5/11/2013 None related to this study E. Tabaraee, D. Shearer, C. - - PowerPoint PPT Presentation

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• E. Tabaraee, D. Shearer, C. Ames, S. Burch, V. Deviren, S.

Berven, S. Hu, D. Chou, P. Mummaneni, B. Tay University of California, San Francisco 5/11/2013

None related to this study

Cervical Myelopathy

Inc incidence

Hirabayashi

Address OPLL Noninstrumented Motion sparing

Safe and Efficacious…

Cervical spondylotic OPLL

Pros Motion preserving Protective Easier revision Avoid fusion/instrument complications Cost-effective?

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Cons

axial neck

pain

C5 palsy closure

Techniques

Open door French door w/ fusion

Spacers

Structural rib allografts Hydroxyapatite spacers Metallic Plates

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Allograft

Pros:

Effective affordable

Cons:

Intraop contour Fragile Postop bracing

Plating Pros:

Rigid fixation

Early rom Hinge healing

Shorter op time? Lower ebl?

Cons:

Expensive Hardware

complications? To compare outcomes, complications, and costs

associated with two of the more common implants used in open-door laminoplasty.

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1.

There is no difference in neck pain and nurick scores at final follow-up for laminioplasty patients with either allograft struts or metallic mini-plates

2.

There is no intraoperative, immediate postoperative,

• r financial benefit to using metallic mini-plates

We performed a retrospective analysis 106 patients. The primary outcomes were neck visual analog scale

(VAS) pain scores and Nurick scores.

Secondary outcomes included length of procedure,

estimated blood loss, length of stay, complications, and direct costs.

Preoperative

Demographics, Charlson Comorbidity index, Nurick,

Neck-VAS

Intraoperative

EBL, operative time, # of levels, # implants

Postoperative

Length of stay, direct costs, Nurick, Neck-VAS, f/u

months

Statistics:

Fisher, t-test

Inclusion Exclusion

• Primary diagnosis of CSM or OPLL
• >18 years of age
• Involving 3 or 4 levels
• Use of either structural rib

allograft struts or metallic mini- plates only

• Revision surgery
• History of either previous or concomitant

cervical fusion

• Diagnosis of spinal cord tumor, multiple

myeloma, or infection

• Use of any other laminar spacers other than

rib allograft or metallic mini-plates

• Use of both rib allograft and mini-plates
• Diagnosis of neuromuscular disease (i.e.

cerebral palsy)

• Diagnosis of neuro-autoimmune disease

(i.e. multiple sclerosis)

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Allograft (n=51) Plates (n=55) p-value Age, mean (SD) 62.2 (1.7) 61.3 (1.7) 0.70 Male Gender, no. (%) 31 (60.8) 32 (58.2) 0.84 Number of Comorbidities, mean (SD) 2.9 (0.3) 3.1 (0.3) 0.66 Charlson Comorbidities Index, mean (SD) 2.7 (0.2) 3 (0.3) 0.42 OPLL, no. (%) 4 (7.8) 10 (18.2) 0.15 Total Months Follow Up, mean (SD) * 31 (3.1) 23 (1.8) 0.005

SD (standard deviation), No. (number), OPLL (ossification of posterior longitudinal ligament), * (statistically significant)

Allograft (n=51) Plates (n=55) p-value Preop neck VAS, mean (SD) 4.3 (0.4) 3.7 (0.5) 0.33 Final Neck VAS, mean (SD) 2 (0.4) 2.2 (0.4) 0.92 Preop Nurick Score, mean (SD) 2 (0.2) 2.3 (0.2) 0.22 Final Nurick Score, mean (SD) 1.4 (0.2) 1.5 (0.2) 0.97

SD (standard deviation), VAS (visual analog scale), * (statistically significant)

Allograft (n=51) Plates (n=55) p-value Surgeon Specialty,

• no. (%)*

<0.001 Orthopaedic Surgery 38 (74.5) 3 (5.5) Neurosurgery 10 (19.6) 52 (94.6) Combined (two surgeons from different specialties 3 (5.9) 0 (0) Estimated blood loss, mean (SD) 287.7 (45.4) 229.9 (27.8) 0.28 Foraminotomies, mean (SD)* 2.7 (0.3) 1.3 (0.2) 0.0001 Number of levels, mean (SD) 4.1 (0.1) 4 (0.1) 0.79 Number of implants, mean (SD)* 3 (0.09) 3.7 (0.1) <0.0001 Length of Procedure, mean (SD)* 161 (5) 136.6 (7.3) 0.007 Length of Stay, mean (SD) 3.8 (0.4) 3.9 (0.4) 0.94 Cervical collar used,

• no. (%)*

51 (100) 17 (30.9) <0.001

SD (standard deviation), no. (number), * (statistically significant)

Allograft (n=51) no. (%) Plates (n=55)

• no. (%)

p-value C5 palsy 4 (7.8) 3 (5.5) 0.67 Persistent wound drainage 1 (2) 0 (0) 0.48 Dural tear 0 (0) 1 (1.8) 1.00 Pulmonary Embolism 1 (2) 0 (0) 0.48 Deep Infection 3 (5.9) 1 (1.8) 0.35 Wound Dehiscence 1 (2) 2 (3.6) 1.00 Lamina Fracture 0 (0) 1 (1.8) 1.00 Foraminal Stenosis 0 (0) 2 (3.6) 0.50 Adjacent Segment Disease 0 (0) 1 (1.8) 1.00 Progressive Kyphosis 2 (3.9) 0 (0) 0.23 Readmission for pain control 1 (2) 0 (0) 0.48 Total Complications 13 ( 23.5) 11 (20) 0.81

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Allograft (n=51)

• no. (%)

Plates (n=55)

• no. (%)

p-value Deep Infection 3 (5.9) 1 (1.8) 0.35 Wound Dehiscence 1 (2) 2 (3.6) 1.00 Lamina Fracture 0 (0) 1 (1.8) 1.00 Foraminal Stenosis 0 (0) 2 (3.6) 0.50 Adjacent Segment Disease 0 (0) 1 (1.8) 1.00 Progressive Kyphosis 2 (3.9) 0 (0) 0.23 Total Reoperations 6 (11.8) 7 (12.7) 1.00 allograft Plate

Collar 2 2.3 No collar N/a 1.8

Results: Average follow-up was 27 months.

The postoperative neck VAS scores and Nurick scores

improved significantly from baseline but there was no difference in the final outcome scores or complications.

The average length of operation and number of

foraminotomies were higher for the allograft group.

Among the plate group, patients treated

without a hard collar did not experience an increase rate of

complications.

The mean direct cost for the mini-plate group was $2098

more.

Not included- Operative time, anesthesia costs, indirect cost

Safe and effective

Kawai (Spine, 1988) Heller (Spine, 2001)

First to compare implants

Plates shorter op time, no bracing necessary Allograft more affordable

Laminoplasty implants

Cost saving vs. laminectomy/fusion

Highsmith (JNS, 2004)

$4200 per C3-6 construct

Marcaio- OR time (J of Anes, 2005) $62/min Agabagi- cost of brace (jaaos, 2011) $750

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Retrospective- selection bias 8 spine surgeons

No standard radiographic follow-up Rehab protocol varied

Not cost-effectiveness study

No accounts of indirect costs

Structural rib allograft struts and metallic mini-plates

result in similar improvements in neck pain and functional outcome scores with no difference in the rate of complications.

Potential benefits of using plates include shorter

procedure length and less need for postoperative immobilization.

This should be weighed against the 15% increase in

direct costs.

Long-term/radiographic data, cost-effectiveness

studies needed

All authors

• Dr. Hu and Dr. Tay
• Tsuji H: Laminoplasty for patients with compressive myelopathy due to so-called spinal canal stenosis in cervical and thoracic regions. Spine 1982;7:28-34.
• Matsuyama Y, Kawakami N, Mimatsu K: Spinal cord expansion after decompression in cervical myelopathy. Investigation by computed tomography myelography and
• ultrasonography. Spine 20: 1657-1663, 1995.
• Hirabayashi K, Watanabe K, Wakano K, Suzuki N, Satomi K, Ishii Y: Expansive open-door laminaplasty for cervical spinal stenotic myelopathy. Spine 1983;8:693-699.
• Ratliff JK, Cooper PR: Cervical laminoplasty: a critical review. J Neurosurg 98: 230-238, 2003.
• Seichi A, Takeshita K, Ohishi I, et al: Long-term results of double-door laminoplasty for cervical stenoticmyelopathy.Spine2001;26:479-487.
• Kawai S, Sunago K, Doi K, Saika M, Taguchi T: Cervical laminaplasty (Hattori’s method): Procedure and follow-up results. Spine 1988;13: 1245-1250.
• Iwasaki M, Ebara S, Miyamoto S, Wada E, Yonenobu K: Expansive Laminoplasty for cervical radiculomyelopathy due to soft disc herniation. Spine 21: 32-38, 1996.
• Sakaura H, Hosono N, Mukai Y, Ishii T, Iwasaki M, Yoshikawa H: Long-term outcome of laminoplasty for cervical myelopathy due to disc herniation: a comparative

study of laminoplasty and anterior spinal fusion. Spine 30:756–759, 2005.

• Heller JG, Edwards CC II, Murakami H, Rodts GE: Laminoplasty versus laminectomy and fusion for multilevel cervical myelopathy: an independent matched cohort
• analysis. Spine 26:1330–1336, 2001.
• Hosono N, Yonenobu K, Ono K: Neck and shoulder pain after laminoplasty. A noticeable complication. Spine 21:1969– 1973, 1996.
• Kawakami M, Tamaki T, Iwasaki H, Yoshida M, Ando M, Yamada H: A comparative study of surgical approaches for cervical compressive myelopathy. Clin Orthop

Relat Res 381:129–136, 2000

• Yoshida M, Tamaki T, Kawakami M, et al: Does reconstruction of posterior ligamentous complex with extensor musculature decrease axial symptoms after cervical

laminoplasty? Spine 2002; 27: 1414-1418.

• Tsuzuki N, Abe R, Saiki K, Iizuka T: Tension-band laminoplasty of the cervical spine. Int Orthop 1996;20:275-284.
• Yoshida M, Otani K, Shibasaki K, Ueda S: Expansive laminaplasty with reattachment of spinous process and extensor musculature for cervicalmyelopathy. Spine

1992;17:491-497.

• Takeuchi K,Yokoyama T, Aburakawa S, et al: Axial symptoms after cervical laminaplasty with C3 laminectomy compared with conventional C3-C7 laminoplasty: A

modified laminoplasty preserving the semispinalis cervicis inserted into axis. Spine 2005;30: 2544-2549.

• Satomi K, Ogawa J, Ishii Y, et al. Short-term complications and long-term results of expansive open-door laminoplasty for cervical stenotic myelopathy. Spine J

2001;1:26–30.

• Tanaka N, Nakanishi K, Fujimoto Y, et al. Expansive laminoplasty for cervical myelopathy with interconnected porous calcium hydroxyapatite ceramic spacers:

comparison with autogenous bone spacers. J Spinal DisordTech 2008;21:547–52.

• Ono A, Yokoyama T, Numasawa T, et al. Dural damage due to a loosened hydroxyapatite intraspinous spacer after spinous processsplitting laminoplasty. Report of two
• cases. J NeurosurgSpine 2007; 7:230–5.
• Deutsch H, Mummaneni PV, Rodts G, Haid RH. Posterior Cervical Laminoplasty Using a New Plating system. J Spinal Disord Tech 2004; 14: 317-320.
• Park AE, Heller JG. Cervical Laminoplasty: Use of a Novel Titanium Plate to Maintain Canal Expansion- Surgical Technique. J Spinal Disord Tech 2004; 14: 265-271.
• Rhee JM, Register B, Hamasaki T, Franklin B. Plate-Only Open Door Laminoplasty Maintains Stable Spinal Canal Expansion with High Rates of Hinge Union and No

Plate Failures. Spine 2010:36: 9-14.

• O’Brien MF, Peterson D, Casey AT, et al. A novel technique for laminoplasty augmentation of spinal canal area using titanium miniplate stabilization. A computerized

morphometric analysis. Spine. 1996;21: 474-483.

• Heller JG, Qureshi AA. “Open door” laminoplasty: biomechanical comparison of current laminar stabilization methods to a novel laminoplasty plate. Spine 2003.
• Shaffrey CI, Wiggins GC, PiccirilliCB, Young JN, Lovell LR. Modified open-door laminoplasty for treatment of neurological deficits in younger patients with congenital

spinal stenosis: analysis of clinical and radiographic data. J Neurosurg. 1999 Apr;90(2 Suppl):170-7.

• Petraglia AL, Srinivasan V, Coriddi M, Whitbeck MG, Maxwell JT, Silberstein HJ. Cervical laminoplasty as a management option for patients with cervical spondylotic

myelopathy: a series of 40 patients. Neurosurgery. 2010 Aug;67(2):272-7.

• Asgari S, Bassiouni H, Massoud N, Schlamann M, Stolke D, Sandalcioglu IE. Decompressive laminoplasty in multisegmental cervical spondylotic myelopathy: bilateral

cutting versus open-door technique. Acta Neurochir (Wien). 2009 Jul;151(7):739-49; discussion 749. Epub 2009 May 13.

• Carreon LY, Anderson PA, McDonough CM, Djurasovic M, Glassman SD. Predicting SF-6D Utility Scores From the Neck Disability Index and Numeric Rating Scales

for Neck and Arm Pain. Spine. 2011; 36 (6): 490-494.