Multilevel cervical laminectomy and fusion with posterior cervical cages

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1 Originl Article Multilevel cervicl lminectomy nd fusion with posterior cervicl cges ABSTRACT Context: Cervicl spondylotic myelopthy (CSM) is progressive disese tht cn result in significnt disility. Single level stenosis cn e effectively decompressed through either nterior or posterior techniques. However, multilevel pthology cn e chllenging, especilly in the presence of significnt spinl stenosis. Three level nterior decompression nd fusion re ssocited with higher nonunion rtes nd prolonged dysphgi. Posterior multilevel lminectomies with forminotomies jeoprdize the one stock required for stle fixtion with lterl mss screws (LMSs). Aims: This is the first cse series of multilevel lminectomy nd fusion for CSM instrumented with posterior cervicl cges. Settings nd Design: Three ptients presented with history of worsening neck pin, numness in ilterl upper extremities nd git disturnce, nd exmintion findings consistent with myelordiculopthy. Cervicl mgnetic resonnce imging demonstrted multilevel spondylosis resulting in moderte to severe ilterl forminl stenosis t three cervicl levels. Mterils nd Methods: The ptients underwent multilevel posterior cervicl lminectomy nd instrumented fusion with interverterl cges plced etween ilterl fcet joints over three levels. Oswestry disility index nd visul nlog scores were collected preopertively nd t ech follow up. Pre nd post opertive imges were nlyzed for chnges in cervicl lignment nd presence of rthrodesis. Results: Postopertively, ll ptients showed mrked improvement in neurologicl symptoms nd neck pin. They hd full resolution of rdiculr symptoms y 6 weeks postopertively. At 12 month follow up, they demonstrted solid rthrodesis on X rys nd computed tomogrphy scn. Conclusions: Posterior cervicl cges my e n lterntive option to LMSs in multilevel cervicl lminectomy nd fusion for cervicl spondylotic myelordiculopthy. Keywords: Cervicl, interverterl cge, lminectomy, myelopthy, spondylosis INTRODUCTION In 1952, Brin et l. were the first to descrie cervicl spondylotic myelopthy (CSM) nd its presenttion spnning minor symptoms to significnt neurologicl compromise. [1] Symptoms of CSM rnge from pin nd numness to wekness, git instility, owel nd ldder dysfunction, nd ultimtely significnt disility. [1 3] The clinicl course of CSM usully follows stedily progressive course of neurologic dysfunction. Tretment consists of decompression nd fusion nd my e performed through nterior, posterior, or comined surgicl pproches. The nterior pproch is commonly used for one or two segment pthology nd offers etter correction of kyphotic deformity nd restortion/mintennce of sgittl lnce. [4] Posterior techniques re preferred in cses of multisegmentl involvement [5 7] lthough such n pproch is ssocited with higher risk of postopertive kyphosis. [8] The literture reflects comprle efficcy of oth techniques in multisegmentl pthology in improving pin nd functionl outcomes. [7,9] Jd N Bou Monsef, Krzysztof B Siemionow Deprtment of Orthopedics, University of Illinois t Chicgo, Chicgo, Illinois, USA Address for correspondence: Dr. Krzysztof B Siemionow, 835 South Wolcott Avenue, Rm E 270, Chicgo, Illinois 60612, USA. E mil: siemiok@gmil.com Wesite: Access this rticle online Quick Response Code This is n open ccess rticle distriuted under the terms of the Cretive Commons Attriution NonCommercil ShreAlike 3.0 License, which llows others to remix, twek, nd uild upon the work non commercilly, s long s the uthor is credited nd the new cretions re licensed under the identicl terms. For reprints contct: reprints@medknow.com DOI: /jcvjs.JCVJS_69_17 How to cite this rticle: Bou Monsef JN, Siemionow KB. Multilevel cervicl lminectomy nd fusion with posterior cervicl cges. J Crniovert Jun Spine 2017;8: Journl of Crnioverterl Junction nd Spine Pulished y Wolters Kluwer Medknow

2 Bou Monsef nd Siemionow: Multilevel cervicl lminectomy nd fusion with posterior cervicl cges Fcetl distrction s tretment of cervicl spondylosis with rdiculopthy nd myelopthy ws descried y Goel. [10,11] Recently, interverterl cervicl cges implnted y posterior pproch ilterlly etween the fcet joints hve demonstrted [12-15] good clinicl nd rdiologicl outcome t 24 months. [16] Stiliztion chieved fter ilterl posterior cervicl cge implnttion is reported to e similr to nterior cervicl discectomy nd fusion (ACDF) nd lterl mss screws (LMSs) in iomechnicl studies. [17,18] This technique stilizes the fcet with instrumented distrction nd chieves indirect posterior cervicl nerve root decompression y significntly incresing forminl re. [19] Results hve supported its sfety nd efficcy for tretment of single level cervicl rdiculopthy. [20] This is the first reported cse series of multilevel lminectomies nd fusions for CSM instrumented with posterior cervicl cges. MATERIALS AND METHODS Between 2015 nd 2016, three ptients with cervicl spondylotic disese were treted using the proposed technique. Written informed consent ws otined from ll ptients. These ptients were nlyzed prospectively, nd ll ptients underwent surgery performed y the corresponding uthor. The indiction for the procedure ws chrcteristic cervicl spondylotic disese mnifested y secondry cnl stenosis. Ptients hd progressive neurologicl symptoms, owel or ldder ltertions, nd filure of nonopertive mngement. None of the ptients hd ossifiction of the posterior longitudinl ligment, posttrumtic injuries, ssocited infective nd tumorous pthology, nd rheumtoid disese. Three ptients with ges rnging from 63 to 80 yers presented with history of progressively worsening neck pin, rdiculopthy, nd mild to moderte git disturnce. Clinicl history nd neurologicl exmintion were consistent with myelordiculopthy in ll ptients. All ptients were evluted using sttic nd dynmic cervicl spine rdiogrphy, computed tomogrphy scnning, nd mgnetic resonnce imging (MRI). Sttic neutrl lterl rdiogrphs were used to ssess cervicl sgittl lnce, wheres nteroposterior rdiogrphs were used to exclude preopertive norml coronl lignment. All rdiogrphic mesurements were otined with the neck in neutrl position [Figure 1]. Cervicl MRI demonstrted multilevel spondylosis resulting in moderte to severe ilterl forminl stenosis t three cervicl levels. The ptients underwent multilevel Figure 1: Preopertive lterl X ry demonstrting multilevel spondylosis posterior cervicl lminectomy nd instrumented fusion with interverterl cges plced etween ilterl fcet joints from C4 to C7, C2 to C5, nd C3 to C6, respectively. Oswestry disility index (ODI) nd visul nlog score (VAS) were collected preopertively nd t postopertive follow up t 14 dys, 6 months, nd 12 months. Preopertive nd postopertive imges were nlyzed for chnges in cervicl lignment nd presence of rthrodesis [Figure 2]. The technique relied on Myfield hed holder with the ptients positioned prone on Jckson tle nd the neck plced in neutrl position. A midline pproch ws performed nd the posterior elements were exposed. At this point, posterior cervicl cges were plced in etween the fcet joints [20] [Figure 3]. A high speed urr ws used to drill trough etween the junction of the lmin nd the lterl mss. The lmin ws removed en loc with Leksell Rongeur nd the spinl cord ws exposed. The lmin one ws ground down in one mill nd used posterolterlly for utogrft. In ddition, 30cc of llogrft chips ws dded posterolterlly [Figure 4]. RESULTS At initil exmintion, ll three ptients hd moderte neck pin (men VAS 8/10) nd cervicl rdiculopthy (men VAS 8/10), men ODI of 60%. Initil tretment ws nonopertive for 6 months, including 6 weeks of physicl therpy. They experienced no improvement in pin or function, nd the next step ws referrl to pin mngement for cervicl epidurl steroid injections. The injections lso filed to provide ny symptomtic or functionl improvement. Shortly therefter, the symptoms progressed to include numness nd wekness Journl of Crnioverterl Junction nd Spine / Volume 8 / Issue 4 / Octoer-Decemer

3 Bou Monsef nd Siemionow: Multilevel cervicl lminectomy nd fusion with posterior cervicl cges Figure 2: Midsgittl mgnetic resonnce imging () demonstrting left C4 C5 prcentrl disc hernition with spinl cord compression (inset). Prsgittl mgnetic resonnce imging () demonstrting left C5 C7 forminl stenosis nd lterl recess stenosis dorsl to the verterl ody of C5 nd C6 Figure 3: Lterl X rys otined intropertively demonstrte no chnge in cervicl lordosis efore () nd fter () plcement of C5 C6 cge. The iggest determinnt of postopertive lignment is cervicl lordosis otined in the Myfield on the opertive tle Figure 5: Sgittl computed tomogrphy scn () of the cervicl spine otined 12 months fter surgery demonstrting evidence of ridging one (rrow) with no evidence of cge migrtion or susidence. Axil computed tomogrphy scn () of the cervicl spine otined 12 months fter surgery demonstrting loction of cervicl cge in reltionship to the fcet joint c d Figure 4: Illustrtion demonstrting surgicl technique which strts with plcement of the cervicl cges (), followed y drilling of the lminectomy trough (), en loc removl of the lmin (c), nd plcement of utogrft posterolterlly (d) in ilterl upper nd lower extremities. Bldder nd owel function were norml [Figure 5]. All ptients showed mrked improvement in neurologicl symptoms nd neck pin postopertively. The ptients chieved full recovery of ilterl upper nd lower extremity function t 14 dys postopertively nd reported men VAS rm score of 4/10, VAS neck score of 6/10, nd men ODI 40. They reported full resolution of rdiculr symptoms y 6 weeks postopertively. At 6 months, the pin hd mrkedly improved, with men VAS rm score of 2/10, VAS neck score of 3/10, nd ODI 28. Sgittl rdiogrphs of the cervicl spine reveled solid rthrodesis in ll cses. At 12 month follow up, the ptients reported men ODI of 28, cervicl VAS for neck of 2/10, rm of 1/10, nd solid rthrodesis on X rys. No kyphotic deformity, implnt filure, or loosening ws oserved. No kyphotic deformity, implnt filure, or loosening hs een oserved [Figure 6]. DISCUSSION Surgicl mngement of cervicl spondylosis my e performed through the nterior, posterior, nd comined (i.e., nterior nd posterior) surgicl pproch. [21] Pthology loction, numer of levels involved, cervicl lignment, nd degree of neck pin re some of the fctors tht influence pproch selection. The lterntive is posterior lminectomy or lminotomy/forminotomy for lterl or forminl discs, which could e performed through minimlly invsive incisions. Cervicl lminectomy cn effectively decompress the spinl cord ut crries the risk of postlminectomy kyphosis, segmentl instility, nd neurologicl deteriortion. [22 24] Posterior lminoforminotomy hs proven to e effective for cervicl mononeuropthy, with the dvntge of mintining stility nd ner norml iomechnics. [25,26] However, tretment of multilevel cervicl spine myelopthy is sujected to severl different considertions thn single level disese. [9] 318 Journl of Crnioverterl Junction nd Spine / Volume 8 / Issue 4 / Octoer-Decemer 2017

4 Bou Monsef nd Siemionow: Multilevel cervicl lminectomy nd fusion with posterior cervicl cges The iomechnicl stility chieved y the construct is comprle to tht of posterior LMS systems. [18] Figure 6: Anteroposterior () nd lterl () cervicl X rys otined 12 months postopertively demonstrting solid rthrodesis from C4 to C7. There ws no chnge in cervicl lordosis etween 6 nd 12 months Conventionlly, nterior pproches hve een preferred for ptients with one or two segment pthology nd posterior techniques for ptients with multisegmentl involvement in the sence of kyphosis. [9,27] The nterior pproch my e prticulrly difficult in such cses nd crries susequent risk of djcent segment degenertion in the future. The dvntges of the minimlly invsive pproch would e significntly reduced due to the wide exposure required. [5] Furthermore, multilevel ACDF my not chieve sufficient decompression of spinl cord. The technique optimlly ddresses compression secondry to disc hernition nd osteophytes locted t the posterior edges of verterl ody nd the posterior longitude ligment. [5] However, it is unle to ddress degenertive nd enlrged fcet joints which were present in this prticulr ptient scenrio. The lterntive then would e posterior multilevel lminectomy or lminotomy/forminotomy. [28] The drwck of posterior forminotomy for root decompression is the technicl difficulty when performed through miniml ccess incisions s well s the risk of xil neck pin nd even instility s the segment is not stilized. Furthermore, forminotomy t C4 5 hs een ssocited with motor plsies of the C 5 root. Posterior lminectomy with wide opening of the forminl spce would e fvorle in this prticulr cse, llowing decompression wy from the offending pthology including osteophytes, ligments, nd discs. This would, however, require fusion which is usully chieved through posterior LMS fixtion systems [29] [Tle 1]. Posterior cervicl cges hve shown comprle efficcy nd sfety to ACDF for tretment of single level cervicl rdiculopthy s well s forminl stenosis. [19,20] The cervicl cge is titnium cge designed to e plced into the cervicl fcets. [10,11,30] By tking dvntge of the inclintion of the cervicl fcet in the trnsverse plne, the cge chieves indirect root decompression y opening the neurl formin. The distrction stilizes the fcet, while rsp nd decortictor re used to promote definitive one heling. Multilevel lminectomy increses the size of the spinl cnl nd llowed us to ddress cord compression. The choice of posterior cervicl cge s opposed to LMSs to ddress the rdiculopthy ws multifctoril. Using LMSs would require performing forminotomies to decompress the nerve roots. Performing such procedure during lminectomy requires more extended one removl of the cervicl lmine t ll 3 levels, which my compromise the one stock required to chieve stle fixtion with LMS s well s it potentilly distorts the visul lndmrks for LMS entry points. The one loss ssocited with forminotomies long with the spce occupied y LMS decreses the surfce re ville for one grft plcement incresing the risks of pseudorthrosis. In the descried technique, fewer implnts re required to stilize the treted levels (6 cges vs. 8 screws + rods + locking cps) significntly reducing the numer of steps in the instrumenttion prt of the cse. The risk of verterl rtery injury with cervicl screws fixtion must lwys e tken into considertion. The posterior cervicl cge technique hs not een ssocited with ny verterl rtery injuries. Cervicl lminectomy with the posterior cervicl cge plcement provides direct decompression of the centrl spinl cnl nd indirect decompression of the neurl formin nd stilizes the suxil cervicl spine while fusion tkes plce. It is importnt to note tht if the ptient is plced in Myfield hed holder, s ws the cse with the ptient in this cse report, the cervicl lordosis is dictted y hed positioning in the Myfield. Plcement of cges will mintin the cervicl lordosis otined on the tle without kyphosis effect. This ws demonstrted with intropertive lterl X rys. The finl lordosis did not differ from immedite postopertive lordosis. Creful ttention to preopertive cervicl lignment is dvised. CONCLUSIONS Comined lminectomy with posterior cervicl cge ppliction chieved sfe nd effective decompression of oth centrl nd forminl stenosis, restortion of cervicl stility, nd susequent one fusion. This technique my hve dvntges over other techniques in decompression nd stiliztion of multilevel CSM with forminl stenosis. Finncil support nd sponsorship Nil. Conflicts of interest Medicl Director Providence Medicl Technology. Journl of Crnioverterl Junction nd Spine / Volume 8 / Issue 4 / Octoer-Decemer

5 Bou Monsef nd Siemionow: Multilevel cervicl lminectomy nd fusion with posterior cervicl cges Tle 1: Reported complictions of posterior cervicl cge nd posterior screw stiliztion Author/Tril Neurologicl complictions Vsculr complictions Other complictions Posterior cervicl cge Dtrx 1.81% 0 1.8% n=169 Posterior screws Moh d [25] 20.3% 0 8.5% stiliztion n=110 Gordon [26] 9.52% 0 8.5% n=21 Dhruv [27] 17.2% % n=198 Mokel [28] 6.8% 0 0 n=44 Hwng [29] n= % Lli H. S [30] 2.79% % n=143 Ktonis [31] 3.5% 0 0.8% n=225 Brrwi [41] 8.14% % n=430 Grhm [42] 14% 0 4.8% n=21 Aumi [43] 1.7% 0.6% 2.22% n=180 Fehlings [44] % n=44 Heller [45] 5.1% 0 7.7% n=78 Levine [46] 25% % n=24 Wellmn [47] n=43 0% 0 9.3% REFERENCES 1. Brin WR, Northfield D, Wilkinson M. The neurologicl mnifesttions of cervicl spondylosis. Brin 1952;75: Toledno M, Brtleson JD. Cervicl spondylotic myelopthy. Neurol Clin 2013;31: Hofstetter CP, Wng MY. Dignostic nd therpeutic chllenges of cervicl myelopthy. World Neurosurg 2014;82:e Greenerg MS. Degenertive cervicl disc disese nd cervicl myelopthy. In: Hndook of Neurosurgery. 8 th ed., Ch. 71. New York, USA: Thieme; Cridi JM, Pumerger M, Hughes AP. Cervicl rdiculopthy: A review. HSS J 2011;7: Mtz PG, Holly LT, Groff MW, Vresilovic EJ, Anderson PA, Hery RF, et l. Indictions for nterior cervicl decompression for the tretment of cervicl degenertive rdiculopthy. J Neurosurg Spine 2009;11: Ruetten S, Komp M, Merk H, Godolis G. Full endoscopic cervicl posterior forminotomy for the opertion of lterl disc hernitions using 5.9 mm endoscopes: A prospective, rndomized, controlled study. Spine (Phil P 1976) 2008;33: Sud K, Aumi K, Ito M, Shono Y, Kned K, Fujiy M. Locl kyphosis reduces surgicl outcomes of expnsive open door lminoplsty for cervicl spondylotic myelopthy. Spine (Phil P 1976) 2003;28: Lel DR, Bono CM. Updte on the dignosis nd mngement of cervicl spondylotic myelopthy. J Am Acd Orthop Surg 2015;23: Goel A, Shh A. Fcetl distrction s tretment for single nd multilevel cervicl spondylotic rdiculopthy nd myelopthy: A preliminry report. J Neurosurg Spine 2011;14: Goel A. Fcet distrction spcers for tretment of degenertive disese of the spine: Rtionle nd n lterntive hypothesis of spinl degenertion. J Crnioverter Junction Spine 2010;1: Goel A. Interfcetl intr-rticulr spcers: Emergence of concept. J Crnioverter Junction Spine 2016;7: Goel A, Shh A, Ptni N, Rmdsi R. Immedite postopertive reversl of disc hernition following fcetl distrction-fixtion surgery: report of four cses. World Neurosurg 2016;94: Goel A. Fcet distrction spcers for tretment of degenertive disese of the spine: Rtionle nd n lterntive hypothesis of spinl degenertion. J Crnioverter Junction Spine 2010;1: Goel A, Fcet distrction-rthrodesis technique: Cn it revolutionize spinl stiliztion methods? J Crnioverter Junction Spine 2011;2: Siemionow K, Jnusz P, Phillips FM, Youssef JA, Iscs R, Tyrkowski M, et l. Clinicl nd rdiogrphic results of indirect decompression nd posterior cervicl fusion for single level cervicl rdiculopthy using n expndle implnt with 2 yer follow up. J Neurol Surg A Cent Eur Neurosurg 2016;77: Voronov LI, Siemionow KB, Hvey RM, Crndng G, Phillips FM, Ptwrdhn AG. Bilterl posterior cervicl cges provide iomechnicl stility: Assessment of stnd lone nd supplementl fixtion for nterior cervicl discectomy nd fusion. Med Devices (Auckl) 2016;9: Voronov LI, Siemionow KB, Hvey RM, Crndng G, Ptwrdhn AG. Biomechnicl evlution of DTRAX( ) posterior cervicl cge stiliztion with nd without lterl mss fixtion. Med Devices (Auckl) 2016;9: Siemionow K, Jnusz P, Glowk P. Cervicl cges plced ilterlly in the fcet joints from posterior pproch significntly increse forminl re. Eur Spine J 2016;25: Journl of Crnioverterl Junction nd Spine / Volume 8 / Issue 4 / Octoer-Decemer 2017

6 Bou Monsef nd Siemionow: Multilevel cervicl lminectomy nd fusion with posterior cervicl cges 20. McCormck BM, Bundoc RC, Ver MR, Igncio JM, Berven SH, Eyster EF. Percutneous posterior cervicl fusion with the DTRAX Fcet System for single level rdiculopthy: Results in 60 ptients. J Neurosurg Spine 2013;18: Odte S, Shikt J, Kimur H, Soed T. Hyrid decompression nd fixtion technique versus plted three verter corpectomy for four segment cervicl myelopthy. J Spinl Disord Tech 2013;29: [Doi: /sd.0013e31827d34]. 22. Di L, Ni B, Yun W, Ji L. Rdiculopthy fter lminectomy for cervicl compression myelopthy. J Bone Joint Surg Br 1998;80: Guigui P, Benoist M, Deurge A. Spinl deformity nd instility fter multilevel cervicl lminectomy for spondylotic myelopthy. Spine (Phil P 1976) 1998;23: Lonstein JE. Post lminectomy kyphosis. Clin Orthop Relt Res 1977;28: Zdelick TA, Zou D, Wrden KE, McCe R, Kunz D, Vndery R. Cervicl stility fter forminotomy. A iomechnicl in vitro nlysis. J Bone Joint Surg Am 1992;74: Hery RF, Ryken TC, Mtz PG, Anderson PA, Groff MW, Holly LT, et l. Cervicl lminoforminotomy for the tretment of cervicl degenertive rdiculopthy. J Neurosurg Spine 2009;11: Lwrence BD, Brodke DS. Posterior surgery for cervicl myelopthy: Indictions, techniques, nd outcomes. Orthop Clin North Am 2012;43:29 40, vii viii. 28. Dodwd SJ, Dodwd SN, Prsrn ML, Svge JW, Ptel AA, Hsu WK. Posterior cervicl forminotomy: Indictions, technique, nd outcomes. Clin Spine Surg 2016;29: Khuygtr B, Kim K, Prk WM, Kim YH. Effect of posterior decompression extent on iomechnicl prmeters of the spinl cord in cervicl ossifiction of the posterior longitudinl ligment. Proc Inst Mech Eng Prt H 2016;230: Shh A. Morphometric nlysis of the cervicl fcets nd the fesility, sfety nd effectiveness of Goel inter-fcet spcer distrction technique. J Crnioverter Junction Spine 2014;5:9-14. Disclimer: Some uses of the device descried in this puliction hve not een pproved or clered y the FDA. Journl of Crnioverterl Junction nd Spine / Volume 8 / Issue 4 / Octoer-Decemer