Surgical decompression is currently the only evidence-based treatment for patients with degenerative cervical myelopathy (DCM). For many patients, surgery halts disease progression, and for some there is even functional improvement.
Once surgery has been agreed as the plan of treatment going forwards between the patient and surgeon, the next key consideration is the exact type of surgery to be performed. Surgical management of DCM can broadly be categorised into: (1) anterior approaches through the front of the neck, and (2) posterior approaches through the back of the neck. Even once the direction of approach has been determined, each type of approach has slight variations – in particular, the posterior approach can be performed via a laminectomy, laminectomy with posterior cervical fusion (PCF) and cervical laminoplasty.
The choice between approach and specific variations requires the surgeon to consider several patient-specific factors (e.g. at what level the compression is located). Significant research has been and is being undertaken to help guide clinical decision making when determining which approach and surgical variation a surgeon should utilise. In an important recent study from the US, Eunice Yang and co-authors investigated the 24-month outcomes following cervical laminoplasty versus laminectomy with posterior cervical fusion for patients with DCM to help address this important gap in our knowledge [1].
How Was This Study Conducted?
The authors performed a retrospective analysis of data from 1141 patients with DCM in the multicentre Quality Outcomes Database (QOD) for cervical spondylotic myelopathy (CSM, also known as DCM). From this initial pool of patients, they included 43 patients undergoing laminoplasty and 191 patients undergoing laminectomy with posterior cervical fusion. Following surgical decompression, each patient was followed up for 24-months with patient reported outcomes measured at 3 and 24 months.
7 primary outcomes were measured including mJOA (the most commonly utilised metric to assess spinal cord function in DCM), visual analog scale (VAS) for arm and neck pain, neck disability index (NDI), and EQ-5D (a standardised measure of health-related quality of life). Secondary outcomes of interest were blood loss during the operation, length of hospital stay following the operation, readmissions, reoperations and ability to return to work and previous activity.
What Was Discovered?
The authors found that patients undergoing laminoplasty had a larger improvement in their 24-month NDI score than patients undergoing laminectomy with posterior cervical fusion. They otherwise found no 3- or 24-month differences in other primary outcomes (including mJOA, VAS arm and neck pain, and EQ-5D).
With regards to secondary outcomes measured, the authors found that patients undergoing laminoplasty had significantly lower estimated blood loss during the operation, a reduced length of post-operative hospital stay, and a higher rate of routine discharge. They also found that laminoplasty was associated with a larger rate of return to activities after 3 months, compared to patients undergoing laminectomy with posterior cervical fusion.
Why Is This Important?
The key finding of this study is the long-term similarity between laminoplasty and laminectomy with posterior cervical fusion across a range of primary outcome measures. Despite this, laminoplasty remains underutilised in the US, although studies such as this are helping to increase its prevalence.
Whilst both procedures appear to be well-tolerated by patients, this study’s findings show that laminoplasty may be associated with a faster recovery process for patients with DCM, as highlighted by the improvements in several secondary outcomes measured at 3 months. Importantly, this is currently only an association, and the underlying reason for this finding may be due to several factors, including the less invasive nature of laminoplasty, but also the reduced length of requirement for collar use and post-operative restrictions in patients undergoing laminoplasty compared to laminectomy with posterior cervical fusion.
We congratulate the authors on their study. Their cohort analysis provides an important contribution to the evidence base and provides the foundations for future studies to build on their findings by utilising larger cohorts. More investigation into this field, particularly in the form of randomised clinical trials comparing the two types of procedure, will undoubtedly help to shed light onto the surgical care of individuals with DCM with the view to improve outcomes for this debilitating condition.
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[1] Yang E, Mummaneni PV, Chou D, et al. Cervical laminoplasty versus laminectomy and posterior cervical fusion for cervical myelopathy: propensity-matched analysis of 24-month outcomes from the Quality Outcomes Database. J Neurosurg Spine. 2023;39(5):671-681. Published 2023 Aug 11. doi:10.3171/2023.6.SPINE23345.