity for the diagnosis of radiculopathy. In patients in whom the subarachnoid

space of the cervical root sleeve does not extend into the neuroforamina, the

intravenous contrast–enhancing periradicular epidural veins appear hyperdense. If

neuroforaminal compression is present, the absence of hyperdense signal would

confirm the diagnosis because of compression of the extradural periradicular space.

Magnetic Resonance Imaging(MRI)

MRI is useful for evaluating the spinal canal diameter, spinal cord, intervertebral discs,

and vertebral ligaments 1,2, 3, 12, 19, 20, 22, 31, 35.

Signal changes on T2-weighted MRI scans

at the level of spinal compression are often increased in patients with cervical

spondylotic myelopathy. This represents edema, inflammation, ischemia,

myelomalacia, or gliosis 31

.However, bone quality assessment on MRI scans is not as

good as with CT 22

. Some studies report an accuracy of MRI in diagnosing surgical

pathology as high as 98% (i.e., cervical disk herniation). With the different signal

acquisition techniques (e.g., T1 or T2), we not only can see unique anatomic details

but can also see the changes within specific tissues, such as a dehydrated black disk.

One can also appreciate the relationship between two or more different structures

because of different signals, such as a herniated disk and nerve root. In myelopathy,

MRI allows visualization of the changes in signal within the cord and thereby aids in

diagnosis and treatment planning.

17

Neurophysiologic Studies

In patients with a clinical syndrome of cervical radiculopathy and confirmatory imaging

(MRI or CTM), neurophysiologic studies are not usually needed. However, when one is

not certain about the patient‟s examination and the imaging findings are of little

value, neurophysiology becomes an important adjunct, especially in differentiating

cervical radiculopathy from peripheral nerve processes. The test consists of a nerve

conduction study (NCS) and needle electromyography (EMG). NCS has four

components: motor NCS, sensory NCS, F-wave study, and H reflex. The

measured latency, amplitude, persistence, and conduction velocities are analyzed

and correlated with findings on EMG. Needle EMG, in contrast, records and

analyzes the signal in the muscle of a specific cervical myotome, with the presence of

fibrillation potentials and positive sharp waves being indicative of muscle fiber

denervation. It usually takes 3 weeks for EMG detectable changes to develop in the

denervated muscle, so one should wait at least 3 weeks from the time of initial

symptoms to perform the test. Sensory evoked potentials and transcranial motor

evoked potentials are of no value in diagnosing radiculopathy or peripheral nerve

pathology but can be used for evaluation of intramedullary processes or intraoperative

monitoring.

Diskography

Diskography in the cervical spine remains very controversial, and there is weak medical

evidence to support fusion of diskographypositive disks for the treatment of axial neck

pain. In patients with chronic axial neck pain but without any definite or

conclusive imaging findings to implicate a specific level, diskography may add useful

information. The specific indication for the test should be to confirm or evaluate

suspected one- or two-level disk disease, generally in patients with de novo axial neck

18

pain that fails conservative treatment. To be used appropriately, concordant pain

should be carefully correlated with both the clinical and imaging findings. A recent

systematic literature review by Buenaventura and associates showed strong evidence

that intradiskal distention (by injecting a small amount of fluid) can produce pain and

moderate evidence supporting its use in identifying patients with chronic cervical

diskogenic pain.

Nonoperative management

Cervical Pain

The symptoms of spondylotic myelopathy are less common than the imaging findings.

The prevalence of chronic neck pain for more than 6 months is approximately 10%

in studies.30

A conservative treatment is usually adopted with a nonsteroidal antiinflammatory drug

(NSAID) as a good initial choice with opioid analgesics and muscle relaxants added as

the severity increases. Most types of axial neck pain should respond to medical

management. If there is still significant disability provocative diskography and facet

joint anaesthetic blocks can identify the sensitive component and either facet joint

injection or disk blocks may be tried. Physiotherapy with isometric exercises also help.

Radiofrequency ablation may provide longer relief of pain if the pain is posterior in

origin. Only patients who fail extensive conservative treatment with correlative

imaging and diskographic findings should be considered for surgery.

Cervical Radiculopathy

Cervical radiculopathy is less common than axial neck pain and occurs in 0.5% to 3%

of individuals, with a peak incidence around the age of 50. Lees and Turner found that

in 50% of patients, the radicular symptoms resolve even though some of these

19

patients might have one temporary recurrence.31

About 25% had improved but had

persisting symptoms, and in about 20% of patients the symptoms persist or worsen.

Sampath and colleagues, monitored 246 patients with a primary symptom of cervical

radiculopathy, of these, 155 (63%) returned for follow-up, with 58 (37%) undergoing

surgical treatment. When comparing the results, the surgically treated patients had

better overall outcomes with greater average patient recovery. Patient satisfaction

was higher in the surgically treated patients (80% versus 60%). 32

Boden found true disk herniation in 10% of asymptomatic patients younger than 40

years as opposed to just 5% of those older than 40.33

A proportion of radiculopathy patients, with milder symptoms, readily respond to an

initial course of conservative treatment with rest, medications (NSAIDs, steroids),

a cervical collar, physical therapy, patient education, and local injections. The

initial period of immobility should be restricted to a few days to avoid

deconditioning and decreased recovery potential. A short course of steroids has

beneficial effect on acute motor neurological recovery. Cervical epidural steroid

injections produce a good temporary response.

Opioid analgesics, muscle relaxants, neuropathic anticonvulsants (i.e. gabapentin) can

be used to treat severe pain. Multiple exercises for treating radiculopathic pain, in

addition to traction, can help by opening the neural foramen. Indications for surgery

include any of the following: acutely worsening neurological status, persistence/

progression of neurological deterioration despite conservative treatment, or

persistent/recurrent arm pain for longer than 6 weeks with confirmatory imaging

findings.

20

Cervical Myelopathy

Conservative treatment recommends intermittent cervical immobilization for at least 8

hours a day to affect the dynamic component.32,35

These studies showed marginal

improvement in some patients, with worsening symptoms developing in a

significant proportion

Matsumoto and coworkers subjected 27 patients to conservative treatment, with 17

of them showing improvement in Japanese Orthopedic Association scores from

16.2 to 13.6, but 10 patients underwent surgery because of neurological worsening.36

Lees and Turner, and Nurick showed the progressive nature of cervical myelopathy,

especially in the group older than 60 years. Most patients exhibited long quiescent

periods with phases of deterioration, instead to steady worsening.

Sampath and colleagues showed decreased overall pain and improved functional

outcome with surgical treatment, but no comparative neurological improvement.32

Operative management

Cervical Pain

Discordant pain within normal appearing adjacent disks is not inconsistent with

good surgical outcomes as for fusion of disks with concordant pain.36

Also patients who undergo analgesic diskography (injection of lidocaine into the disk)

and have relief of symptoms may be good candidates for surgery.

Patients with primarily diskogenic pain who failed conservative treatment and had

characteristic imaging findings can be considered for one- or two-level anterior cervical

diskectomy and fusion (ACDF). In patients who are shown to have a facet joint pain

pattern, posterior fusion could be considered.

21

Cervical Radiculopathy

The goal of surgery for primarily radicular symptoms should be decompression of the

affected nerve root or roots and is indicated for patients who exhibit acute deterioration,

progressive neurological worsening, or persistent arm pain despite a trial of

conservative treatment. Posterolateral laminoforaminotomy and anterior cervical

diskectomy with or without fusion are two procedures well described. One-level or

multilevel laminectomy is rarely indicated for typical radiculopathy.

When surgery is considered, sagittal cervical spine alignment should be considered.

The presence of a cervical kyphotic deformity should be considered as a relative

contraindication to posterior decompression.

Posterior Approach for Diskectomy

Because disk herniation is a ventral pathology the ideal surgical candidate for

posterior foraminotomy is a patient with a one- or possibly two level lateral or far

lateral (foraminal) disk herniation with consistent physical and imaging findings. The

posterior approach can also be considered in any patient with a history of previous

surgery and with dysphagia or vocal cord paralysis who may be at risk for the

complications associated with an anterior approach.

Zeidman and Ducker reported a success rate of 97% in treating radicular pain.37

Cadaver studies have shown that up to 50% of the cervical facet can be safely

resected without causing postoperative instability, especially when operating

unilaterally.38

The advantages of posterior approach over ACDF, include direct visualization of the

root, preservation of the remaining disk and motion segment, and avoidance of

recurrent laryngeal nerve injury and dysphagia. It also possibly prevents degenerative

22

complications in adjacent segments related to the anterior fusion. Even though

posterolateral laminoforaminotomy has multiple advantages, ACDF is a more

frequently used approach, that has broader indications for the treatment of cervical

radiculopathy, myeloradiculopathy, or both.

A new technique of microendoscopic posterior cervical laminoforaminotomy for

diskectomy was developed. Indications for the minimally invasive paramedian

approach are nearly identical to those for an open procedure unless another

intraoperative maneuver is being contemplated or it is a complex reoperative case.

Adamson reported 97% excellent or good results with patients returning to their

preoperative employment and baseline level of physical activity using this technique.39

,

90% of the patients went home the same day, 84% did not require additional

prescription medication after the first 7 days and 60% returned to work or to their

preoperative daily activities 1 week or less after surgery.

Ruetten and colleagues reported similar results, but with a new fully endoscopic

technique for cervical posterior foraminotomy.40

The goal of the minimally invasive procedure is to produce the good results and low

risk profile of the well-established open procedures while trying to minimize

trauma to surrounding tissue. With a significantly decreased operative field, the

minimally invasive approaches require appropriate surgeon training and mastery of the

local anatomy.

Anterior Cervical Diskectomy with or without Fusion

Despite its advantages, the ideal candidate for the posterolateral foraminotomy

approach is a patient in whom the disk herniation is lateral and there is no

concurrent ventral cord compression or segmental instability. In many

circumstances, however, the offending disease component is either midline or

23

paramedian and cannot be safely approached posteriorly. A proportion of patients

have cervical myeloradiculopathy from disk disease, with either the radicular or

myelopathic component being more pronounced. An anterior approach allows the

surgeon to more readily address both symptom complexes. Those with either

effective kyphosis or a straightened cervical spine should not generally be considered

for extensive posterior decompression. Placement of the interbody spacer in ACDF

adds at least 5 degrees of lordosis per level. In short, the anterior approach can be

much more versatile and is the approach of choice when a herniated disk or an

osteophyte is midline or paramedian (or both) or when there is evidence of

additional myelopathy, kyphosis, or instability.

Cervical Myelopathy

The surgery for cervical myelopathy aims at decompression of the spinal cord,

restoration of sagittal alignment, and stabilization of any instability.

In choosing an approach for a patient with cervical myelopathy, most important factor

that should be evaluated is the sagittal curvature and the site of compressive pathology.

In a patient with fewer than three levels of ventral disease, the anterior approach is

preferred. Patients with more than three levels of compression are generally treated by

posterior decompression, especially with preserved lordotic curvature. A multilevel

laminectomy is associated with shorter operative times and fewer perioperative

complications.

Laminoplasty should be considered when multilevel posterior decompression is

planned, particularly if lordosis is preserved. In patients with marked stiffening or

ankylosis (as commonly seen in older adults), posterior decompression alone might

suffice. Younger patients with full range of motion in flexion and extension are at risk

for a delayed swan neck deformity after laminectomy, one should consider

24

including concomitant lateral mass fixation and posterolateral fusion. Additionally,

patients with mobile subluxation at one or several levels should be considered for

posterior instrumentation and fusion when multilevel laminectomy is performed. The

presence of posterior ligamentous hypertrophy is directly dealt with during posterior

decompression. In the presence of cervical lordosis, posterior decompression will

lead to dorsal migration of the spinal cord away from the ventral pathology and result

in indirect decompression. The posterior approach is contraindicated in patients with

kyphosis but can be used as additional stabilization in those who require aggressive,

long-segment (greater than two-level vertebrectomies) anterior correction and

decompression.

An alternative method of treatment for spinal degeneration was propsed by Goel et al,

which involved distraction of the facets and forced introduction of „Goel facet spacers‟.

He reported that the process of facetal distraction resulted in a remarkable reversal of

almost the entire gamut of changes in the degeneration of the spine.99

Surgical treatment algorithm for cervical spondylotic myelopathy44

25

Procedures

Lateral mass fixation-In the subaxial spine, the lateral masses provide the most

secure points for fixation. Multiaxial screws 3.5 to 4.0 mm in diameter and up to 16

mm in length can routinely be placed segmentally. C3 through C6 are instrumented

frequently; the lateral masses at C7 are often thin and angled obliquely, which makes

screw placement difficult. Pedicle screws are frequently used at this level for fixation

because the pedicles of C7 are relatively large. Several techniques for the insertion of

lateral mass screws have been described.

Jeannert and Magerl described a technique of insertion in which starting point is

slightly medial and cranial to the geometric center of the lateral mass; using a

point slightly caudal to that can help optimize the length of the screw and minimize

interference with the cranially adjacent facet joint.47

This location is marked with a

small bur. A twist drill with a depth stop is then used to drill the pilot hole. The angle

is approximately 20 to 30 degrees medial to lateral and parallel to the facet joints. The

hole is drilled until the ventral cortex is breached. This may occur at a depth between

12 and 16 mm or greater, depending on the patient‟s size, the presence of

osteophytes, and the precise trajectory taken. The depth is measured directly, the hole

is tapped, and the screw is placed.

The Roy-Camille method begins with an entry point at the center of the lateral mass.48

The screw is placed with 10 degrees of lateral angulation and 0 degrees of cephalad

angulation.

An and coauthors described a modified technique using an entry point located 1

mm medial to the midpoint of the lateral mass.49

The screw is placed with 30

degrees of lateral angulation and 15 degrees of cephalad angulation.

26

The rods are contoured to match the sagittal alignment and secured to the screws.

Current multiaxial lateral mass screws can accommodate minor variations in sagittal

and coronal alignment of the screws. It is important, however, to minimize the force

exerted on any individual screw to avoid the possibility of fixation failure. Cross-

linkages to increase construct rigidity are available for most instrumentation systems.

To perform a laminaplasty, a partial-thickness trough is drilled on the contralateral

side in the corresponding location. It is important that this trough be straight for the

length of the laminaplasty to prevent adjacent laminae from impinging on each other

when they are hinged open. The depth of the trough should be such so as to allow the

laminae to be greensticked open but remain attached to the lateral masses. In most

cases it is sufficient to drill to the ventral cortex of the laminae; attention must also be

paid to removal of the cortex at the rostral and caudal aspect of each lamina.

After completion of the hinge-side trough, the laminaplasty is carefully opened. The

ligamentum flavum at the rostral and caudal limits of the decompression must be

thinned or removed. A small up-going curet is placed underneath the cut edge of one

of the central laminae, and gentle pressure is placed on the spinous process at

the same level. By elevating the cut edge with the curet and simultaneously pressing

on the spinous process, the laminaplasty is gradually opened. Applying pressure to

two points safeguards against the laminae snapping back and striking the spinal

cord if one point fails.

There are several ways to maintain the laminaplasty opening. Small titanium plates

may be affixed to the lateral mass and the lamina with small screws. There are plates

made especially for this purpose. Alternatively, instrumentation from a maxillofacial

fracture repair set may be adapted for use. The plate is anchored to the center of the

lateral mass to avoid impingement on the adjacent facet joints. An alternative

27

or supplemental method to maintain the laminaplasty is to place a spacer, either

bone or synthetic, into the opening and suture or wire it in place.

Different approaches to laminoplasty include the open­door, the midline

“French­window,” and the Z­plasty techniques.63,66

OUTCOME

There are many historical reports of the results of posterior surgery for cervical

degenerative disease, but there is a lack of reports with validated outcomes.45

There are few studies comparing surgical techniques, which have low evidential

quality.

Outcomes depend, in large part, on the type of pathology present rather than on the

specific procedure.

Retrospective studies report good to excellent outcomes on mostly nonvalidated

outcome measures for 70% to 98% of patients treated with laminoforaminotomy

for cervical radiculopathy.37,39

The proportion of patients in whom improvement is

achieved may depend to some degree on the specific symptoms present; one

study has reported that pain resolves more reliably than weakness, which

improves in more patients better than sensory abnormalities do.39

There are mixed data regarding prognostic factors for patients undergoing surgery for

CSM. A longer duration and increased severity of symptoms correlated with a lower

likelihood of significant improvement or a lesser degree of improvement than seen in

patients with a shorter or less severe symptomatic period preoperatively; the effect

may vary with patient age.46

Multiple uncontrolled studies of cervical laminectomy, laminectomy and fusion, and

laminaplasty have reported significant clinical improvement in patients with

28

myelopathy. All these studies suffer from the methodologic limitations of

noncomparative study designs. Comparisons of outcomes of specific techniques

are likewise fraught with potential bias, and absolute statements about the

relative effectiveness of one procedure versus another are not warranted based on

current evidence.50,61

Laminectomy has traditionally been the approach to spinal canal decompression in

patients with myelopathy. Concerns over the long-term effects of resultant segmental

instability and/or kyphosis, has led to the development of alternatives to cervical

laminectomy. Laminoplasty preserves the neural arch and skeletal anchors for

paraspinal musculature, which decreases the adverse effects of laminectomy while

allowing adequate canal expansion. It works best in patients with neutral or lordotic

spines. Another alternative is laminectomy and fusion, which allows posterior canal

expansion and maintains stability. This modification theoretically avoids problems

associated with laminectomy alone. Furthermore, with the use of internal fixation

devices, it may allow reduction of kyphosis to lordosis, thereby broadening

indications for posterior spine surgery in the treatment of myelopathy50

Mauer et al.51

studied 10 patients with CSM who underwent multilevel laminectomy

and posterior lateral fusion using Luque rectangle and facet wires. The study

evaluated patients preoperatively and postoperatively using the Harsh scale (a 6-point

ordinal scale evaluating gait). The average follow-up was only 10.1 months with a

range of 6–14 months. Nine of the 10 patients had subjective and objective

improvement on Harsh scale. There were no neurological complications, but there

were 3 wound seromas and 1 superficial infection.

Epstein52

retrospectively reviewed 5 cases of OPLL treated with laminectomy

and lateral mass fusion with facet wire fixation Nurick scale was used , over an

29

average follow-up of 13 months (range 6–20 months. The average Nurick score

improved from 4.4 (preoperatively) to 1.4 (at follow-up). Fusion occurred by 3.6

months in all patients.

Kumar et al53

performed a retrospective study of 25 patients with patients undergoing

posterior laminectomy with lateral mass fusion and fixation for CSM after a mean 48-

month follow-up for. Patients were assessed using Harsh scale for gait.and an

improvement in 76% of patients was reported. Patients with less severe myelopathy

(Grade IIIA or better) improved more than severely affected patients. Patients with

poor outcomes according to the Harsh scale demonstrated a statistically significant

increase in depression but not in social functioning. The authors did not report any

change in alignment from the pre-operative to postoperative period. Two patients

had neurological complications, 1 from an epidural hematoma.

Huang and associates54

retrospectively evaluated 31 patients with CSM or OPLL at a

minimum of 6 months of follow-up (average 15 months). Postoperative MR imaging

at a mean of 3.8 months was done in all patients to assess adequacy of decompression

and changes in cord signal. Twenty-two (71%) of 31 patients had improvement in

Nurick score of ≥1 point(2.6 to 1.8); the difference was statistically significant.

Postoperative MR imaging revealed that only 1 patient had residual mild cord

compression, and this patient demonstrated significant neurological improvement.

All 15 patients with preoperative myelomalacia had residual spinal cord

abnormalities. Myelomalacia did not affect outcome, neither did age or duration of.

Pseudarthrosis developed in 1 patient, requiring a repeated operation. The authors

reported that all patients were thought to have solid arthrodeses at the last follow-

up. Three deep wound infections requiring reoperation developed in 3 patients, and 2

patients had C-5 root palsies that resolved.

30

Houten and Cooper55

retrospectively reviewed 38 patients with CSM or OPLL

who underwent laminectomy and lateral mass plating and concluded that laminectomy

and lateral mass fusion prevented kyphosis and resulted in neurological recovery

equal to or greater than anterior approaches.. Outcomes were assessed using the

modified JOA and Cooper scales and on imaging. Clinical follow-up was a mean 30.2

months with a minimum 6-month follow-up. Radiographic follow-up was only a

mean of 5.2 months. Significant improvement in neurological function occurred in 97%

of patients. The modified JOA score improved from 12.9 to 15.6. Radiographic

alignment by the cervical index was unchanged postoperatively. Two neurological

complications, a C-5 nerve root palsy and a radiculopathy from a misplaced screw,

occurred along with one wound infection.

Morio and colleagues56

reviewed 51 patients with myelopathy from CSM or OPLL

treated with French door laminoplasty and on-lay posterior lateral fusion and assessed

them according to JOA score, radiography, and MR imaging at a mean 48 months

(range 12– 108 months). Overall, the JOA recovery rate was 50.9%. The average JOA

score increased from 9.7 to 13.4. Significantly reduced motion was present at all fused

levels, but pseudarthrosis was common. There was a significant correlation of better

outcomes in patients who had < 30% of the preoperative motion. Other significant

positive correlations were greater preoperative and postoperative spinal cord area and

lordotic alignment. The spinal canal was adequately decompressed by MR imaging in

all cases. The laminoplasty technique resulted in adequate spinal canal decompression.

Neurological recovery correlated with the preoperative severity of spinal cord

compression. However, the lack of the control group and retrospective nature of the

study limited these conclusions.

31

Miyazaki et al.57

reported on 46 patients with CSM or OPLL with spinal instability or

deformity who underwent French door laminoplasty and on-lay posterolateral bone

graft placement, with an average follow-up of 53 months (range 12–118 months).

Neurological improvement occurred in 89% of patients with a 5 JOA points

improvement in 46% of patients, 3–4 points in 13%, and 1–2 points in 30%.

Kyphosis increased in 40%, and fusion failed in 35% of cases. Progressive

instability developed in 1 patient, and paraplegia developed 7 hours postoperatively in

another. The authors reported satisfactory neurological outcomes, but the radiographic

results were poor; the noninstrumented technique of posterolateral fusion may have

contributed to these poor radiographic results. The authors found no correlation

between radiographic results and neurological outcome.

Gonzalez-Feria and PeraitaPeraita58

performed a multicenter retrospective review of

525 patients with CSM treated in the Iberian Peninsula using the anterior approach in

195 patients, laminectomy in 242, a combined anterior and posterior approach in 42,

and laminectomy and fusion with spinous “crab plates” process plates in 41

patients. In all treatment groups, 60% of patients improved neurologically and

6.5% deteriorated. There was an overall mortality of 3%. The average improvement by

Nurick scale was 0.9. Laminectomy and posterior fusion yielded significantly better

neurological recovery compared to all other methods. Patients who underwent

laminectomy and posterior fusion improved an average of 2.0 Nurick grades, whereas

the mean improvement with the anterior approach was 1.2, and with laminectomy

was 0.9.

Hamanishi and Tanaka59

reported on 69 patients with CSM who underwent

laminectomy or laminectomy and fusions with on-lay bone grafting onto the lateral

masses. Thirty-five patients underwent laminectomy, and 34 underwent laminectomy

32

and fusion. Outcomes were assessed at a mean of 3.5 years postoperatively using the

JOA scale and percent recovery. The authors found similar rates of recovery (51%

improvement in JOA score) in both groups. The time from onset of symptoms or injury

strongly correlated to neurologic recovery in both groups. Radiographically, instability

developed in 2 patients who did not undergo fusion, and progressive kyphosis

devloped in 5. In the fusion group, only an 80% fusion rate was noted, and instability

developed in 2 patients. Six of 35 (17%) patients who did not undergo fusion

developed kyphotic malalignment compared with 4 (12%) of 34 patients who

underwent fusion.

Heller et al.60

performed a study in 26 patients with CSM or OPLL who

underwent either laminoplasty or laminectomy with lateral mass plate fixation and

autogenous grafting. The mean follow-up period was 26 months (range 9–46 months).

Patients who underwent fusion had worse kyphosis but less maximum stenosis. The

study evaluated patients using the Nurick scale, subjective symptom reporting,

and gait. The authors reported no statistically significant differences in

neurological recovery between the 2 groups, and there were no differences in

postoperative axial pain scores. In all instances, however, the authors observed better

results in the laminoplasty group. These patients had better functional outcomes as

evidenced by better gains in Nurick scores; they also had a lower complication rate.

Radiographically, there was no difference in alignment between the groups, although

severe kyphosis developed in 1 patient who underwent fusion. There was a significant

difference in complications rates between the 2 groups with no complications

occurring in the laminoplasty group. In the fusion group, 2 patients experienced

neurological deterioration, a deep infection developed in 1 patient, 5 patients had

33

pseudarthrosis, 2 patients had hardware failure, and in 1 patient, adjacent

degeneration requiring anterior cervical decompression and fusion occurred.

Paul A. Anderson, M.D., Paul G. Matz and others in their systematic review concluded

that laminectomy with fusion (arthrodesis) is an effective strategy to improve functional

outcome in CSM and OPLL.50

According to Timothy C. Ryken, and others the theoretical effects of posterior

decompression are to permit dorsal migration of the spinal cord away from anterior

compressive osteophytes, to decrease compression of the spinal cord itself, and to

improve vascular perfusion. Potentially significant complications of multilevel

laminectomy performed for CSM are the development of postoperative spinal

instability, kyphosis, and/or spondylolisthesis111

Gonzalez-Feria and Peraita-Peraita108

described a large cooperative multicenter survey

of 521 patients with cervical myelopathy, 242 of whom underwent laminectomy.

They reported a mean improvement for this group as 0.92 on the Nurick scale.

Adams and Logue, Casotto115

and Buoncristiani114

, Epstein et al1112

, Fager113

, Gorter

and associates117

, Kato et al.116

, Miyazaki and Kirita118

in their studies have reported a

success in treating CSM with decompressive laminectomies ranges from

approximately 15 to 60%. These studies all were generally lacking in follow-up, but

most were published in the 1970s.

Kaptain et al.119

reported on 46 patients undergoing laminectomy who underwent pre-

and postoperative radiography. The development of a postoperative deformity

(kyphosis) was more than twice as likely in patients with a “straight” preoperative spine

(loss of lordosis) than in those with a normal preoperative lordosis. However, the

preoperative spinal alignment was not shown to be predictive of outcome.

34

The report by Kaminsky et al.120

had a case-control study design with matched 22

laminectomy and 20 laminoplasty patients. Both groups showed improvement in their

myelopathy scores (Nurick scale), and an increase in motor recovery was demonstrated

in the laminoplasty group. In the laminectomy group, a better outcome was associated

with a smaller degree of preoperative deficit (r = 0.84; p < 0.0001). This result

was consistent with the observations of Nurick in the historic 1972 paper.

Perez-Lopez et al.121

compared a cohort of 19 patients with laminectomies to 17 patients

who underwent laminectomy and fusion. They found a similar improvement in Nurick

score (0.84 vs 1.24) and an increase in postoperative kyphosis with laminectomy alone

(7 vs 24%).

Timothy C. Ryken111

and others in their systematic review found laminectomy to be an

acceptable therapy for near-term functional improvement of CSM.

Cervical laminoplasty is recommended in the treatment of myelopathy in the setting of

CSM or OPLL. Using the JOA scale, ~55–60% recovery rate is anticipate62

. The

impetus for laminoplasty was the desire to decompress long segments while avoiding

postlaminectomy membrane formation and/or kyphotic deformity.63

The authors of

multiple reports have demonstrated that laminoplasty increases canal

diameter.64,65

However, this increase in canal diameter appears to be at the expense of

pain and diminished ROM.

Baba et al67

examined posterior cord migration in 55 patients who underwent

open­door Laminoplasty using an index that examined the distance from the

anterior spinal canal (posterior surface of the vertebral body) to the center of the

spinal cord and reported an average shift of 55.3% relative to baseline in patients

whose JOA scale scores improved > 50%, and an average shift of 27.7%

relative to baseline in patients whose JOA scale scores improved < 50%.

35

Matsuyama et al.68

reported on 44 patients with cervical myelopathy (26 with

CSM and 18 with OPLL) who underwent Laminoplasty. The authors measured the

cross­sectional area, sagittal diameter, and transverse diameter of the spinal cord

prior to surgery, immediately afterward, and 1 month postoperatively. They

correlated results with JOA scale scores. Increased cross­sectional area was considered

“expansion.” The authors found that gradual expansion (over the course of 1 month)

was associated with a 68.4% recovery rate, while a 32.6% recovery rate was seen

without gradual expansion.

Wada et al.73

discussed a series of 50 patients with CSM who underwent Laminoplasty.

They found that a transverse cord area < 40 mm2,a long duration of symptoms, and a

poor anteroposterior canal ratio were predictive of poor outcome. Less predictive were

patient age and presence of a poor preoperative JOA scale score. Also, multisegmental

hyperintensity on T2­weighted images correlated strongly with a poor outcome

(p<0.01).

Kihara et al.69

studied, 151 patients (132 with CSM and 19 with OPLL) who underwent

open­door laminoplasty over a 7­month period. He found, the mean JOA scale score

improved significantly in this cohort. Simultaneously, ROM decreased from 36.9 to

29.1°(p < 0.01).

Saruhashi and colleagues reviewed 30 patients who underwent French­window

laminoplasty for CSM.80

After 5 years JOA scores improved from average of 8.8 to

11.9(p < 0.001). Simultaneously, alignment deteriorated in some (loss of 12.5°) and

stabilized in others (gain of 1.1°). In comparing these 2 groups, the authors observed no

significant difference in mean JOA scale scores.

Kawaguchi and colleagues71

described a modified laminoplasty technique used in 28

patients with a mean age of 62.7 years. They placed bone spacers at every other level,

36

with no bone placed on the hinge side and compared ROM with 28 historical control

patients who underwent standard open­door laminoplasty (mean age 60.4 years). Range

of motion was preserved 48% in the open­door group and 71% in modified

laminoplasty group (p < 0.02). An average of only 0.8 levels were fused in the modified

group compared to 2.1 in the control group (p < 0.0001).

Edwards et al.72

specifically evaluated pain in 18 patients who underwent laminoplasty

by splitting of the spinous process (mean age 54 years, 2­year follow­up) using

Robinson pain scale. Pain decreased significantly in this group (2.0 to 0.9; p <

0.002).Also, ROM diminished significantly (37 to 23°; p < 0.05) compared to a

historical control group of patients who underwent laminectomy (22 patients, mean

age 54 years).

Kaminsky et al.83

found that the pain level was significantly reduced (57 vs 8%, p <

0.004) with laminoplasty in 20 consecutive patients (mean age 53 years).

Takeuchi et al.84

modified a C3–7 laminoplasty to preserve the C2–3 muscular

attachments, and compared their results in 40 patients to 16 historical control patients.

The modified laminoplasty group had significantly fewer patients with severe pain (p <

0.02). They compared this technique to C4–7 laminoplasty with undercutting of the C­3

lamina. In this Class III study, the authors demonstrated no difference in clinical

outcomes, but did show reduced pain and muscle atrophy with this modified technique.

The most commonly described complication after laminoplasty is arm weakness due to

C­5 palsy.85,86,87

Hatta and colleagues88

compared selective laminoplasty (in 26 patients with an

average age of 60 years, and a 19­month follow­up period) to a historical control

group of 25 patients who underwent the standard open­door technique (mean age 62

years, 38­month follow­up period). All patients had CSM over 2–3 levels. Recovery

37

assessed with JOA scale scores was 66% in both groups. The authors compared the

posterior cord shift between the 2 groups. In the selective laminoplasty group, posterior

shift was 1.1 mm, with 0% C­5 palsy. In the standard historical control group, cord shift

was 2.7 mm with 8% C­5 palsy. Accordingly, posterior cord shift was associated with

C­5 palsy. Through selective laminoplasty, incidence of C­5 palsy was reduced, while

maintaining a similar level of improvement in JOA scores.

Sasai et al90

reported on 111 patients who underwent laminoplasty. One group of 74

patients had preoperative EMG studies was compared with another group of 37 patients

who did not undergo preoperative EMG. Eleven of 74 patients with abnormal EMG

results at C­5 underwent prophylactic foraminotomy. In the first group, none of the

patients had postoperative radiculopathy, while postoperative radiculopathy developed

in 3 patients in latter group. The authors concluded that preoperative EMG was helpful.

Komogata and colleagues89

did not show a correlation between EMG abnormalities and

C­5 palsy.

Both Uematsu et al.91

and Chiba et al.92

examined the relationship of C­5 postoperative

palsy to clinical factors. In a series of 365 patients, Uematsu and colleagues reported an

incidence of 5.5% for C­5 palsy and that the development of C­5 palsy did not correlate

with degree of stenosis, clinical severity of myelopathy, or the spinal curvature index.

They reported that elevation of the laminae to an angle > 60° was associated with

greater likelihood of C­5 palsy.

Chiba and colleagues studied 208 patients of laminoplasty. Segmental motor paralysis

developed in 15 patients, in most cases at C­5. Weakness developed an average of 4.6

days after surgery. Fourteen of 15 patients had severe dysesthetic pain in the

hands prior to surgery, a symptom that did not improve. Magnetic resonance

imaging evaluation after surgery showed focal hyperintensity on T2­weighted images

38

in all 15 patients with segmental motor paralysis, in contrast to an incidence of 58% in

the patients without deficit.

Ratliff and Cooper94

reported an incidence of postlaminoplasty kyphosis of 10% in a

study of 92 patients with OPLL, Iwasaki et al.85

described a long­term kyphosis rate of

8% in 56 patients over a 10­year period, and Saruhashi et al.80

showed patients who

developed kyphosis (−12.5°) had similar clinical outcomes as those who had lordosis

preserved (+1.1°).

Maeda et al.95

reported follow­up in 30 of 44 patients who underwent laminoplasty for

OPLL. The average patient age was 59 years, and the follow­up period averaged 3.2

years. The authors found that the curvature index reduced from 14.5 to 2% after

laminoplasty, with ROM deteriorating from 41 to 24°. They reported a correlation

between diminished ROM, diminished curvature index, and reduced JOA scale scores.

Kimura and colleagues96

examined the “boomerang” deformity that occasionally

developed in the spinal cord with posterior shift after split laminae laminoplasty. They

reviewed 39 consecutive cases of laminoplasty (in patients with CSM, OPLL, and

cervical disc herniation) for cervical myelopathy. The boomerang deformity developed

in 8 patients with migration of the spinal cord between the split laminae. These patients

were compared with 31 patients in whom this deformity did not develop. There were no

significant differences in age, pre- and postoperative JOA scale scores, or recovery

rates between patients with and without this deformity. Patients who developed the

“boomerang” spinal cord deformities were significantly more likely to have had a lower

flattening ratio (sagittal/transverse diameter; p < 0.027) and/or a lower transverse.

Axial neck and parascapular pain is common in CSM and has been a topic of intense

debate among proponents and detractors of the cervical laminoplasty procedure. The

study comparing60

pain between laminoplasty and lateral mass fusion, as measured by

39

narcotic intake and functional restriction (Robinson scale) found no difference in the

groups. The causative factors for pain after a posterior decompressive procedure

include extensive posterior dissection, detachment of the cervical musculature and

muscular atrophy, cervical alignment, radiculopathy leading to pain referred to the neck

and shoulder girdle, and length of time of immobilization. Although there is evidence

for fusion in the treatment of single-level diskogenic neck pain, evidence that fusion

improves neck pain after multilevel cervical decompression is lacking. In this study,

neck and parascapular pain appeared to respond to both surgeries, but the Visual

Analog Scale, NDI, and SF-36 showed that laminoplasty appeared to be superior in

reducing pain Both groups showed improvements in their Nurick grade and mJOA

score postoperatively. Only the improvement in the Nurick grade for the Laminoplsty

group was statistically significant (P,.05) Although the lateral mass fuion group

generally showed improvement in all self-reported outcome measures, none of these

results was statistically significant. The results suggest that patients may benefit from

both procedures and that the complication rates are low.

AIMS & OBJECTIVES

40

3. AIMS AND OBJECTIVES

The aim of the present study was to

- determine clinical, radiological, and patient satisfaction outcomes between cervical

decompressive laminectomy, cervical laminoplasty and cervical laminectomy and

lateral mass fusion for degenerative cervical spine disease.

- determine the ideal posterior approach for patients with degenerative cervical spine

disease.

MATERIAL AND METHODS

41

4. MATERIALS AND METHODS

In this retrospective study all the patients who underwent surgery for degenerative

cervical spine disease via posterior approach at our institute from January 2000 to june

2013, were considered. Only patients in the age group of 18 to 70 years and who had a

minimum followup of 1 year were included. Those not fulfilling this criteria we

excluded from study. The patients were divided into 3 groups based on the type of

surgery they underwent- Laminoplasty, Laminectomy alone or Laminectomy and

lateral mass fixation.

Information available from medical records were analysed. Patients were interviewed

on their scheduled follow up dates. Others were contacted via questionarres sent by

post.

Apart from basic details, pre-intervention complaints, details of examination, imaging

characteristics were charted. The following variables were considered…

Presenting symptoms-

- Motor- stiffness/weakness

- Sensory – pain/ numbness/parasthesias

- Bladder/bowel symptoms

- History of previous spine surgery

Examination

- Motor- Bulk/tone/power of muscle groups as upper limb proximal/distal, lower

limb proximal/distal on either side- graded using the 5-level MRC (Medical Research

Council) scale,

42

- spasticty –graded using simplified Nuricks grading

Grade 0: No evidence of spinal cord disease

Grade I: Symptoms of spinal cord disease, but no difficulty in walking

Grade II: Slight difficulty in walking

Grade III: Difficulty in walking, but not so severe as to require assistance

Grade IV: Able to walk only with another person's assistance or with the aid of

a frame

Grade V: Chair- or bed-bound

- Sensory-posterior column involvement/spinothalamic involvement.

After surgery- examination findings were charted on the 1st post op day, at the time of

discharge, 6weeks after discharge, 6 months after discharge, 1 year after discharge. The

following were considered and compared to the status at last visit.

1. Sensory – improvement/remained same/worsened

2. Bladder function- improved/same

3. Tone- improved/same/worsened

4. Bulk of muscles- improved/same/worsened

5. Power- was charted as in pre op

6. Spasticity graded as pre op.

Complications, need for redo surgeries were also noted.

43

Imaging-

Based on the available data, images the presence or absence of certain key features

were considered-

- Loss of lordosis

- osteophytes

- canal stenosis

- PIVD

- OPLL

- ligamentum flavum hypertrophy

- myelomalacia

- scoliosis

At the end of 1 year , the variables that were considered were graded based on the

overall improvement, worsening, status quo compared to the preop status.

1. Sensory involvement was considered as numnbness, parasthesias as

symptoms or involvement of posterior coloumn or spinothalamic tracts at

examination, and was compared with the post op status and graded as

improvement/remained same/worsened

2. Bladder function- improved/same

3. Tone- improved/same/worsened

4. Bulk of muscles- improved/same/worsened

44

5. Power- worst preop power was considered and the corresponding power in

the same limb was considered at the end of 1 year. Also, any worsening of

power in the other limbs was considered. It was graded as -

improved/same/worsened

6. Spasticity graded as pre op – Finally at the end of 1 year it was compared

with the preop nuricks grade aand grade as improved/same/worsened. Also

the mean preop nuricks grade was compared the mean preop nuricks grade

at the end of 1 year and for each group.

7. Pain – was expressed as a percent, based on the feedback from patients sent

via post or during personal interview- a questionnaire considering the

severity of pain at that particular time, during various daily activities.

As such the end point of follow-up for all the variables were considered at the end of 1

year, except for pain, about which the patients were interrogated in the month of june

2014 and thus had a variable temporal gap from the time of surgery.

After collection of data, they were charted into tables and analysed using SPSS. Chi-

square test and Mann Whitney U test were used for analysing statistical significance.

results

45

5. RESULTS

Out of 105 patients operated for degenerative cervical spine disease between January

2000 to August 2013, 82 patients met the inclusion criteria for this study, the other

patients were either lost to follow up or died . Of the 82 patients included in this study ,

43 underwent Laminoplasty, 22 underwent Laminectomy and 17 underwent

Laminectomy with lateral mass fusion.

43

22

17

0

Number of patients

Laminoplasty

Laminectomy

Laminectomy and Lateral MassFusion

46

The age distribution in these groups has been tabulated below-

Table 1. Age distribution

Age

Laminoplasty Laminectomy

Lateral mass

fusion 2

P

Count Percent Count Percent Count Percent

<=40 7 16.3 2 9.5 0 0.0

14.94* 0.021

41 - 50 17 39.5 5 23.8 7 41.2

51 - 60 16 37.2 5 23.8 7 41.2

>60 3 7.0 9 42.9 3 17.6

Mean ±

SD

48.5 ± 10.8 55 ± 10.5 53.5 ± 6.8

The mean age in the laminoplasty group was 48.5+/-10.8 yrs, laminectomy group was

55 +/-10.5 yrs, lateral mass fusion group was 53.8+/-6.8yrs.

47

Table 2.-Sex distribution in the 3 groups

Sex

Laminoplasty Laminectomy

Lateral mass

fusion 2

P

Count Percent Count Percent Count Percent

Male 36 83.7 19 86.4 13 76.5

0.7 0.704

Female 7 16.3 3 13.6 4 23.5

There was no significant difference in the Sex distribution among the study groups.

Interpretation of the Presenting symptoms-

The presenting symptoms in each of the groups has been tabulated. There was no

significant difference noted among the groups.

Table 3. Comparison of presenting symptoms based on group

Signs and

Symptoms

Laminoplasty Laminectomy

Lateral mass

fusion 2

P

Count Percent Count Percent Count Percent

Spasticity

Yes 42 97.7 22 100.0 17 100.0

0.92 0.632

No 1 2.3 0 0.0 0 0.0

Weakness

Yes 32 74.4 16 72.7 6 35.3

8.93* 0.012

No 11 25.6 6 27.3 11 64.7

48

Parasthesias

Yes 22 51.2 22 100.0 3 17.6 27.98

**

0.000

No 21 48.8 0 0.0 14 82.4

Numbness

Yes 15 34.9 10 45.5 12 70.6

6.27* 0.043

No 28 65.1 12 54.5 5 29.4

Pain

Yes 27 62.8 13 59.1 7 41.2

2.37 0.306

No 16 37.2 9 40.9 10 58.8

Bladder/bo

wel

Yes 13 30.2 8 36.4 6 35.3

0.3 0.860

No 30 69.8 14 63.6 11 64.7

Others

Yes 3 7.0 1 4.5 0 0.0

1.29 0.526

No 40 93.0 21 95.5 17 100.0

Duration

<10 16 37.2 14 63.6 9 52.9

4.32 0.115 >=1

0 27 62.8 8 36.4 8 47.1

Previous

surgeries

Yes 8 18.6 4 18.2 1 5.9

1.6 0.449

No 35 81.4 18 81.8 16 94.1

49

The most common presenting symptom was spasticity affecting the lower limbs with

difficulty in walking fast, climbing stairs etc. In the upperlimbs patients had loss of

dexterity and grip weakness. Some had radicular symptoms such as weakness of one or

both arms, difficulty in raising arm, bending elbow. Numbness and parasthesias were

also frequently reported as tingling sensation over limbs, loss of sensation. Pain was

most commonly nuchal in location aggravating on flexion and extension, affecting

range of motion. Sphincteric involvement commonly presented as hesitancy, increased

frequency of micturition. Sexual dysfunction was noted in some patients.

The mean duration of symptoms in the laminoplasty group was 19.34 months, in the

laminectomy group was 14.5 months and in the lateral mass fusion group was 22.8

months.

42

22

17 15

22

14

0

5

10

15

20

25

30

35

40

45

Laminoplasty Laminectomy Lateral massfusion

spascticity

weakness

parasthesias

numbness

pain

bladder bowel involvement

others

50

OUTCOME

1.POWER

Table Comparison of power in Laminoplasty group

Preop weakness

Post Count Percent Z# P

Absent

Worsened 1 12.5

2.65** 0.008 Same 7 87.5

Present

Worsened 3 8.6

4.49** 0.000 Same 4 11.4

Improved 28 80.0

Fig. Comparison of power in Laminoplasty group

.

12.58.6

87.5

11.4

0.0

80.0

0.0

20.0

40.0

60.0

80.0

100.0

Perc

en

tag

e

worsened same Improved

Absent Present

In the Laminoplasty group, pre-

operatively weakness was present in 35

of 43 people (81,3%), of which 28

improved(80%), 4(11.4%) remained

the same and 3(8.6%) worsened, with

improvement in power being

statistically significant.

Weakness was absent in 8 of 43

(18.6%)people of which 7(11.4%)

remained the same and 1(12.5%)

worsened.

51

Table Comparison of power in Laminectomy group

Preop weakness

Post Count Percent Z# P

Absent

Same 1 100.0

- - Worsened 0 0.0

Present

Same 2 9.5

3.9**

0.000

Worsened 1 4.8

Improved 18 85.7

Fig. Comparison of power in Laminectomy group

Table Comparison of power in Lateral mass fusion group

Preop weakness

Post Count Percent Z# P

Absent

Same 1 100.0

- - Improved 0 0.0

Present

Same 5 31.3

3.32** 0.001 Improved 11 68.8

100.0

9.50.0

4.80.0

85.7

0.0

20.0

40.0

60.0

80.0

100.0

Perc

en

tag

e

same worsened Improved

Absent Present

In the laminectomy group

preoperatively weakness was present

in the 21 of 22(95.4%) patients of

which 18 improved(85.7%), 2(9.5%)

remained same and 1(4.8%)

worsened, with improvement being

statistically significant.

Weakness was absent in 1 of

22(4.45%) patients , whose power

remained same after surgery

52

Fig. Comparison of power in Lateral mass fusion group

2. Sensory(any form as a symptom or on examination, excluding pain)-

Table Comparison of sensory in Laminoplasty group

Preop involvement

Post Count Percent Z# P

Absent

Same 4 100.0

2* 0.046 Worsened 0 0.0

Present

Same 2 5.1

1.81 0.071 Worsened 13 33.3

Improved 24 61.5

Fig. Comparison of sensory in Laminoplasty group

100.0

31.3

0.0

68.8

0.0

20.0

40.0

60.0

80.0

100.0P

erc

en

tag

e

same Improved

Absent Present

100.0

5.1 0.0

33.3

0.0

61.5

0.0

20.0

40.0

60.0

80.0

100.0

Perc

en

tag

e

same worsened Improved

Absent Present

In the lateral mass fusion group

preoperatively weakness was present

in 16/17(94.1%) people of which

11(68.8%) improved and 5(31.3%)

remained same, with no case of

worsening. Weakness was absent in

1 of 17(5.8%) patients whose power

remained the same after surgery.

In the laminoplasty group

preoperatively sensory disturbances

were present in 39 of 43(90.67%)

patients of which 24(61.5%)

improved, 13(33.3%) worsened and

2(5.1%) remained the same, with

improvement not being statistically

significant.

Sensory involvement was absent in

4 of 43(9.3%) people, who

remained the same after surgery

53

.

Table Comparison of sensory in Laminectomy group

Preop involvement

Post Count Percent Z# P

Absent Worsened 0 0.0

Improved 0 0.0

Present Worsened 7 31.8

1.71 0.088 Improved 15 68.2

Fig. Comparison of sensory in Laminectomy group

.

Table Comparison of sensory in Lateral mass fusion group

Preop involvement

Post Count Percent Z# P

Absent Same 1 100.0

- - Improved 0 0.0

Present Same 1 6.3

3.87** 0.000 Improved 15 93.8

0.0

31.8

0.0

68.2

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

Perc

en

tag

e

worsened Improved

Absent Present

In the laminectomy group sensory

involvement was present in all

22(100%) patients of which 15

(68.2%)improved and 7(31.8%)

worsened, the improvement being

not of statistical significance

54

Fig. Comparison of sensory in Lateral mass fusion group

BULK

Table Comparison of bulk in Laminoplasty group

Preop atrophy

Post Count Percent Z# P

Absent Same 34 100.0

5.83** 0.000 Worsened 0 0.0

Present

Same 8 88.9

1 0.317 Worsened 1 11.1

Fig. Comparison of bulk in Laminoplasty group

.

100.0

6.3 0.0

93.8

0.0

20.0

40.0

60.0

80.0

100.0P

erc

en

tag

e

same Improved

Absent Present

100.0

88.9

0.0

11.1

0.0

20.0

40.0

60.0

80.0

100.0

Perc

en

tag

e

same worsened

Absent Present

In the lateral mass fusion group

sensory involvement was

present in 16 of 17

(94.11%)patients of which

15(93.8%) improved and

1(6.3%) remained the same, the

improvement reaching

statistical significance.

Sensory involvement was

absent in 1 patient who

remained the same after

In the laminoplasty group,

preoperatively atrophy was present in

9 of 43(20.9%) patients of which

8(88.9%) remained the same after

surgery, 1(1.1%) worsened and none

improved.

Atrophy was absent in 34 of

43(79.06%) patients all of whom

remained the same after surgery

55

Table Comparison of bulk in Laminectomy group

Preop atrophy

Post Count Percent Z# P

Absent Same 13 100.0

3.61** 0.000 Worsened 0 0.0

Present

Same 8 88.9

1 0.317 Worsened 1 11.1

Fig. Comparison of bulk in Laminectomy group

Table Comparison of bulk in Lateral mass fusion group

Preop atrophy

Post Count Percent Z# P

Absent

Same 14 100.0

3.74** 0.000 Worsened 0 0.0

Present

Same 3 100.0

0 1.000 Worsened 0 0.0

100.0

88.9

0.0

11.1

0.0

20.0

40.0

60.0

80.0

100.0

Perc

en

tag

e

same worsened

Absent Present

In the laminectomy group atrophy

was present in 9 of 22(40.9%)

patients , 8(88.9%) remained same

and 1(11.1%) worsened after

surgery. It was absent in 13of

22(4.54%) patients all remained the

same after surgery

56

Fig. Comparison of bulk in Lateral mass fusion group

Sphincteric (bladder) involvement

Table Comparison of bladder involvement in Laminoplasty group

Preop involvement

Post Count Percent Z# P

Absent

Same 30 100.0

5.48** 0.000 Improved 0 0.0

Present

Same 1 7.7

3.46** 0.001 Improved 12 92.3

Fig. Comparison of bladder involvement in Laminoplasty group

100.0 100.0

0.0 0.0

0.0

20.0

40.0

60.0

80.0

100.0P

erc

en

tag

e

same worsened

Absent Present

100.0

7.70.0

92.3

0.0

20.0

40.0

60.0

80.0

100.0

Perc

en

tag

e

same Improved

Absent Present

In the lateral mass fusion group

atrophy was present in 3 of

17(17.64%) patients and absent

in 14 of 17(82.3%) patients all

of whom remained the same

after surgery

In the laminoplasty group

preoperatively bladder involvement

was present in 13 of 43(30.23%)

patients of which 12(92.3%)

improved post operatively, 1(7.7%)

remained the same.It was absent in

30(69.76%)patients pre-operatively

and all of them remained same

57

Table Comparison of bladder involvement in Laminectomy group

Pre Post Count Percent Z# P

Absent Same 14 100.0 3.74** 0.000

Improved 0 0.0

Present Same 1 12.5 2.65** 0.008

Improved 7 87.5

Fig. Comparison of bladder involvement in Laminectomy group

Table Comparison of bladder involvement in Lateral mass fusion group

Pre Post Count Percent Z# P

Absent Same 11 100.0

3.32** 0.001

Improved 0 0.0

Present Same 0 0.0

2.45** 0.000

Improved 6 100.0

100.0

12.5

0.0

87.5

0.0

20.0

40.0

60.0

80.0

100.0

Perc

en

tag

e

same Improved

Absent Present

In the laminectomy group bladder

involvement was seen in 8

(18.6%)patients, 7(87.5%) of them

improved after surgery, 1(12.5%)

remained same.It was absent in

14(63.6%) patients pre-operatively

who maintained their bladder

function after surgery.

58

Fig. Comparison of bladder involvement in Lateral mass fusion group

SPASTICITY- Nuricks grading

Table Comparison of spasticity in Laminoplasty group

Preop spasticity

Post Count Percent Z# P

Absent

Worsened 0 0.0

- - Improved 0 0.0

Present

Worsened 2 4.7

5.24** 0.000 Same 8 18.6

Improved 33 76.7

Fig. Comparison of spasticity in Laminoplasty group

100.0

0.0 0.0

100.0

0.0

20.0

40.0

60.0

80.0

100.0P

erc

en

tag

e

same Improved

Absent Present

0.04.7

0.0

18.6

0.0

76.7

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

Perc

en

tag

e

worsened same Improved

Absent Present

In the lateral mass fusion group,

bladder function was affected

preoperatively in 6 of 17(35.29%)

patients and all(100%) of them

improved after surgery. It was

absent in 11(64.7%) patients who

remained the same after surgery

In the laminoplasty group spasticity was

seen in all(100%) the patients ,

33(76.7%) of them improved, 8(18.6%)

remained the same and 2(4.7%)

worsened.

59

Table Comparison of spasticity in Laminectomy group

Preop spasticity

Post Count Percent Z# P

Absent

Worsened 0 0.0

- - Improved 0 0.0

Present

Worsened 2 9.1

3.15** 0.002 Same 5 22.7

Improved 15 68.2

Fig. Comparison of spasticity in Laminectomy group

Table Comparison of spasticity in Lateral mass fusion group

Preop spasticity

Post Count Percent Z# P

Absent

Same 0 0.0

- - Improved 0 0.0

Present

Same 2 11.8

3.87** 0.000 Improved 15 88.2

0.0

9.1

0.0

22.7

0.0

68.2

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

Perc

en

tag

e

worsened same Improved

Absent Present

In the laminectomy group, all(100%) the

patients had spasticity preoperatively, 15

of 22 (68.2%)improved, (22.7%)5

remained the same and 2 (9.1%)

worsened.

60

Fig. Comparison of spasticity in Lateral mass fusion group

The outcome with regards to power, sensory involvement, bulk , bladder function,

spasticity were compared between the 3 groups.

Table Comparison of post power between group

Post power Laminoplasty Laminectomy Lateral mass

fusion Group Z# p

Worsened 4 (9.3) 1 (4.5) 0 (0) A & B 1.38 0.167

Same 11 (25.6) 3 (13.6) 6 (35.3) A & C 0.21 0.837

Improved 28 (65.1) 18 (81.8) 11 (64.7) B & C 1.08 0.280

# Mann-Whitney U Test

Fig. Comparison of post power between group

0.0

11.8

0.0

88.2

0.0

20.0

40.0

60.0

80.0

100.0P

erc

en

tag

e

same Improved

Absent Present

9.34.5

0.0

25.6

13.6

35.3

65.1

81.8

64.7

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

Perc

en

tag

e

worsened same Improved

Laminoplasty Laminectomy Lateral mass fusion

In the lateral mass fusion group

all(100%) the patients had spasticity

preoperatively, of which 15(88.2%)

improved and 2 (11.8%) remained the

same.

There was no statistically

significant difference in outcome

of power amongst the three

groups.

61

Table Comparison of post sensory between group

Post sensory

Laminoplasty Laminectomy

Lateral mass fusion

Group Z# P

Worsened 13 (30.2) 7 (31.8) 0 (0) A & B 0.6 0.549

Same 6 (14) 0 (0) 2 (11.8) A & C 2.55* 0.011

Improved 24 (55.8) 15 (68.2) 15 (88.2) B & C 1.72 0.086

# Mann-Whitney U Test *: - Significant at 0.05 level

Fig. Comparison of post sensory between group

Table Comparison of post bulk between group

Post bulk Laminoplasty Laminectomy Lateral mass

fusion Group Z# P

Worsened 1 (2.3) 1 (4.5) 0 (0) A & B 0.49 0.627

Same 42 (97.7) 21 (95.5) 17 (100) A & C 0.63 0.530

Improved 0 (0) 0 (0) 0 (0) B & C 0.88 0.379

# Mann-Whitney U Test

30.2 31.8

0.0

14.0

0.0

11.8

55.8

68.2

88.2

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

Perc

en

tag

e

worsened same Improved

Laminoplasty Laminectomy Lateral mass fusion

There was statistically significant

difference between the sensory

outcomes between Laminoplasty

and lateral mass fusion groups with

lateral mass fusion group showing

more percentages of improved

sensory outcomes.

62

Fig. Comparison of post bulk between group

Table Comparison of Sphincteric involvement between group

Post bladder involvement

Laminoplasty Laminectomy

Lateral mass fusion

Group Z# p

Worsened 0 (0) 0 (0) 0 (0) A & B 0.33 0.745

Same 31 (72.1) 15 (68.2) 11 (64.7) A & C 0.56 0.577

Improved 12 (27.9) 7 (31.8) 6 (35.3) B & C 0.23 0.822

# Mann-Whitney U Test

Fig. Comparison of sphincteric involvement between group

2.3 4.50.0

97.795.5100.0

0.0 0.0 0.0

0.0

20.0

40.0

60.0

80.0

100.0P

erc

en

tag

e

worsened same Improved

Laminoplasty Laminectomy Lateral mass fusion

0.0 0.0 0.0

72.168.2

64.7

27.931.8

35.3

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

Perc

en

tag

e

worsened same Improved

Laminoplasty Laminectomy Lateral mass fusion

There was no significant

difference in the outcome

amongst the three groups with

regards to bulk of muscles

There were no significant differences

in the outcome of bladder function

among the groups.

63

Table Comparison of spasticity between group

Post spasticity

Laminoplasty Laminectomy Lateral mass

fusion Group Z# p

Worsened 2 (4.7) 2 (9.1) 0 (0) A & B 0.79 0.432

Same 8 (18.6) 5 (22.7) 2 (11.8) A & C 1.04 0.299

Improved 33 (76.7) 15 (68.2) 15 (88.2) B & C 1.52 0.128

# Mann-Whitney U Test

Fig. Comparison of spasticity between group

The overall outcome was analysed, and the results obtained were as follows-

Power Table Comparison of power in all group

Preop weakness

Post Count Percent Z# P

Absent

Worsened 1 10.0

3** 0.003 Same 9 90.0

Present

Worsened 4 5.6

6.79** 0.000 Same 11 15.3

Improved 57 79.2

4.79.1

0.0

18.622.7

11.8

76.7

68.2

88.2

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

Perc

en

tag

e

worsened same Improved

Laminoplasty Laminectomy Lateral mass fusion

There was no significant

difference in the outcome of

spasticity amongst the three

groups.

64

Fig. Comparison of power in all group

Sensory

Table Comparison of sensory in all group

Pre Post Count Percent Z# P

Absent Same 5 100.0

2.24* 0.025 Worsened 0 0.0

Present

Same 3 3.9

3.95** 0.000 Worsened 20 26.0

Improved 54 70.1

Fig. Comparison of sensory in all group

10.05.6

90.0

15.3

0.0

79.2

0.0

20.0

40.0

60.0

80.0

100.0P

erc

en

tag

e

worsened same Improved

Absent Present

100.0

3.9 0.0

26.0

0.0

70.1

0.0

20.0

40.0

60.0

80.0

100.0

Perc

en

tag

e

same worsened Improved

Absent Present

Amongst the 82 patients that were

studied, weakness was present in

72(87.8%), out of which 57(79.2%)

improved, 11(15.3%) remained

same and 4(5.6%) worsened.

Ten(12.19%) patients did not have

weakness pre-operatively and

9(90%) of them remained same

while only 1(10.0%) worsened.

Improvement in the weakness

group and power remaining same

in the group without weakness

Among the 82 patients sensory

disturbances were seen in

77(93.9%) patients of which

54(70.1%) improved, 3(3.9%)

remained the same and 20(26.0%)

worsened. Improvement was

statistically significant.

65

BULK

Table Comparison of bulk in all group

Preop atrophy present

Post Count Percent Z# p

Absent Same 61 100.0

7.81** 0.000 Worsened 0 0.0

Present

Same 19 90.5

1.41 0.157 Worsened 2 9.5

Fig. Comparison of bulk in all group

Sphincteric(bladder) involvement

Table Comparison of bladder involvement in all group

Pre Post Count Percent Z# p

Absent

Same 55 100.0

7.42** 0.000 Improved 0 0.0

Present

Same 2 7.4

5** 0.000 Improved 25 92.6

100.0

90.5

0.0

9.5

0.0

20.0

40.0

60.0

80.0

100.0

Perc

en

tag

e

same worsened

Absent Present

Amongst the patients 21 of

82(25.6%) had atrophy

preoperatively, 2(9.5%) worsened

and 19(90.5%) remained the same,

it was absent in 61 of 82(19.05%)

patients and all(100%) remained

the same, which was of statistical

significance.

66

Fig. Comparison of bladder involvement in all group

Spasticity

Table Comparison of spasticity in all group

Preop spasticity

Post Count Percent Z# p

Absent

Worsened 0 0.0

- - Improved 0 0.0

Present

Worsened 4 4.9

7.21** 0.000 Same 15 18.3

Improved 63 76.8

Fig. Comparison of spasticity in all group

100.0

7.40.0

92.6

0.0

20.0

40.0

60.0

80.0

100.0P

erc

en

tag

e

same Improved

Absent Present

0.04.9

0.0

18.3

0.0

76.8

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

Perc

en

tag

e

worsened same Improved

Absent Present

Bladder disturbances were present in

27 of 82(6.27%) patients, of which

25(92.6%) improved and 2(7.4%)

remained the same, which was of

statistical significance and absent in

55 of 82(67.07%) and all of them

remained same.

All the 82(100%) patients had

spasticity preoperatively, of which

63 improved (76.8%), 15(18.3%)

remained same and 4(4.9%)

worsened. The improvement was

statistically significant.

67

Imaging correlation

Table Percentage distribution of the sample according to selected variables

Imaging feature Count Percent

Opll 43 52.4

Myelomalacia 64 78.0

Pivd 78 95.1

Loss of lordosis 82 100.0

Stenosis 81 98.8

Osteophytes 49 59.8

Lf hypertrophy 19 23.2

Scoliosis 2 2.4

Fig. Percentage distribution of the sample according to selected variables

Loss of lordosis, PIVD, Canal

stenosis were the most common

features present in all the

patients

68

ASSOCIATION OF WEAKNESS WITH IMAGING FEATURES

Association between post op power with imaging of all the patients

Imaging feature Worsened Same Improved

Z# p Count Percent Count Percent Count Percent

Opll Absent 1 2.6 10 25.6 28 71.8

0.59 0.553 Present 4 9.3 10 23.3 29 67.4

Myelomalacia Absent 1 5.6 4 22.2 13 72.2

0.28 0.781 Present 4 6.3 16 25.0 44 68.8

Pivd Absent 0 0.0 0 0.0 4 100.0

1.34 0.182 Present 5 6.4 20 25.6 53 67.9

Loss of

lordosis

Absent 0 0.0 0 0.0 0 0.0

Present 5 6.1 20 24.4 57 69.5

Stenosis Absent 0 0.0 0 0.0 1 100.0

0.66 0.512 Present 5 6.2 20 24.7 56 69.1

Osteophytes Absent 3 9.1 7 21.2 23 69.7

0.12 0.907 Present 2 4.1 13 26.5 34 69.4

LF

hypertrophy

Absent 4 6.3 16 25.4 43 68.3 0.44 0.658

Present 1 5.3 4 21.1 14 73.7

Scoliosis Absent 5 6.3 18 22.5 57 71.3

1.94 0.052 Present 0 0.0 2 100.0 0 0.0

The above table shows presence or absence of imaging features in all the patients

included in the study with regards to outcome of power after surgery. None of the

features reached a statistically significant level with regards to outcome of power after

surgery

69

Fig. Association between post op power with selected variables

Table Association between post op power with selected variables in Laminoplasty

Worsened Same Improved

Z# p Count Percent Count Percent Count Percent

Opll Absent 0 0.0 7 31.8 15 68.2 0.82 0.410 Present 4 19.0 4 19.0 13 61.9

Myelomalacia Absent 1 14.3 2 28.6 4 57.1 0.53 0.597 Present 3 8.3 9 25.0 24 66.7

Pivd Absent 0 0.0 0 0.0 4 100.0 1.49 0.136 Present 4 10.3 11 28.2 24 61.5

Loss of lordosis

Absent 0 0.0 0 0.0 0 0.0 - - Present 4 9.3 11 25.6 28 65.1

Stenosis Absent 0 0.0 0 0.0 1 100.0 0.72 0.472 Present 4 9.5 11 26.2 27 64.3

Osteophytes Absent 2 10.5 4 21.1 13 68.4 0.31 0.760 Present 2 8.3 7 29.2 15 62.5

LF hypertrophy

Absent 3 8.1 10 27.0 24 64.9 0.06 0.950 Present 1 16.7 1 16.7 4 66.7

Scoliosis Absent 4 9.3 11 25.6 28 65.1 - - Present 0 0.0 0 0.0 0 0.0

None of the features show statistical significance, with regards to outcome of power in

the laminoplasty group.

70

Table Association between post op power with imaging in Laminectomy

Worsened Same Improved

Z# p Count Percent Count Percent Count Percent

Opll Absent 1 12.5 1 12.5 6 75.0

0.71 0.477 Present 0 0.0 2 14.3 12 85.7

Myelomalacia Absent 0 0.0 0 0.0 5 100.0

1.17 0.243 Present 1 5.9 3 17.6 13 76.5

Pivd Absent 0 0.0 0 0.0 0 0.0

- - Present 1 4.5 3 13.6 18 81.8

Loss of lordosis

Absent 0 0.0 0 0.0 0 0.0 - -

Present 1 4.5 3 13.6 18 81.8

Stenosis Absent 0 0.0 0 0.0 0 0.0

- - Present 1 4.5 3 13.6 18 81.8

Osteophytes Absent 1 14.3 1 14.3 5 71.4

0.95 0.345 Present 0 0.0 2 13.3 13 86.7

LF hypertrophy

Absent 1 8.3 1 8.3 10 83.3 0.1 0.922

Present 0 0.0 2 20.0 8 80.0

Scoliosis Absent 1 4.5 3 13.6 18 81.8

- - Present 0 0.0 0 0.0 0 0.0

None of the features show statistical significance, with regards to outcome of power in

the laminectomy group.

TableAssociation between post op power with imaging in Lateral mass fusion

Worsened Same Improved

Z# p Count Percent Count Percent Count Percent

Opll Absent 0 0.0 2 22.2 7 77.8

1.16 0.246 Present 0 0.0 4 50.0 4 50.0

Myelomalacia Absent 0 0.0 2 33.3 4 66.7

0.12 0.904 Present 0 0.0 4 36.4 7 63.6

Pivd Absent 0 0.0 0 0.0 0 0.0

- - Present 0 0.0 6 35.3 11 64.7

Loss of lordosis

Absent 0 0.0 0 0.0 0 0.0 - -

Present 0 0.0 6 35.3 11 64.7

Stenosis Absent 0 0.0 0 0.0 0 0.0

- - Present 0 0.0 6 35.3 11 64.7

Osteophytes Absent 0 0.0 2 28.6 5 71.4

0.47 0.638 Present 0 0.0 4 40.0 6 60.0

LF hypertrophy

Absent 0 0.0 5 35.7 9 64.3 0.08 0.939

Present 0 0.0 1 33.3 2 66.7

Scoliosis Absent 0 0.0 4 26.7 11 73.3

1.98* 0.048 Present 0 0.0 2 100.0 0 0.0

None of the features show statistical significance, with regards to outcome of power in

the Lateral mass fusion group.

71

ASSOCIATION OF SENSORY INVOLVEMENT WITH IMAGING FEATURES

.Table Association between post op sensory deficits with imaging features in all

the patients

Imaging features Worsened Same Improved

Z# p Count Percent Count Percent Count Percent

Opll Absent 8 20.5 2 5.1 29 74.4

1.38 0.169 Present 12 27.9 6 14.0 25 58.1

Myelomalacia Absent 6 33.3 4 22.2 8 44.4

1.9 0.057 Present 14 21.9 4 6.3 46 71.9

Pivd Absent 2 50.0 0 0.0 2 50.0

0.88 0.381 Present 18 23.1 8 10.3 52 66.7

Loss of

lordosis

Absent 0 0.0 0 0.0 0 0.0

Present 20 24.4 8 9.8 54 65.9

Stenosis Absent 0 0.0 0 0.0 1 100.0

0.71 0.479 Present 20 24.7 8 9.9 53 65.4

Osteophytes Absent 9 27.3 1 3.0 23 69.7

0.29 0.769 Present 11 22.4 7 14.3 31 63.3

LF

hypertrophy

Absent 15 23.8 5 7.9 43 68.3 0.68 0.494

Present 5 26.3 3 15.8 11 57.9

Scoliosis Absent 20 25.0 8 10.0 52 65.0

1.01 0.314 Present 0 0.0 0 0.0 2 100.0

The above table shows presence or absence of imaging features in all the patients

included in the study with regards to outcome of sensory deficits after surgery. None of

the variables had significant values.

72

Fig. Association between post op sensory with selected variables

Table Association between post op sensory with imaging in Laminoplasty

Imaging features Worsened Same Improved

Z# p Count Percent Count Percent Count Percent

Opll Absent 7 31.8 1 4.5 14 63.6

0.61 0.540 Present 6 28.6 5 23.8 10 47.6

Myelomalacia Absent 3 42.9 2 28.6 2 28.6

1.36 0.173 Present 10 27.8 4 11.1 22 61.1

Pivd Absent 2 50.0 0 0.0 2 50.0

0.52 0.606 Present 11 28.2 6 15.4 22 56.4

Loss of lordosis

Absent 0 0.0 0 0.0 0 0.0 - -

Present 13 30.2 6 14.0 24 55.8

Stenosis Absent 0 0.0 0 0.0 1 100.0

0.86 0.391 Present 13 31.0 6 14.3 23 54.8

Osteophytes Absent 6 31.6 1 5.3 12 63.2

0.51 0.612 Present 7 29.2 5 20.8 12 50.0

LF hypertrophy

Absent 12 32.4 3 8.1 22 59.5 0.49 0.623

Present 1 16.7 3 50.0 2 33.3

Scoliosis Absent 13 30.2 6 14.0 24 55.8

- - Present 0 0.0 0 0.0 0 0.0

There was no significant difference in outcome of sensory deficits in laminoplasty

group with respect to imaging features

73

Table Association between post op sensory with imaging in Laminectomy

Worsened Same Improved

Z# p Count Percent Count Percent Count Percent

Opll Absent 1 12.5 0 0.0 7 87.5

1.44 0.151 Present 6 42.9 0 0.0 8 57.1

Myelomalacia Absent 3 60.0 0 0.0 2 40.0

1.5 0.133 Present 4 23.5 0 0.0 13 76.5

Pivd Absent 0 0.0 0 0.0 0 0.0

- - Present 7 31.8 0 0.0 15 68.2

Loss of lordosis

Absent 0 0.0 0 0.0 0 0.0 - -

Present 7 31.8 0 0.0 15 68.2

Stenosis Absent 0 0.0 0 0.0 0 0.0

- - Present 7 31.8 0 0.0 15 68.2

Osteophytes Absent 3 42.9 0 0.0 4 57.1

0.74 0.458 Present 4 26.7 0 0.0 11 73.3

LF hypertrophy

Absent 3 25.0 0 0.0 9 75.0 0.73 0.462

Present 4 40.0 0 0.0 6 60.0

Scoliosis Absent 7 31.8 0 0.0 15 68.2

- - Present 0 0.0 0 0.0 0 0.0

There was no significant difference in outcome of sensory deficits in laminectomy

group with respect to imaging features.

Table Association between post op sensory deficits with imaging in Lateral mass fusion

Worsened Same Improved

Z# p Count Percent Count Percent Count Percent

Opll Absent 0 0.0 1 11.1 8 88.9

0.09 0.931 Present 0 0.0 1 12.5 7 87.5

Myelomalacia Absent 0 0.0 2 33.3 4 66.7

1.98* 0.048 Present 0 0.0 0 0.0 11 100.0

Pivd Absent 0 0.0 0 0.0 0 0.0

- - Present 0 0.0 2 11.8 15 88.2

Loss of lordosis

Absent 0 0.0 0 0.0 0 0.0 - -

Present 0 0.0 2 11.8 15 88.2

Stenosis Absent 0 0.0 0 0.0 0 0.0

- - Present 0 0.0 2 11.8 15 88.2

Osteophytes Absent 0 0.0 0 0.0 7 100.0

1.22 0.222 Present 0 0.0 2 20.0 8 80.0

LF hypertrophy

Absent 0 0.0 2 14.3 12 85.7 0.68 0.499

Present 0 0.0 0 0.0 3 100.0

Scoliosis Absent 0 0.0 2 13.3 13 86.7

0.53 0.594 Present 0 0.0 0 0.0 2 100.0

There was no significant difference in outcome of sensory deficits in lateral mass fusion

group with respect to imaging features.

74

ASSOCIATION OF ATROPHY WITH IMAGING FEATURES

Table Association between post op bulk with imaging features in all the

patients

Imaging features Worsened Same

Z# P Count Percent Count Percent

Opll Absent 1 2.6 38 97.4

0.07 0.945 Present 1 2.3 42 97.7

Myelomalacia Absent 0 0.0 18 100.0

0.75 0.450 Present 2 3.1 62 96.9

Pivd Absent 1 25.0 3 75.0

2.98** 0.003 Present 1 1.3 77 98.7

Loss of lordosis Absent 0 0.0 0 0.0

- - Present 2 2.4 80 97.6

Stenosis Absent 0 0.0 1 100.0

0.16 0.874 Present 2 2.5 79 97.5

Osteophytes Absent 2 6.1 31 93.9

1.73 0.083 Present 0 0.0 49 100.0

LF hypertrophy Absent 2 3.2 61 96.8

0.78 0.435 Present 0 0.0 19 100.0

Scoliosis Absent 2 2.5 78 97.5

0.23 0.822 Present 0 0.0 2 100.0

The above table shows presence or absence of imaging features in all the patients

included in the study with regards to effects of surgery on bulk of muscles. The only

75

statistically significant value was for PIVD with relation of bulk remaining same after

surgery.

Fig. Association between post op bulk with selected variables

Table Association between post op bulk with imaging in Laminoplasty

Imaging features Worsened Same

Z# p Count Percent Count Percent

Opll Absent 0 0.0 22 100.0

1.02 0.306 Present 1 4.8 20 95.2

Myelomalacia Absent 0 0.0 7 100.0

0.44 0.659 Present 1 2.8 35 97.2

Pivd Absent 1 25.0 3 75.0

3.12** 0.002 Present 0 0.0 39 100.0

Loss of lordosis Absent 0 0.0 0 0.0

- - Present 1 2.3 42 97.7

Stenosis Absent 0 0.0 1 100.0

0.15 0.877 Present 1 2.4 41 97.6

Osteophytes Absent 1 5.3 18 94.7

1.12 0.261 Present 0 0.0 24 100.0

LF hypertrophy Absent 1 2.7 36 97.3

0.4 0.687 Present 0 0.0 6 100.0

Scoliosis Absent 1 2.3 42 97.7

- - Present 0 0.0 0 0.0

There was no significant difference in outcome of bulk of muscles in laminoplasty

group with respect to imaging features.

76

Table Association between post op bulk with imaging in Laminectomy

Imaging features Worsened Same

Z# p Count Percent Count Percent

Opll Absent 1 12.5 7 87.5

1.32 0.186 Present 0 0.0 14 100.0

Myelomalacia Absent 0 0.0 5 100.0

0.54 0.588 Present 1 5.9 16 94.1

Pivd Absent 0 0.0 0 0.0

- - Present 1 4.5 21 95.5

Loss of lordosis

Absent 0 0.0 0 0.0 - -

Present 1 4.5 21 95.5

Stenosis Absent 0 0.0 0 0.0

- - Present 1 4.5 21 95.5

Osteophytes Absent 1 14.3 6 85.7

1.46 0.143 Present 0 0.0 15 100.0

LF hypertrophy

Absent 1 8.3 11 91.7 0.91 0.361

Present 0 0.0 10 100.0

Scoliosis Absent 1 4.5 21 95.5

- - Present 0 0.0 0 0.0

There was no significant difference in outcome of bulk of muscles in laminectomy

group with respect to imaging features.

Table Association between post op bulk with imaging in Lateral mass fusion

Imaging features Worsened Same

Z# p Count Percent Count Percent

Opll Absent 0 0.0 9 100.0

0 1.000 Present 0 0.0 8 100.0

Myelomalacia Absent 0 0.0 6 100.0

0 1.000 Present 0 0.0 11 100.0

Pivd Absent 0 0.0 0 0.0

- - Present 0 0.0 17 100.0

Loss of lordosis

Absent 0 0.0 0 0.0 - -

Present 0 0.0 17 100.0

Stenosis Absent 0 0.0 0 0.0

- - Present 0 0.0 17 100.0

Osteophytes Absent 0 0.0 7 100.0

0 1.000 Present 0 0.0 10 100.0

LF hypertrophy

Absent 0 0.0 14 100.0 0 1.000

Present 0 0.0 3 100.0

Scoliosis Absent 0 0.0 15 100.0

0 1.000 Present 0 0.0 2 100.0

77

There was no significant difference in outcome of bulk of muscles in lateral mass

fusion group with respect to imaging features.

ASSOCIATION OF SPHINCTERIC(BLADDER) DYSFUNCTION WITH IMAGING

FEATURES

Table Association between post op sphincteric(bladder) dysfunction with

imaging in all the patients

Same Improved

Z# P Count Percent Count Percent

Opll Absent 27 69.2 12 30.8

0.05 0.958 Present 30 69.8 13 30.2

Myelomalacia Absent 13 72.2 5 27.8

0.28 0.779 Present 44 68.8 20 31.3

Pivd Absent 2 50.0 2 50.0

0.86 0.388 Present 55 70.5 23 29.5

Loss of

lordosis

Absent 0 0.0 0 0.0 - -

Present 57 69.5 25 30.5

Stenosis Absent 0 0.0 1 100.0

1.51 0.131 Present 57 70.4 24 29.6

Osteophytes Absent 24 72.7 9 27.3

0.52 0.606 Present 33 67.3 16 32.7

LF

hypertrophy

Absent 44 69.8 19 30.2 0.12 0.907

Present 13 68.4 6 31.6

Scoliosis Absent 55 68.8 25 31.3

0.94 0.346 Present 2 100.0 0 0.0

78

The above table shows presence or absence of imaging features in all the patients

included in the study with regards to effects of surgery on bladder function. None of the

variables had a statistically significant value.

Fig. Association between post op bladder involvement with imaging in all the patients

Table Association between post op bladder dysfunction with imaging features in Laminoplasty group

Imaging features Same Improved

Z# P Count Percent Count Percent

Opll Absent 16 72.7 6 27.3

0.09 0.925 Present 15 71.4 6 28.6

Myelomalacia Absent 4 57.1 3 42.9

0.95 0.341 Present 27 75.0 9 25.0

Pivd Absent 2 50.0 2 50.0

1.02 0.307 Present 29 74.4 10 25.6

Loss of lordosis Absent 0 0.0 0 0.0

- - Present 31 72.1 12 27.9

Stenosis Absent 0 0.0 1 100.0

1.61 0.108 Present 31 73.8 11 26.2

Osteophytes Absent 14 73.7 5 26.3

0.2 0.838 Present 17 70.8 7 29.2

LF hypertrophy Absent 26 70.3 11 29.7

0.65 0.513 Present 5 83.3 1 16.7

Scoliosis Absent 31 72.1 12 27.9

- - Present 0 0.0 0 0.0

There was no significant difference between in outcome of bladder dysfunction in

laminoplasty group.

79

Table Association between post op bladder dysfunction with imaging features in Laminectomy group

Same Improved

Z# P Count Percent Count Percent

Opll Absent 5 62.5 3 37.5

0.42 0.673 Present 10 71.4 4 28.6

Myelomalacia Absent 4 80.0 1 20.0

0.63 0.528 Present 11 64.7 6 35.3

Pivd Absent 0 0.0 0 0.0

- - Present 15 68.2 7 31.8

Loss of lordosis

Absent 0 0.0 0 0.0 - -

Present 15 68.2 7 31.8

Stenosis Absent 0 0.0 0 0.0

- - Present 15 68.2 7 31.8

Osteophytes Absent 5 71.4 2 28.6

0.22 0.827 Present 10 66.7 5 33.3

LF hypertrophy

Absent 8 66.7 4 33.3 0.16 0.870

Present 7 70.0 3 30.0

Scoliosis Absent 15 68.2 7 31.8

- - Present 0 0.0 0 0.0

There was no significant difference between in outcome of bladder dysfunction in

laminectomy group.

Table Association between post op bladder dysfunction with imaging features in Lateral mass fusion group

Imaging feature Same Improved

Z# p Count Percent Count Percent

Opll Absent 6 66.7 3 33.3

0.17 0.862 Present 5 62.5 3 37.5

Myelomalacia Absent 5 83.3 1 16.7

1.15 0.250 Present 6 54.5 5 45.5

Pivd Absent 0 0.0 0 0.0

- - Present 11 64.7 6 35.3

Loss of lordosis Absent 0 0.0 0 0.0

- - Present 11 64.7 6 35.3

Stenosis Absent 0 0.0 0 0.0

- - Present 11 64.7 6 35.3

Osteophytes Absent 5 71.4 2 28.6

0.47 0.638 Present 6 60.0 4 40.0

LF hypertrophy Absent 10 71.4 4 28.6

1.22 0.224 Present 1 33.3 2 66.7

Scoliosis Absent 9 60.0 6 40.0

1.08 0.281 Present 2 100.0 0 0.0

There was no significant difference in outcome of bladder dysfunction in lateral mass

fusion group with respect to imaging features.

80

ASSOCIATION OF SPASTICITY WITH IMAGING FEATURES

Table Association between post op spasticity with imaging features in all the

patients

Imaging features Worsened Same Improved

Z# p Count Percent Count Percent Count Percent

Opll Absent 2 5.1 9 23.1 28 71.8

0.98 0.328 Present 2 4.7 6 14.0 35 81.4

Myelomalacia Absent 0 0.0 4 22.2 14 77.8

0.23 0.819 Present 4 6.3 11 17.2 49 76.6

Pivd Absent 0 0.0 1 25.0 3 75.0

0.03 0.977 Present 4 5.1 14 17.9 60 76.9

Loss of

lordosis

Absent 0 0.0 0 0.0 0 0.0 - -

Present 4 4.9 15 18.3 63 76.8

Stenosis Absent 0 0.0 0 0.0 1 100.0

0.55 0.585 Present 4 4.9 15 18.5 62 76.5

Osteophytes Absent 2 6.1 7 21.2 24 72.7

0.73 0.467 Present 2 4.1 8 16.3 39 79.6

LF

hypertrophy

Absent 3 4.8 11 17.5 49 77.8 0.36 0.720

Present 1 5.3 4 21.1 14 73.7

Scoliosis Absent 4 5.0 15 18.8 61 76.3

0.78 0.437

Present 0 0.0 0 0.0 2 100.0

The above table shows presence or absence of imaging features in all the patients

included in the study with regards to effects of surgery on spasticity. None of the

variables were statistically significant.

81

Fig. Association between post op spasticity with selected variables

Table Association between post op spasticity with imaging in Laminoplasty

Imaging features Worsened Same Improved

Z# p Count Percent Count Percent Count Percent

Opll Absent 0 0.0 6 27.3 16 72.7

0.43 0.668 Present 2 9.5 2 9.5 17 81.0

Myelomalacia Absent 0 0.0 2 28.6 5 71.4

0.27 0.789 Present 2 5.6 6 16.7 28 77.8

Pivd Absent 0 0.0 1 25.0 3 75.0

0.03 0.977 Present 2 5.1 7 17.9 30 76.9

Loss of lordosis

Absent 0 0.0 0 0.0 0 0.0 - -

Present 2 4.7 8 18.6 33 76.7

Stenosis Absent 0 0.0 0 0.0 1 100.0

0.55 0.584 Present 2 4.8 8 19.0 32 76.2

Osteophytes Absent 1 5.3 4 21.1 14 73.7

0.42 0.678 Present 1 4.2 4 16.7 19 79.2

LF hypertrophy

Absent 2 5.4 6 16.2 29 78.4 0.52 0.600

Present 0 0.0 2 33.3 4 66.7

Scoliosis Absent 2 4.7 8 18.6 33 76.7

- - Present 0 0.0 0 0.0 0 0.0

There was no significant difference in outcome of spasticity in laminolplasty group

with respect to imaging features.

82

Table Association between post op spasticity with imaging in Laminectomy group

Imaging features Worsened Same Improved

Z# p Count Percent Count Percent Count Percent

Opll Absent 2 25.0 2 25.0 4 50.0

1.58 0.114 Present 0 0.0 3 21.4 11 78.6

Myelomalacia Absent 0 0.0 2 40.0 3 60.0

0.24 0.811 Present 2 11.8 3 17.6 12 70.6

Pivd Absent 0 0.0 0 0.0 0 0.0

- - Present 2 9.1 5 22.7 15 68.2

Loss of lordosis

Absent 0 0.0 0 0.0 0 0.0 - -

Present 2 9.1 5 22.7 15 68.2

Stenosis Absent 0 0.0 0 0.0 0 0.0

- - Present 2 9.1 5 22.7 15 68.2

Osteophytes Absent 1 14.3 3 42.9 3 42.9

1.63 0.102 Present 1 6.7 2 13.3 12 80.0

LF hypertrophy

Absent 1 8.3 3 25.0 8 66.7 0.12 0.904

Present 1 10.0 2 20.0 7 70.0

Scoliosis Absent 2 9.1 5 22.7 15 68.2

- - Present 0 0.0 0 0.0 0 0.0

There was no significant difference in outcome of spasticity in laminectomy with

respect to imaging features.

Table Association between post op spasticity with imaging in Lateral mass fusion

Imaging features Worsened Same Improved

Z# p Count Percent Count Percent Count Percent

Opll Absent 0 0.0 1 11.1 8 88.9

0.09 0.931 Present 0 0.0 1 12.5 7 87.5

Myelomalacia Absent 0 0.0 0 0.0 6 100.0

1.08 0.281 Present 0 0.0 2 18.2 9 81.8

Pivd Absent 0 0.0 0 0.0 0 0.0

- - Present 0 0.0 2 11.8 15 88.2

Loss of lordosis

Absent 0 0.0 0 0.0 0 0.0 - -

Present 0 0.0 2 11.8 15 88.2

Stenosis Absent 0 0.0 0 0.0 0 0.0

- - Present 0 0.0 2 11.8 15 88.2

Osteophytes Absent 0 0.0 0 0.0 7 100.0

1.22 0.222 Present 0 0.0 2 20.0 8 80.0

LF hypertrophy

Absent 0 0.0 2 14.3 12 85.7 0.68 0.499

Present 0 0.0 0 0.0 3 100.0

Scoliosis Absent 0 0.0 2 13.3 13 86.7

0.53 0.594 Present 0 0.0 0 0.0 2 100.0

There was no significant difference in outcome of spasticity in lateral mass fusion

group with respect to imaging features.

83

PAIN

Patients were asked to self -assess their neck pain in the follow up period.

Laminoplasty

Pain present Pain absent

27/43 16/43

Laminectomy

Pain present Pain absent

13/22 9/22

Lateral mass fusion

Pain present Pain absent

7/17 10/17

Pain at the time of presentation was present in 27 of 43 patients in the laminectomy

group, 13 of 22 patients in the laminectomy group and 7 of 17 patients in the lateral

mass fusion group.

In the laminoplasty group 25/43(58.13%) patients responded to the feedback request.

The average pain score was-33%.

In the laminectomy group 14/22(63.6%) patients responded to the feedback request.

The average pain score was- 48%.

84

In the lateral mass fusion group 14/17(82.35%) patients responded to the feedback

request. The average pain score was- 28.7%.

COMPLICATIONS AND RE-EXPLORATIONS

Laminoplasty group

In the Laminoplasty group complications were seen in 7 of 43 patients(16.27%)- 2

wound related, 1 root avulsion, 1 Horners‟ syndrome,2 graft displacement,2 C5

paraesis, which resolved with conservative treatment.

Resurgeries were seen in 3 of these patients- 2 wound resuturings, 1 rib graft removal, 1

re-exploration with extension laminoplasty 1 level up.

1 case of meningitis leading to death was also encountered- not included in the study.

33

48

28.7

0

pain

laminoplasty

laminectomy

lateral mass fusion

85

Laminectomy group

In the laminectomy group complications were seen in 4 of 22 patients(18.1%) .2

pulmonary complications with respiratory distress, requiring ventilator support, 1

requiring tracheostomy

1 meningitis, 1 C5 paresis.

Lateral mass fusion

In the lateral mass fusion group, complications were seen in 1 of 17 patients (5.8%)-

wound related not requiring resuturing.

DISCUSSION

86

6. DISCUSSION

There have been studies which retrospectively compare the outcome of various

posterior approaches for degenerative cervical spine disease. But, there is still lack of

concrete evidence to suggest one procedure is better than the other. This study also

aimed to clearly define the outcomes after the procedures.

The choice of procedure still is majorly surgeon dependent, with cost of procedure and

affordability also playing a role in developing countries like ours.

In the present retrospective study the patients were mostly above the age of 40 years ,

similar to the study by Truumees et al7

,in the laminectomy group had a mean age

higher than laminoplasty and lateral mass fusion groups(55yrs vs 48.5yrs 53.8yrs),

with nearly equal sex distribution.

The presenting symptoms in all the three groups most commonly were

spasticity(97.7%vs 100%vs 100%), weakness and parasthesias were significantly

higher in the laminoplasty group than laminectomy and lateral mass fusion groups(74.4

% vs 72.73% vs 35.3%) and (22 vs 22% vs 17.6%). Other common presenting

symptoms were numbness, bladder symptoms, sexual dysfunction. Pain as a presenting

symptom was much more common in the laminoplasty group than in laminectomy and

lateral mass fusion groups.(62.8% vs 59.1% vs 41.2%). These observations were

similar to the study by Connell et al8. The mean duration of symptoms in the

laminoplasty group was 19.34 months, in the laminectomy group was 14.5 months and

in the lateral mass fusion group was 22.8 months.

Laminoplasty has been performed and outcome analysed in various studies56

,57

. It has

been performed by different techniques56

.The authors have found significant

improvement in the neurological outcomes as well as radiographically it has shown to

increase the canal dimensions and increase in spinal cord area. Due to maintenance of

87

posterior elements the incidence of kyphosis also has been found to be low. In the our

study the power of limbs was found to have improved significantly(80% of

patients).Also there was improvement in the sensory deficits of the patients

(61%).Spasticity, graded using Nuricks grading, improved significantly(76.7%), which

was consistent with the studies reviewed. Bladder dysfunction also improved in 92.3%

of patients, which was better than that reported by Lee Et al97

The bulk of muscles did not show any improvement and tended to remain the same.

Laminectomy has also been traditionally performed to increase the spinal cord area for

stenosed canal 62,63,64,65,66,67

. It provides space for posterior migration of the spinal cord

and thus relieves symptoms of stenosis and cord compression. But major drawback is

removal of posterior support of the vertebral column, leading to increased incidence of

kyphosis58,71

. The results of the present study were consistent with the outcomes in the

reviewed studies with post operatively power improving in 85.7% of patients, sensory

deficits improving in 68.2% of patients, bladder function improving in 87.5% of

patients, and spasticity improving in 68.2% of patients. The bulk of the muscles

remained same in most the patients while it worsened in few.

Laminectomy with lateral mass fusion overcomes the drawback of posterior column

removal of laminectomy alone, thereby maintaining the decompression effect and

providing with posterior support to the vertebral coloumn52,53,54

.Studies have shown this

procedure to be effective in relieving stenosis and also decreasing the rates of post op

kyphosis seen in laminectomy alone55

It has shown to significantly improve gait of

patients as well as radiological improvement in the canal diameter and alignment of

columns. Our study has shown results similar to the studies reviewed, with patients

showing significant improvement in the post-operative power in 68.8% of patients,

sensory deficits improvement in 93.8% of patients, Bladder function improvement in

88

Pre and post-operative images of a 42 years old male with CSM who

underwent laminectomy and lateral mass fusion. a. Preop saggital MRI,

B.Preop axial MRI,C. Post op Saggital MRI

A

B

C

89

100% of patients, improvement in spasticity in 88.2% of patients. Bulk like in the other

groups did not show any change.

In our study after a follow up of 1 year, statistically significant improvement in power

was seen in all the patients It was more in laminectomy group 85.7% compared to

laminoplasty and lateral mass fusion groups(80% vs 68.5%).However, the differences

were not statistically significant. Improvement in statistically significant spasticity was

also found in all the groups, with better results found in lateral mass fusion

group(88.8%) as compared to laminoplasty and laminectomy groups,(76.7% vs

68.2%).However the differences were not statistically significant. These results were

similar to the observation by Hamanishi and Tanaka59

who compared the results of

laminectomy alone and laminectomy and lateral mass fusion. They found after a mean

follow up of 3.5 years postoperatively using the JOA scale and percent recovery, that

the rates of recovery were similar in both the groups. (51% improvement in JOA score

in both groups). The time from onset of symptoms or injury strongly correlated to

neurologic recovery in both groups. Radiographic instability developed in 2 patients

and 5 progressed to kyphosis, the laminectomy group. In the fusion group, only an 80%

fusion rate was noted, and 2 developed instability. Kyphosis developed in 17%

patients who did not undergo fusion compared with 12% who did. However, the 2

treatment groups were dissimilar in that the fusion group had instability or kyphosis and

worse JOA scores. Any comparison of outcomes is therefore biased against the fusion

group. However, Glen R. Manzano et al found in theirs study that both laminoplasty

and lateral mass fusion patients showed improvements in their Nurick grade and mJOA

score postoperatively, but improvement in the Nurick grade for the laminoplasty group

only was statistically Significant98

.

90

Post operative xrays of a patient who underwent lateral mass fusion.A,.post op day1. B&C Flexion –

extension x-rays after 1 year.

A

B

C

91

This was in contrast to the results of the present study which showed statistically

significant improvement in the power and nuricks scores.

In the present study sensory improvements were seen in all the patients with

statistically significant better improvements found in lateral mass fusion group(93.8%)

as compared to the other groups(61.5% vs 68.2%). Improvement in bladder dysfunction

was also seen in all the three groups, it was more in the lateral mass fusion group than

in laminoplasty or laminectomy groups(100%vs92.3%vs87.5%), although these

differences were not not significant. . Chiba and colleagues92

described a

retrospective series of 208 patients who underwent laminoplasty. Fourteen of 15

patients had severe dysesthetic pain in the hands prior to surgery, a symptom that

did not improve. This was in contrast to the study done by Heller et al.60

who

compared laminoplasty and laminectomy with lateral mass fixation in 26 patients after

a mean follow-up period of 26 months. In their study patients who underwent fusion

had more severe kyphosis and less of stenosis than the laminoplasty patients. Nurick

scale, subjective symptom reporting, and gait were used as parameters. They found

no significant differences in neurological recovery and in postoperative axial pain

scores between the 2 groups. However the results of laminoplasty were found to be

better in all instances who had better functional outcomes and lower complication rate.

Radiographically, there was no difference in between the groups, but kyphosis

developed in 1 patient who underwent fusion. There were no complications in the

laminoplasty group and in the fusion group, 2 neurological deterioration,1 deep

infection, 5 pseudarthrosis, 2 hardware failure, 1 adjacent level disease requiring

surgery developed.

92

Axial neck and parascapular pain is common in degenerative cervical spine disease has

been debated over intensely. The study comparing60

pain between laminoplasty and

lateral mass

Pre and post op images of a 45 years old patient who underwent Laminoplasty for CSM.

A. Preop saggita MRI. B &C .Post- op Flexion –extension x-rays.

A

B C

93

fusion, as measured by narcotic intake and functional restriction (Robinson scale) found

no difference in the groups. The causative factors for pain after a posterior

decompressive procedure include extensive posterior dissection, detachment of the

cervical musculature and muscular atrophy. In the present study laminoplasty group

25/43(58.13%) patients responded to the feedback request, 14/22(63.6%) patients

responded I the laminectomy group while in the lateral mass fusion group

14/17(82.35%) patients responded. The average pain score in the laminoplasty group

was 33%, 48% in the laminectomy group and 28.7% in the lateral mass fusion group.

Based on these available data the pain score was much lower in the lateral mass fusion

group followed by laminoplasty and laminectomy, showing pain relief is better with

lateral mass fusion. Glen R. Manzano et al found that the lateral mass fusion group

showed improvement in all self-reported outcome measures, none of these results was

statistically significant98.

Our patients had undergone preoperative imaging workup with dynamic x-rays, CT

scan , MRI. Most of these patients on imaging had loss of lordosis(100%),

PIVD(95.1%), canal stenosis(98.8%).OPLL was found in 52.4% and

myelomalcia(78.0%).The presence or absence of these features did not seem to affect

the outcome of patients in any of the groups. Huang and associates54

found there was

no difference in clinical improvement between patients with or without myelomalacia.

Wada et al.93

multisegmental hyperintensity on T2­weighted images correlated strongly

with a poor outcome.

Morio and colleagues56

found better outcomes with preoperative lordotic alignment,

however loss of lordosis did not significantly affect the outcome in our study.

94

Miyazaki et al.57

studied 46 patients with CSM or OPLL who had spinal instability or

deformity, and found no correlation between radiographic results and neurological

outcome.

Kaptain et al.69

reported on 46 patients undergoing laminectomy that the preoperative

spinal alignment was not predictive of outcome.

Pre and Post op images of a 47 years old male who underwent decompressive

laminectomy, had a previous history of ACD. A. Preop saggital MRI. B &C Flexion –extension

x-rays 1 year after surgery.

A

B C

95

Wada et al.94

in a series of 50 patients with cervical spondylotic myelopathy who

underwent laminoplasty reported that a poor anteroposterior canal ratio correlated with

poor outcome. However, canal stenosis was found not to affect outcome in our study.

Epstein51

in his study on Laminoplasty patients reported 3 wound seromas and 1

superficial infection.

Huang54

reported in his that pseudarthrosis developed in 1 patient, requiring a repeated

operation. Three deep wound infections requiring reoperation developed in 3 patients,

and 2 patients had C-5 root palsies that resolved.

Houten and Cooper55

in his study on lateral mass fixation with plates , had 2

neurological complications, a C-5 nerve root palsy and a radiculopathy from a

misplaced screw, along with one wound infection.

Heller 60

in his study found a significant difference in complications rates between 2

groups with no complications occurring in the laminoplasty group while in the

fusion group, 2 patients experienced neurological deterioration, a deep infection

developed in 1 patient, 5 patients had pseudarthrosis, 2 patients had hardware

failure.

In contrast to the above studies, the lateral mass fusion group in our study had

complications in 1 of 17 patients(5.8%)- 1 case of wound gaping not requiring

resuturing. In the Laminoplasty group complications were seen in 7 of 43

patients(16.27%)- 2 wound related, requiring resuturing, 1 root avulsion, 1Horners‟

syndrome,2 graft displacement, requiring removal in 1 case,2 C5 paraesis, which

resolved with conservative treatment. In the laminectomy group complications were

seen in 4 of 22 patients(18.1%)Two pulmonary complications with respiratory distress;

requiring ventilator support, 1 requiring tracheostomy;1 meningitis,1 C5 paresis.

CONCLUSIONS

96

7. CONCLUSIONS

The three procedures, laminoplasty, laminectomy and laminectomy with lateral

mass fixation, provide reliable means of treatment for multi-level degenerative

cervical spine disease, with comparable improvement in the outcome - motor

power, spasticity and sphincteric function.

Improvement of sensory symptoms was found to be better in the laminectomy

with lateral mass fusion group as compared to the other 2 groups.

Patient satisfaction with regards to post-operative nuchal pain was better after

lateral mass fusion, followed by laminoplasty.

The present study did not find any correlation between the pre-operative

radiological findings and outcome after surgery.

Muscular atrophy if present, does not improve after any of the three

decompressive procedures.

The rate of complications were much less in the lateral mass fusion group than

in laminoplasty or laminectomy alone groups.

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97

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ANNEXURES

Annexure 1

Sree Chitra Tirunal Institute for Medical Sciences & Technology

Proforma for patients with Cervical Spinal Canal Stenosis

1. General information

a. Name

b. Age

c. Gender

d. Occupation

e. Address

f. Hospital No

g. Date of admission

h. Date of discharge

2. Presentation

a. Presenting symptoms

i. Motor weakness

ii. Sensory symptoms

iii. Pain

b. Duration

c. Bowel bladder symptoms

d. Previous surgeries any

e. Symptoms related to other systems

f. Co-morbidities

g. Family History

3. Examination

a. General examination

b. Vital signs including Blood pressure

c. Sensory examination

d. Motor examination- Bulk

- Tone

- Power UL&LL– distal

- - Proximal

e. Bowel, bladder/autonomic

f. Preop Nuricks grade

4. Preop imaging-

a. X ray cervical spine -static,/ dynamic

b. CT Scan cervical spine - Static,

c. MRI cervical spine - PLL, OPLL, LF, Facets, Disc

a. Brain screening

b. USG/CT abdomen

d. Lab investigations

i. Hb

ii. PCV

iii. BUN/S.Cr

iv. Protein

v. S. Calcium

vi. S. Vit B12

e. Surgery

a. Date

b. Approach

c. Levels of laminectomy

d. Study Group

f. Postoperative period

a. Neurological examination- 1st day , discharge, 6weeks, 6 months ,1 year

i. Sensory

ii. Motor- bulk

iii. – tone

iv. – power –UL distal

Proximal

– LL distal

proximal

b. Local wound complications

c. Any re-exploration

i. Indication

ii. Any complication following re-exploration including neurological

deterioration

d. Date of discharge

e. Clinical grade at the time of discharge

g. Follow up

a. Neurological examination

b. Functional grade

c. Follow up imaging

d. Any evidence of recurrence/ adjacent level disease / re stenosis

e. Any other surgery in the follow up

Annexure 2

Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences & Technology, Thiruvananthapuram – 695011

QUESTIONNARE

To,

Name ________________________________

Address _________________________________

Dear ………………………….,

This questionnaire has been designed to give us information as to how your neck pain has

affected your ability to manage in everyday life. Please mark the box that most closely describes your

problem .

Section 1: Pain Intensity

* I have no pain at the moment

* The pain is mild at the moment

* The pain is moderate at the moment

* The pain is severe at the moment

* The pain is the worst imaginable at the moment

Section 2: PersonalCare (Washing, Dressing, etc.)

* I can look after myself normally without causing extra pain

* I can look after myself normally but it causes extra pain

* It is painful to look after myself and I am slow and careful

* I need some help but can manage most of my personal care

* I need help every day in most aspects of self care

* I do not get dressed, I wash with difficulty and stay in bed

Section 3: Lifting

* I can lift heavy weights without extra pain

* I can lift heavy weights but it gives extra pain

* Pain prevents me lifting heavy weights off the floor, but I can manage if they are conveniently placed,

for example on a table

* Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are

conveniently positioned

* I can only lift very light weights

* I cannot lift or carry anything

Section 4: Reading

* I can read as much as I want to with no pain in my neck

* I can read as much as I want to with slight pain in my neck

* I can read as much as I want with moderate pain in my neck

* I can’t read as much as I want because of moderate pain in my neck

* I can hardly read at all because of severe pain in my neck

* I cannot read at all

Section 5: Headaches

* I have no headaches at all

* I have slight headaches, which come infrequently

* I have moderate headaches, which come infrequently

* I have moderate headaches, which come frequently

* I have severe headaches, which come frequently

* I have headaches almost all the time

Section 6: Concentration

* I can concentrate fully when I want to with no difficulty

* I can concentrate fully when I want to with slight difficulty

* I have a fair degree of difficulty in concentrating when I want to

* I have a lot of difficulty in concentrating when I want to

* I have a great deal of difficulty in concentrating when I want to

* I cannot concentrate at all

Section 7: Work

* I can do as much work as I want to

* I can only do my usual work, but no more

* I can do most of my usual work, but no more

* I cannot do my usual work

* I can hardl y do any work at all

* I can’t do any work at all

Section 8: Driving

* I can drive my car without any neck pain

* I can drive my car as long as I want with slight pain in my neck

* I can drive my car as long as I want with moderate pain in my neck

* I can’t drive my car as long as I want because of moderate pain in my neck

* I can hardly drive at all because of severe pain in my neck

* I can’t drive my car at all

Section 9: Sleeping

* I have no trouble sleeping

* My sleep is slightly disturbed (less than 1 hr sleepless)

* My sleep is mildly disturbed (1-2 hrs sleepless)

* My sleep is moderately disturbed (2-3 hrs sleepless)

* My sleep is greatly disturbed (3-5 hrs sleepless)

* My sleep is completely disturbed (5-7 hrs sleepless)

Section 10: Recreation

* I am able to engage in all my recreation activities with no neck pain at all

* I am able to engage in all my recreation activities, with some pain in my neck

* I am able to engage in most, but not all of my usual recreation activities because of pain in my neck

* I am able to engage in a few of my usual recreation activities because of pain in my neck

* I can hardly do any recreation activities because of pain in my neck

* I can’t do any recreation activities at all

Score: /50 Transform to percentage score x 100 = %points

Scoring:

1. For each section the total possible score is 5: if the first statement is marked the section score =

0, if the last statement is marked it = 5.

2. If all ten sections are completed the score is calculated as follows:

Example:16(total scored)/50 (total possible score) x 100 = 32%

3. If one section is missed or not applicable the score is calculated:

16(total scored)/45 (total possible score) x 100 = 35.5%

4. Minimum Detectable Change (90% confidence): 5 points or 10 %point