Cervical Laminoplasty

Overview

“Laminoplasty” refers to multiple surgical procedures that involve reconstruction of the vertebral lamina subsequent to the spinal canal being opened. Typically, the term “laminoplasty” refers to the creation of hinges that allow lifting of the lamina without its complete removal.

The purpose of cervical laminoplasty was to prevent issues that often arise from laminectomy, such as postoperative segmental instability, kyphosis, perineural adhesions, and delayed neurological deterioration.

 

History of Laminoplasty

Laminoplasty has evolved significantly since its inception, with various techniques developed to enhance its effectiveness and reduce postoperative complications. Here is an overview of its history and development:

The initial method of laminoplasty was a modification of Kirita’s laminectomy technique. This involved using an air drill to thin and partially remove the laminae along the midline. The edges of the laminae near the pedicles were further thinned until they became flexible enough to be bent and lifted. Swift lifting of multiple laminae was crucial for decompressing several segments of the spinal cord simultaneously. Once lifted, the laminae were excised using scissors.

Following this, the z-plasty technique for laminoplasty was developed. In this method, once the laminae were thinned, z-shaped incisions were made in each lamina. These laminae were then lifted and secured with sutures, reconstructing the widened spinal canal. This technique showed significant neurological improvement post-procedure.

A more radical modification was the en bloc laminectomy, which involved bilateral cutting of the laminae along a line separating the laminar arches and articular processes, completely detaching them from their bony connections. The laminae were reflected to create a flap that floated on the spinal cord without fixation sutures or bone grafting.

The expansive open-door laminoplasty technique was then introduced. This involves drilling bilateral bony gutters along the laminae border adjacent to the medial section of the pedicles. The lamina border is removed on one side, and the laminae are pushed laterally towards the other side, resembling an opening door, thereby enlarging the spinal canal. Sutures are used to support the yellow ligaments and deep muscles around the facets of the hinge side to prevent the laminar door from closing.

Another significant development was a modified laminoplasty technique that splits the spinous processes and laminae along the midline, creating bilateral hinges along the lateral borders of the laminae. These are then lifted to expand the spinal canal.

While many “new methods” of laminoplasty have been described, the fundamental approaches can be categorized into the open-door technique, involving a hinge on one side, and the double-door technique, utilizing hinges on both sides. Various modifications have been implemented to prevent the expanded lamina from closing, including sutures, autologous bone grafts, hydroxyapatite or other ceramic materials, titanium miniplates or spacers, allografts, and hydroxyapatite screws.

Postoperative kyphosis and neck pain are potential complications arising from detachment of posterior cervical muscles during laminoplasty. Initially, some surgeons detached and then reattached the semispinalis cervicis muscle on the C2 spinous process, but later studies recommended preserving this attachment for better outcomes. Preservation of muscle attachment on the C7 spinous process was also found to be significant.

Techniques were developed to preserve muscle attachments on the spinous processes, such as exposing the spinous processes and laminae on one side via subperiosteal dissection, thus maintaining the attachment of the semispinalis muscles on one side. A prospective randomized study showed that preserving muscle attachment significantly decreased axial pain compared to open-door laminoplasty where muscle attachments were completely dissected.

These advancements led to myoarchitectonic spinolaminoplasty, which demonstrated improved neurosurgical cervical spine scores, minimal loss of lordosis post-surgery, and a low incidence of axial neck pain. Further clinical studies are required to validate these findings and address concerns about postoperative instability and reduced range of motion identified in previous posterior decompression procedures.

Laminoplasty has come a long way, with various innovative techniques improving patient outcomes and reducing complications, reflecting the continuous evolution and refinement of this surgical procedure.

 

Steps of Laminoplasty

Laminoplasty is a surgical procedure designed to relieve pressure on the spinal cord in the cervical spine.

Preparation: Before the surgery, you will undergo a series of pre-operative tests and consultations to ensure you are a good candidate for laminoplasty. On the day of the surgery, you will be given anesthesia to ensure you are comfortable and pain-free during the procedure.

Incision: Once you are anesthetized, the surgeon makes a small incision in the back of your neck. The size and location of the incision depend on the specific area of the spine that needs to be addressed.

Exposure: The muscles and tissues are gently moved aside to expose the cervical vertebrae (the bones of the neck). This allows the surgeon to access the lamina, which are the parts of the vertebrae that form the back of the spinal canal.

Creating the Hinge: The surgeon then creates a hinge on one side of the lamina. This involves carefully cutting through the bone but not completely detaching it. The hinge allows the lamina to open like a door.

Opening the Door: On the opposite side of the lamina, the surgeon makes another cut to create an opening. This side is carefully separated to allow the “door” to swing open, thereby expanding the spinal canal and relieving pressure on the spinal cord.

Securing the Lamina: Once the lamina is opened, it is held in place using small bone grafts or metal hardware such as plates or screws. These supports help to maintain the expanded position of the spinal canal and ensure stability.

Closing the Incision: After securing the lamina, the surgeon will carefully close the incision with sutures or staples. The muscles and tissues are returned to their normal positions, and the skin is closed.

 

Indication for Laminoplasty

Laminoplasty is a method of decompressing the spinal cord through a dorsal approach that is particularly effective when the lordosis of the cervical spine is maintained.

Laminoplasty is recommended for patients who have cervical spinal canal stenosis, continuous OPLL, and multiple spondylotic lesions, particularly in the lordotic cervical spine. Laminoplasty is indicated for patients with cervical kyphosis who require decompression of more than three levels, as it can improve myelopathy even in the presence of kyphosis.

Clinical improvement after laminoplasty may not be satisfactory if the focal kyphosis angle is more than 13° or if the thickness of OPLL is beyond the K-line. In such cases, the most compressed segment can be subjected to anterior decompression with fusion after laminoplasty.

Postoperative Outcome

Various scales, including the Nurick grade, JOA scale, and Neurosurgical Cervical Spine Scale (NCSS), are used to assess the clinical status of cervical myelopathy. The recovery rate is determined by calculating the difference between the JOA scale score before and after surgery and expressing it as a percentage.

In one study, laminoplasty was found to have good results in improving neurological recovery in patients, with a reported recovery rate of 66%. Neurosurgical literature commonly employs NCSS to describe the status of patients due to its clear and simple nature.

 

Benefits of Cervical Laminoplasty

The primary benefits of cervical laminoplasty include:

  1. Spinal Cord Decompression: Effective relief from symptoms caused by spinal cord compression.
  2. Preservation of Spinal Stability: Unlike laminectomy, laminoplasty maintains the integrity of the spinal structure, reducing the risk of postoperative instability.
  3. Reduced Risk of Postoperative Deformity: Laminoplasty has a lower risk of post-surgical spinal deformity compared to other procedures.

 

Risks and Complications

As with any surgery, cervical laminoplasty carries potential risks, including:

  • Infection: Postoperative infections can occur but are relatively rare.
  • Bleeding: There is a risk of excessive bleeding during or after the surgery.
  • Nerve Injury: Potential injury to spinal nerves, which can lead to numbness, weakness, or even paralysis.
  • C5 Palsy: A specific complication involving weakness in the shoulder and arm, often temporary but can be permanent in rare cases.
  • Recurrent Symptoms: In some cases, symptoms may recur, necessitating further treatment.

 

Kyphosis Development

Literature has shown that laminoplasty may result in kyphosis development in some patients, although the incidence of this varies between studies. Preserving the functionality of the posterior musculature can prevent the loss of cervical lordosis.

Maintaining the functional preservation of the posterior musculature is crucial because it is responsible for the mechanical force that maintains cervical lordosis, with the semispinalis cervicis and capitis playing a significant role in this. Myoarchitectonic spinolaminoplasty has been observed to lead to the least loss of lordosis, presumably due to the preservation of all posterior muscle attachments.

Biomechanical Studies

According to biomechanical studies conducted on cadavers, the range of motion in response to physiological load increased after laminectomy with or without foraminotomy. However, open-door laminoplasty did not significantly differ from the intact spine in terms of range of movement.

Double-door laminoplasty demonstrated a higher level of stability in the cervical spine compared to laminectomy. However, the load to failure was lower in the spines after laminoplasty. Kyphotic deformity was observed in animal studies after laminectomy in goats and rabbits, while laminoplasty did not result in such deformities.

The results of clinical studies were inconsistent, with some studies demonstrating no significant difference between laminectomy and laminoplasty, while others showed that laminoplasty was associated with better outcomes. The inconsistent results between laminectomy and laminoplasty in clinical studies may be attributed to the failure of laminoplasty procedures to maintain or rebuild muscle attachments.

 

Recovery and Rehabilitation

Recovery from cervical laminoplasty varies but generally includes:

  • Hospital Stay: Patients typically stay in the hospital for a few days post-surgery for monitoring.
  • Pain Management: Pain is managed with medications. Initially, there may be some discomfort at the surgical site.
  • Physical Therapy: Rehabilitation is crucial to regain strength and mobility. Physical therapy usually starts within a few weeks post-surgery.
  • Activity Restrictions: Patients are advised to avoid heavy lifting and strenuous activities for several weeks.

Full recovery can take several months, during which the patient gradually resumes normal activities under the guidance of their healthcare provider.

 

Research and Innovations

Recent research and advances in spinal surgery techniques continue to improve the safety and efficacy of cervical laminoplasty. Innovations include:

  • Minimally Invasive Techniques: Efforts to reduce tissue damage and recovery time through less invasive surgical approaches.
  • Improved Implants and Tools: Development of better surgical tools and implants that enhance the stability and durability of the procedure.
  • Enhanced Imaging and Navigation: Use of advanced imaging technologies to improve surgical precision and outcomes.

 

Patient Considerations

Before deciding on cervical laminoplasty, patients should consider:

  • Detailed Consultation: Discuss all potential risks, benefits, and alternatives with the surgeon.
  • Second Opinion: Seeking a second opinion can provide additional perspective on the necessity and approach to surgery.
  • Realistic Expectations: Understanding the recovery process and setting realistic goals for postoperative outcomes.

 

Conclusion

Cervical laminoplasty is a crucial surgical option for patients suffering from severe cervical spinal cord compression. It offers significant relief from debilitating symptoms while preserving spinal stability and function. With advances in surgical techniques and postoperative care, the prognosis for patients undergoing this procedure continues to improve. If you are experiencing symptoms of cervical spine compression, consult with a spine specialist to explore whether cervical laminoplasty is the right treatment for you.

Do you have more questions? 

What is the typical recovery time after cervical laminoplasty?

Recovery time varies, but most patients can expect to return to light activities within a few weeks. Full recovery, including return to work and more strenuous activities, generally takes between 2 to 8 weeks, depending on the individual and the nature of their work

Will I need physical therapy after cervical laminoplasty?

Yes, physical therapy is often recommended after cervical laminoplasty to help strengthen the neck muscles, improve mobility, and ensure proper healing​

How long will I need to wear a cervical collar after surgery?

The duration of wearing a cervical collar varies. It could be a few days to several weeks, depending on your specific case and your surgeon’s recommendations​

What kind of pain management can I expect post-surgery?

Pain management typically involves oral medications, including painkillers and muscle relaxants. NSAIDs are usually avoided for the first six weeks to not impede the healing process

Are there any dietary restrictions post-surgery?

There are no specific dietary restrictions, but staying hydrated and consuming a balanced diet rich in vitamins and minerals can aid in recovery. Avoid alcohol and tobacco as they can hinder healing

Can cervical laminoplasty be performed on patients with advanced arthritis?

Cervical laminoplasty may not be suitable for patients with advanced arthritis where there is minimal motion left in the spine. Other surgical options might be more appropriate in such cases

How is cervical laminoplasty different from other spinal surgeries like laminectomy or discectomy?

Cervical laminoplasty reshapes the lamina to relieve pressure while preserving spinal motion. Laminectomy involves removing the lamina, often leading to spinal fusion, while discectomy involves removing a herniated disc​

What are the signs of infection I should look out for after surgery?

Signs of infection include redness, swelling, warmth, and drainage from the incision site, as well as fever. Contact your healthcare provider immediately if you notice these symptoms​

Is cervical laminoplasty a permanent solution for spinal stenosis?

While cervical laminoplasty can provide long-term relief, it may not be a permanent solution for everyone. Some patients may experience recurring symptoms or complications over time​

Can cervical laminoplasty improve my range of motion?

Cervical laminoplasty aims to preserve your current range of motion rather than improve it. It prevents further loss of motion by avoiding spinal fusion

How soon after surgery can I resume driving?

You should avoid driving until your follow-up visit and you are no longer taking narcotic pain medications. Your ability to turn your head sufficiently to drive safely is also a factor​

What types of activities should I avoid during recovery?

Avoid lifting anything heavier than 10 pounds, pushing, pulling, and strenuous activities. Gradually increase walking as it is beneficial for recovery​

How long will I stay in the hospital after the procedure?

Hospital stays typically range from 1 to 2 nights, depending on your recovery progress and any complications that may arise​

Are there long-term complications associated with cervical laminoplasty?

Long-term complications are rare but can include loss of spinal alignment, kyphosis, recurrent stenosis, and lordosis​

Will cervical laminoplasty cure my neck pain completely?

While many patients experience significant relief from symptoms, there is no guarantee that pain will be completely eliminated. Success rates vary, and some patients may have residual pain​

What is the success rate of cervical laminoplasty?

Success rates are quite good, with up to 70% of patients experiencing relief from symptoms for up to 10 years post-surgery. Individual results vary based on several factors

Can I engage in sports after recovering from cervical laminoplasty?

Once fully recovered and cleared by your surgeon, you may be able to return to some sports. However, activities that put significant strain on the neck should be avoided or approached with caution

Will I have a visible scar after cervical laminoplasty?

The incision is typically made in the back of the neck, and while there will be a scar, it usually fades over time. Proper incision care can help minimize its appearance​

How does the surgeon decide between the open door and French door techniques?

The choice of technique depends on the specific anatomy and condition of your spine. Your surgeon will choose the method that offers the best outcome for your situation​

Are there any non-surgical alternatives to cervical laminoplasty?

Non-surgical options include physical therapy, medications, and epidural steroid injections. These can be effective for managing symptoms but may not address the underlying cause as effectively as surgery​

What happens if the laminoplasty doesn’t relieve my symptoms?

If symptoms persist after surgery, further evaluation is necessary. Additional treatments, including other surgical options or revision surgeries, might be considered​

How should I care for my incision after surgery?

Keep the incision clean and dry, inspect it daily for signs of infection, and follow your surgeon’s instructions on changing dressings and using any prescribed ointments or medications​

Can cervical laminoplasty be done as an outpatient procedure?

Cervical laminoplasty is typically performed as an inpatient procedure, requiring a hospital stay of 1 to 2 nights for monitoring and initial recovery

How does my general health affect the outcome of cervical laminoplasty?

Your general health, including factors like age, overall fitness, and the presence of other medical conditions, can significantly affect your recovery and the overall success of the surgery​

What lifestyle changes should I make after cervical laminoplasty?

Post-surgery, you should maintain a healthy diet, avoid smoking and excessive alcohol, engage in regular low-impact exercise, and follow your healthcare provider’s recommendations for neck care and physical therapy

I am Vedant Vaksha, Fellowship trained Spine, Sports and Arthroscopic Surgeon at Complete Orthopedics. I take care of patients with ailments of the neck, back, shoulder, knee, elbow and ankle. I personally approve this content and have written most of it myself.

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