Study On Clinical Efficacy Of Cervical Expansive Open-door Laminoplasty For Multilevel Cervical Spondylotic Myelopathy

Objectives:1. To compare the clinical efficacy of laminoplasty with Centerpiece fixation versus anchor fixation for MCSM.2. To compare the clinical efficacy of laminoplasty with Centerpiece fixation versus anterior cervical subtotal corpectomy and fusion for MOPLL.3. To evaluate clinical efficacy and safety of cervical laminoplasty and anterior cervical decompression and fusion for multilevel cervical spondylotic myelopathyMethods:1. Laminoplasties with Centerpiece fixation and with Anchor method for MCSM were compared. Between October2010and October2012,67patients underwent cervical expansive laminoplasty for multilevel cervical spondylotic myelopathy in Orthopedic Department of Tongji Hospital were enrolled in this study. Among them45patients underwent laminoplasty with Centerpiece fixation (Group C) and22patients underwent laminoplasty with Anchor fixation (Group A). Common preoperative findings (sex, age and symptom duration), neurological findings (pre and postoperative JOA scores and recovery rate of JOA score), radiological findings (pre and postoperative AP diameter, enlargement rate of AP diameter, pre and postoperative ROM and preservation rate of ROM) and incidence of complication were observed. In this part we designed new tables of evaluation of complication severity for laminoplasty and applied to evaluate complications of two groups in this study.2. Laminoplasty with Centerpiece and corpectomy with fusion for multilevel OPLL were compared.28patients who underwent surgical treatment for MOPLL from October 2010to October2012in Orthopaedic department of Tongji hospital, were enrolled in this study. From them,17patients received laminoplasty with Centerpiece fixation (Group LAMP) and11patients received anterior cervical corpectomy and fusion (Group CORP). The common preoperative clinical findings, neurological findings, radiological findings and complication were observed.3. Clinical efficacies and operation safeties of laminoplasty and ADF for MCSM were compared by meta-analysis method. After designing the key question, we formulated the search strategy. The databases used in this search were EMBASE, PubMed and The Cochrane library. And the literature search was performed with key words. According the inclusion and exclusion criteria, appropriate literatures were selected out. Then values of recovery rate of JOA score, preservation rate of ROM, operation time and intraoperative blood loss were extracted from selected literatures. These data were analysed using the Revman5.1with meta-analysis method. If the indicators could not be combined, the descriptive systematic review was used to evaluate them.Results:1. In first part,67patients were successfully followed up, including48cases of male and19cases of female. The mean age at surgery was60.3years. Group C was consisted of45cases and Group A was22cases. In preoperative clinical findings, there was no statistical difference. The symptom period of Group C (38.2months) was significantly long than of Group A (10.4months). Preoperative JOA score of Group C was10.1and of Group A was9.7, there was no statistical difference between two groups (p>0.05). Recovery rate of JOA score of Group C and Group A were66.4%and61.2%respectively, no significant difference recognized between two groups (p>0.05). The average operation time of Group C (185.8min) similar with Group A (191.0min) and the intraoperative blood loss had no difference between two groups (440.0ml and515.9ml respectively). The sagittal diameters on C5level of two groups had no statistical difference, but the enlargement rate of AP diameters were significantly different; Group A60.5%, Group C27.5%(p<0.05). In22cases (32.8%) of total67patients appeared axial symptoms, and11cases (16.4%) complained neck movement disorder, and10cases (14.9%) had C5palsy at the time of last follow-up. The incidence of C5palsy in Group A (27.3%) significantly higher than in Group C (8.9%)(p<0.05). Former two complications had no statistical difference in incidence. In the current study we applied new designed evaluation table of laminoplasty complications and observed severity deviation of complications. Among22cases with axial symptom,50%were grade Ⅲ,4.5%were grade Ⅴ. In11cases with neck movement disorder,45.4%were grade Ⅰ,9.1%were grade Ⅲ,9.1%were grade Ⅴ. In10cases with C5palsy,60%were grade Ⅱ, no observed grade Ⅳ.2. In second part,28patients were enrolled in this study, male21, female7, the mean age was60.4years, average follow-up time was18.6months. From them, Group LAMP included17cases and Group CORP11cases, between two groups there was no significant difference in preoperative common clinical findings. The average preoperative JOA score of28cases was9.7, which increased to14.4(mean RR of JO A was64.2%) after surgery. Mean pre and postoperative JOA score of Group CORP were9.0and14.3, and its recovery rate was65.5%. And the pre and postoperative JOA score of Group LAMP were10.2and14.5, and its recovery rate was63.4%, which has no statistical difference with Group CORP. the intraoperative blood loss of Group CORP (754.5ml in average) was larger than Group LAMP (376.5ml in average) and the operative time of Group CORP (332.9minutes in average) was longer than Group LAMP (194minutes in average)(p<0.05). The number of segment of Group CORP was2.5and of Group LAMP was4.2(p<0.05). In the cervical X-ray examination, average preoperative ROM was32.8°, postoperative was19.6°, the preservation rate of ROM was63.8%in average. Preoperative ROM of Group CORP of27.7°decreased to16.7°after surgery and in Group LAMP36.0°before surgery decreased to21.5°after surgery. The preservation rates of two groups were63.0%and64.5%respectively, and there was no significant difference between two groups. Mean C2-C7angle of Group CORP was11.5零before surgery, which increased to16.2°after surgery, on the contrary, C2-C7angle of Group LAMP of13.6°decreased to9.1°(p<0.05). At the last follow-up there was no kyphotic complication in Group CORP, but there were3cases with kyphotic changes in Group LAMP. Group CORP had complications as followed:3cases with CSF leak,4cases with dysphasia and3cases with dysphonia. And Group LAMP had6cases with axial symptom and3cases with C5nerve rood palsy.3. In third Part, through the including and excluding process,7citations enrolled to current analysis.5literature compared JOA recovery rate between LAMP group and ADF group. Results of heterogeneity test were as followed:Chi2=16.21, I2=69%, P=0.006, there was statistical heterogeneity. The results of Meta-analysis showed that synthesized standard mean difference (SMD) was-0.27,95%CI为-0.65-1.10, the difference in JOA recovery rate between two groups was no statistically significant.5literatures compared operation time between LAMP group and ADF group. Results of heterogeneity test were as followed:Chi2=35.93, I2=89%, P<0.00001, there was statistical heterogeneity. The results of Meta-analysis showed that synthesized SMD was-1.39,95%CI was-2.16～-0.62, the difference in operation time between two groups was statistically significant. This says the operation time of LAMP group shorter than of ADF group. These5literatures also compared intraoperative blood loss between two groups. Results of heterogeneity test were as followed:Chi2=9.39,12=57%, P=0.05, there was statistical heterogeneity. The results of Meta-analysis showed that synthesized SMD was-0.63,95%CI was-1.04～-0.33, the difference in operation time between two groups was statistically significant. This means the intraoperative blood loss of LAMP group less than of ADF group. Although3of8literatures reported ROM change of two groups, but2of them didn’t record the standard deviation, so meta-analysis was not allowed. Two literatures reported follow-up results more than10years, one of them revealed no difference in ROM between two groups, and another one reported statistical difference. And another one literature, which follow-up time was5years, reported no significant difference in ROM between two groups.Conclusion:1. For the multilevel cervical spondylotic myelopathy, there was no difference in RR of JOA, operation time and blood loss between Centerpiece fixation laminoplasty and anchor fixation laminoplasty. The enlargement of AP diameter of spinal canal was better controlled in Centerpiece group than anchor group and the incidence of C5palsy was lower.2. Both laminoplasty with Centerpiece fixation and cervical corpectomy with titanium mesh lead to significant neurological recovery in multilevel OPLL, and there was no significant difference in neurological recovery rate between two groups. Laminoplasty cohort with Centerpiece fixation tended to have shorter operation time and less blood loss than cervical corpectomy cohort. So it is believed that laminoplasty may be the preferred method of treatment for multilevel OPLL in the absence of preoperative kyphosis.3. In neurological recovery rate there was no significant difference between two methods for multilevel cervical spondylotic myelopathy at more than3year follow-up. The operative time of laminoplasty shorter than anterior decompression and fusion, and intraoperative blood loss also less. In the preservation of region of motion was no difference between two methods. In conclusion laminoplasty is preferred and safer than anterior decompression and fusion for multilevel cervical spondylotic myelopathy.