颈椎后路植入物固定修复多节段脊髓型颈椎病：可改善症状但降低了颈椎活动度

doi:10.3969/j.issn.2095-4344.2015.22.011

中国组织工程研究 ›› 2015, Vol. 19 ›› Issue (22): 3496-3502.doi: 10.3969/j.issn.2095-4344.2015.22.011

• 脊柱植入物 spinal implant • 上一篇下一篇

颈椎后路植入物固定修复多节段脊髓型颈椎病：可改善症状但降低了颈椎活动度

赵勇1，褚言琛²，李学森²，马金龙²，邹云雯²

1青岛大学，山东省青岛市 266003；2青岛大学附属医院脊柱外科，山东省青岛市 266003

收稿日期:2015-04-26 出版日期:2015-05-28 发布日期:2015-05-28
通讯作者: 邹云雯，教授，青岛大学附属医院脊柱外科，山东省青岛市 266003
作者简介:赵勇，男，1987年生，汉族，硕士，主要从事脊柱外科方面的研究。
基金资助:
山东省自然科学基金资助项目(ZR2011HM052)

Cervical posterior implant fixation for multi-segment cervical spondylotic myelopathy: improves symptoms but diminishes cervical range of motion

Zhao Yong¹, Chu Yan-chen², Li Xue-sen², Ma Jin-long², Zou Yun-wen²

1Qingdao University, Qingdao 266003, Shandong Province, China
2Department of Spine Surgery, the Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China

Received:2015-04-26 Online:2015-05-28 Published:2015-05-28
Contact: Zou Yun-wen, Professor, Department of Spine Surgery, the Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
About author:Zhao Yong, Master, Qingdao University, Qingdao 266003, Shandong Province, China
Supported by:
the Natural Science Foundation of Shandong Province, No. ZR2011HM052

摘要/Abstract

摘要：

背景：颈椎后路单开门椎管成形单侧侧块内固定与全椎板切除双侧侧块内固定通过扩大椎管有效容积治疗脊髓型颈椎病，并且两种固定方法的疗效和安全性并不清楚。
目的：观察颈后路单开门椎管成形单侧侧块内固定与全椎板切除双侧侧块内固定治疗多节段脊髓型颈椎病，植入物与宿主生物相容性。
方法：回顾性分析117例多节段(≥3个)脊髓型颈椎病患者病历资料，分为单开门组65例和全椎板切除组52例，分别采用单开门椎管成形单侧侧块内固定及全椎板切除双侧侧块内固定治疗。对两组患者固定前及末次随访进行JOA评分、估算恢复率，观察神经恢复情况，并通过侧位X射线片测量颈椎曲度指数和颈椎活动度进行评估。
结果与结论：两组平均随访时间28个月(12-59个月)。两组均无C5神经根麻痹患者。两组末次随访JOA评分均高于固定前(P < 0.01)。两组间JOA评分、恢复率、末次随访颈椎曲度指数比较差异均无显著性意义(P > 0.05)。两组末次随访颈椎活动度均低于固定前(P < 0.01)。结果说明，颈后路单开门椎管成形单侧侧块内固定与全椎板切除双侧侧块内固定在改善神经功能、缓解疼痛、减少并发症上有相似的疗效，但一定程度上降低了颈椎活动度。

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

关键词: 植入物, 脊柱植入物, 多节段脊髓型颈椎病, 单开门椎管成形, 全椎板切除, 减压融合, 侧块螺钉内固定, 脊髓损伤, 山东省自然科学基金

Abstract:

BACKGROUND: Cervical Open-door laminoplasty with unilateral mass screw fixation and laminectomy with bilateral mass screw fixation are both procedures that treat cervical spondylotic myelopathy by expanding the space available for the spinal cord. Effectiveness and safety of two operative methods remain unclear.
OBJECTIVE: To investigate the biocompatibility of implant and host between open-door laminoplasty with unilateral mass screw fixation and laminectomy with bilateral mass screw fixation to treat multi-segment cervical spondylotic myelopathy.
METHODS: Data of 117 patients with multi-segment cervical spondylotic myelopathy (≥ 3 segments) were retrospectively analyzed. Sixty-five cases underwent open-door laminoplasty with unilateral mass screw fixation (laminoplasty group). Fifty-two cases underwent laminectomy with bilateral mass screw fixation (laminectomy group). Clinical outcomes were evaluated by the Japanese Orthopaedic Association scoring system and by recovery rate. Cervical curvature index and cervical range of motion were assessed by X-ray films in both groups.
RESULTS AND CONCLUSION: The average follow-up time was 28 months (range 12-59 months) in both groups. No C5 nerve root palsy occurred in the two groups. Japanese Orthopaedic Association scores were greater during final follow-up than pre-fixation in both groups (P < 0.01). No significant difference in Japanese Orthopaedic Association score, recovery rate, and final follow-up cervical curvature index was detected in both groups (P > 0.05). Cervical range of motion was lower during final follow-up than pre-fixation in both groups (P < 0.01). Results confirmed that open-door laminoplasty with unilateral mass screw fixation and laminectomy with bilateral mass screw fixation have similar effectiveness in the improvement of neurological function, relieving pain and reducing complications, but will greatly reduce the cervical range of motion.

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

Key words: Tissue Engineering, Cervical Spondylosis, Spinal Canal, Spine

中图分类号:

R318

赵勇，褚言琛，李学森，马金龙，邹云雯. 颈椎后路植入物固定修复多节段脊髓型颈椎病：可改善症状但降低了颈椎活动度[J]. 中国组织工程研究, 2015, 19(22): 3496-3502.

Zhao Yong, Chu Yan-chen, Li Xue-sen, Ma Jin-long, Zou Yun-wen. Cervical posterior implant fixation for multi-segment cervical spondylotic myelopathy: improves symptoms but diminishes cervical range of motion[J]. Chinese Journal of Tissue Engineering Research, 2015, 19(22): 3496-3502.

图/表（结果） 3

Quantitative analysis of participants and baseline data
Of the original 216 patients, 117 with multi-segment CSM were eligible for participation. Sixty-five patients (45 men and 20 women) with a mean age of 62.2 years (range, 41-78 years) underwent open-door laminoplasty with unilateral mass screw fixation (Figure 3A). Fifty-two patients (32 men and 20 women) with a mean age of 62.2 years (range, 39-84 years) underwent laminectomy with bilateral mass screw fixation (Figure 3B). No statistical difference in sex, age, or operative levels was found between the two groups. The postoperative JOA scores, cervical curvature index, range of motion of the two groups were not significantly different (Table 3). The whole follow-up period lasted 28 months (range, 12-59 months). During the follow-up period, no C5 nerve root palsy occurred in the two groups. At the final follow-up, only 2 patients suffered axial symptoms, with an incidence of 1.7 % (2 of 117).

Functional results
There were statistically significant differences between preoperative and final follow-up JOA scores in each group (P < 0.001; Table 2). The preoperative and final follow-up JOA scores were 9.23±1.56/13.51±1.16 in laminoplasty group, 9.03±1.44/13.60±1.28 in laminectomy group, respectively. No statistically significant difference was found in final follow-up JOA scores between two groups (Table 2). The neurological recovery was excellent in 4 (6.2%, laminoplasty group), 6 (11.5%, laminectomy group)
patients, good in 44 (67.7%, laminoplasty group, 30 (57.7%, laminectomy group), fair in 17 (26.1%, laminoplasty group), 16 (30.8%, laminectomy group) and there were no poor cases in two groups (Table 2). The recovery rate was 55.6±10.49 % in laminoplasty group, 57.6±13.38 % in laminectomy group in final follow-up, and no statistically significant differences between two groups (P < 0.001; Table 2).

Radiological results
No significant difference in preoperative and final follow-up cervical curvature index was found between the two groups (P > 0.05; Table 2, Figure 4). The cervical range of motion decreased from 36.66±6.76/36.29±7.75 (laminoplasty group/laminectomy group) preoperatively to 26.90±6.06/27.14±6.43 (laminoplasty group/laminectomy group) at the final follow-up (P < 0.001; Table 2, Figure 4).

Adverse reaction
No complications such as deep infection, pseudarthrosis, or screw loosening occurred. No closure of opened laminae was observed in laminoplasty group; and no screw extrusion, breakage, or nerve injury was observed in two groups.

参考文献

[1] Machino M, Yukawa Y, Hida T, et al. The prevalence of pre- and postoperative symptoms in patients with cervical spondylotic myelopathy treated by cervical laminoplasty. Spine. 2012,37:E1383-E1388.
[2] Kim TJ, Bae KW, Uhm WS, et al. Prevalence of ossification of the posterior longitudinal ligament of the cervical spine. Joint Bone Spine. 2008;75:471-474.
[3] Fujimori T, Iwasaki M, Okuda S, et al. Long-term results of cervical myelopathy due to ossification of the posterior longitudinal ligament with an occupying ratio of 60% or more. Spine. 2014;39:58-67.
[4] Lao LF, Zhong GB, Li XF, et al. Laminoplasty versus laminectomy for multi-level cervical spondylotic myelopathy: a systematic review of the literature. J Orthop Surg Res 2013;8:45.
[5] Fehlings MG, Arvin B. Surgical management of cervical degenerative disease: the evidence related to indications, impact, and outcome. J Neurosurg Spine. 2009;11: 97-100.
[6] Kadanka Z, Mares M, Bednaník J, et al. Approaches to spondylotic cervical myelopathy conservative versus surgical results in a 3-year follow-up study. Spine. 2002; 27:2205-2211.
[7] Kaminsky SB, Clark CR, Traynelis VC. Operative treatment of cervical spondylotic myelopathy and radiculopathy. A comparison of laminectomy and laminoplasty at five year average follow-up. Iowa Orthop J. 2004;24:95-105.
[8] Matz PG, Anderson PA, Holly LT, et al. The natural history of cervical spondylotic myelopathy. J Neurosurg Spine. 2009;11:104-111.
[9] Nurick S. The pathogenesis of the spinal cord disorder associated with cervical spondylosis. Brain.1972,95:87-100.
[10] Papadopoulos CA, Katonis P, Papagelopoulos PJ,et al. Surgical decompression for cervical spondylotic myelopathy: correlation between operative outcomes and MRI of the spinal cord. Orthopedics. 2004;27:1087-1091.
[11] Della Pepa GM, Roselli R, La Rocca G et al. Laminoplasty is better of laminectomy in cervical stenotic myelopathy: myth or truth? 2014;18(Suppl 1):50-54.
[12] Pal D, Bayley E, Magaji S, et al. Freehand determination of the trajectory angle for cervical lateral mass screws: how accurate is it? Eur Spine J. 2011;20:972-976.
[13] Hirabayashi K, Miyakawa J, Satomi K, et al. Operative results and postoperative progression of ossification among patients with ossification of cervical posterior longitudinal ligament. Spine. 1981;6:354-364.
[14] Takeshita K, Murakami M, Kobayashi A,et al. Relationship between cervical curvature index (Ishihara) and cervical spine angle (C2-7). Orthop Sci. 2001;6:223-226.
[15] Ryken TC, Heary RF, Matz PG, et al. Cervical laminectomy for the treatment of cervical degenerative myelopathy. J Neurosurg Spine. 2009;11:142-149.
[16] Derenda M, Kowalina I. Cervical laminoplasty–review of surgical techniques, indications, methods of efficacy evaluation, and complications. Neurol Neurochir Pol. 2006;40: 422-432.
[17] Hale JJ, Gruson KI, Spivak JM. Laminoplasty: a review of its role in compressive cervical myelopathy. Spine J. 2006;6: 289S-298S.
[18] Matsumoto M, Chiba K, Toyama Y. Surgical treatment of ossification of the posterior longitudinal ligament and its outcomes: posterior surgery by laminoplasty. Spine. 2012;37: E303-E308.
[19] Chen Y, Guo Y, Chen D, et al. Long-term outcome of laminectomy and instrumented fusion for cervical ossification of the posterior longitudinal ligament. Int Orthop. 2009;33: 1075-1080.
[20] Hyun SJ, Riew KD, Rhim SC. Range of motion loss after cervical laminoplasty: a prospective study with minimum 5-year follow-up data. Spine J. 2013;13:384-390.
[21] Yusof MI, Hassan E, Abdullah S. Predicted cervical canal enlargement and effective cord decompression following expansive laminoplasty using cervical magnetic resonance imaging. Surg Radiol Anat. 2011;33:109-115.
[22] Sodeyama T, Goto S, Mochizuki M, et al. Effect of decompression enlargement laminoplasty for posterior shifting of the spinal cord. Spine. 1999;24(15):1527-1531.
[23] Houten JK, Cooper PR. Laminectomy and posterior cervical plating for multilevel cervical spondylotic myelopathy and ossification of the posterior longitudinal ligament: effects on cervical alignment, spinal cord compression, and neurological outcome. Neurosurgery. 2003;52:1081-1088.
[24] Anderson PA, Matz PG, Groff MW, et al. Laminectomy and fusion for the treatment of cervical degenerative myelopathy. J Neurosurg Spine. 2009;11:150-156.
[25] Hostin RA, Wu C, Perra JH, et al. A biomechanical evaluation of three revision screw strategies for failed lateral mass fixation. Spine. 2008;33:2415-2421.
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中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

引言

Cervical spondylotic myelopathy (CSM) is one of the most prevalent and increasingly observed neurological disorders in the geriatric population[1]. Symptoms include sensory disturbances in the extremities, clumsiness of the hands, gait disturbances, and urinary dysfunction. Multi-segment CSM, which is characterized by multi-segmental spinal cord compression because of cervical degenerative myelopathy, ossification of the posterior longitudinal ligament, multi-segment cervical stenosis, and ligamentum flavum hypertrophy, is a common spinal disorder all over the world[2-3]. The natural course is often poor. Multi-segment CSM is a progressive disease that often requires surgical intervention for decompressing the spinal cord and preventing further damage[4]. So far, the available selection of surgical procedures exists, including anterior approaches, posterior approaches, or a combination of both. However, there is considerable controversy in surgical management because CSM surgery is often multi-segment, especially when the discussion is limited to whether posterior procedure is best for multi-level posterior cervical decompression. When considering the posterior approach, the two most common posterior cervical surgeries for the treatment of multi-level CSM are laminoplasty and laminectomy[5-10]. Both of the procedures are generally thought to be effective approaches

for decompressing the spinal cord by expanding the space. Although some neurological function can be recovered after surgery, a degree of irreversible neurological damage is unfortunately unavoidable in patients with CSM. Until recently, cervical posterior operative method was performed as a common surgical procedure for multi-segment CSM; however, complications, such as postsurgical instability, kyphotic deformity, and restenosis by epidural scar, affect the postoperative result[11]. After laminectomy or laminoplasty without fixation, many cervical complications occurred, such as instability and curvature change. With the rapid development of fixation in the department of orthopedics, screw rod system has been widely applied to cervical posterior approach operation in the clinic, and the complications after operation have been greatly reduced. The cervical posterior operation with lateral mass screw fixation has become an effective method that can provide ample decompression and stability of cervical vertebra. Although the lateral mass screw fixation has been widely used in clinic, the therapeutic effectiveness that two operative methods treat multi-segment cervical spondylotic myelopathy by expanding the space available for the spinal cord and providing stability remains unclear.

The purpose of this retrospective study was to investigate the surgical efficacy of open-door laminoplasty with lateral mass screw fixation and laminectomy with lateral mass screw fixation for the treatment of multi-segment CSM. The aim was to confirm the therapeutic effectiveness of the two surgical modalities that could achieve a better decompression outcome and to evaluate their clinical and radiographic results and complications.

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

材料方法

Design
A retrospective analysis.

Time and setting
The experiment was conducted in the Department of Spine surgery, The Affiliated Hospital of Qingdao University in China from December 2014 to February 2015.

Subjects
Clinical and radiological data from patients with multi-segment CSM who underwent open-door laminoplasty with unilateral mass screw fixation and laminectomy with bilateral mass screw fixation between January 2010 and December 2013 were reviewed.

Inclusion criteria
(1) A clear diagnosis made by history, physical examination, plain radiographs, computed tomography (CT), and magnetic resonance imaging (MRI); (2) multi-segment CSM (≥ 3 segments); (3) a minimum of postoperative 12-month follow-up; (4) complete pre- and post-operative imaging and clinical data records.

Exclusion criteria
(1) Patients lost to follow-up; (2) any history of rheumatoid arthritis, cerebral palsy, or tumors; (3) previous cervical surgery; (4) destructive spondyloarthritis caused by hemodialysis; (5) injuries; (6) severe kyphotic deformity and spinal fusion with instrumentation; (7) thoracic spondylotic myelopathy; and (8) lumbar spinal canal stenosis.

Of the original 216 patients, 117 with multi-segment CSM were eligible for participation. Of these, 117 patients who were observed for more than 12 months after surgery were enrolled in this study (follow-up rate, 91.1%). The 117 patients were divided into two groups according to procedure: the open-door laminoplasty with unilateral mass screw fixation (laminoplasty group) and the laminectomy with bilateral mass screw fixation (laminectomy group). The laminoplasty group comprised 45 males and 20 females with a mean age of 62.2 years (range, 41-78 years) and average disease duration of 26.32 months (range, 10-49 months). The laminectomy group comprised 32 males and 20 females with a mean age of 62.2 years (range, 39-84 years) and average disease duration of 28.16 months (range, 8-56 months). All patients presented with symptoms of myelopathy. Each patient whose clinical findings were consistent with the diagnosis of progressive cervical myelopathy was failed to respond to nonsurgical treatment. All patients had cord compression at three or more segments confirmed by radiography. There was no significant difference in gender, age, disease duration, type, and affected segments between the two groups (P > 0.05; Table 1).

Spinal implant
All patients underwent the internal fixation via posterior cervical pathway and fusion in Vertex system that was produced by American Medtronic Sofamor Danek Company.

Methods
Surgical procedure
The patients were placed in the prone position with the head holder under general anesthesia. A standard posterior midline exposure was performed for both procedures.

Open-door laminoplasty was conducted with unilateral mass screw fixation. When lamina and lateral mass facet complexes were exposed, screws were placed with the Magerl technique on the hinge side[12]. Rods of appropriate size were selected and bent to match the contour of the lateral masses, and secured to the lateral masses by screws. The interspinous ligaments were cut at the superior and inferior ends of the target levels, with the supraspinous ligaments entirely preserved. On the open side, a full-thickness trough was drilled at the junction of the lateral mass and the lamina with a high-speed burr, and a partial-thickness trough was drilled at the hinge side. The ligamentum flavum was removed with part of the cortical bone on the open side of the expanded levels, because it was hypertrophic, causing double-sided compression in most patients. The lamina was elevated from the open side towards the hinge side for approximately 8 to 10 mm and stabilized with 8 or 10 mm screws and rods. Autologous bone debris was embedded into the hinge trough as a bone graft to stimulate fusion. No bone graft was used as a strut on the open side.

Laminectomy was conducted with bilateral mass screw fixation. When the compressed levels were identified based on the preoperative data, screws were placed bilaterally with the Magerl technique[12]. Rods of appropriate size were selected and bent to match the contour of the lateral masses, and secured to the lateral masses by screws. The supraspinous and interspinous ligaments and the total lamina with the ligamentum flavum of the target levels were removed completely with a high-speed drill and rongeur. Subsequently, enlarged laminectomy (including the removal of the inside edges of facet joints and adequate decompression of neural foramina) was performed from pedicle to pedicle to ensure adequate decompression of the spinal cord. Bone grafts from dissected spinous processes were placed laterally on both sides of facet joints.
All patients were required to stay in bed for the first week after surgery, and thereafter walking was allowed with a cervical collar for 8 weeks.

Clinical assessment
The severity of myelopathy before and after surgery was evaluated according to a scoring system proposed by the Japanese Orthopedic Association (JOA) for CSM (JOA score). A perfect JOA score for CSM was 17 points. The improvements of neurological function in JOA scores were expressed as recovery rate. The recovery rate was determined as following formula originally suggested by Hirabayashi[13]: recovery rate (%)= (postoperative JOA score-preoperative JOA score)/[17 (normal functional score)-preoperative JOA score] × 100. The recovery rate for each patient was classified into 4 grades: those greater than 75% were categorized as excellent for activities of daily living, those that were 50%-74% were categorized as good, those that were 25%-49% were categorized as fair, and those that were less than 24% were categorized as poor.

Radiological assessments
Preoperative and final follow-up cervical alignments were measured in the profile of neutral plain radiographs by cervical curvature index as described by Ishihara[14] (Figure 1). Line segment A is drawn between the postero-inferior edge of the C2 and C7 spinal bodies. The four lines, a1-a4, are drawn perpendicular to line A from each postero-inferior edge of the C3, C4, C5, and C6 vertebral bodies. The cervical curvature index (Ishihara) is the percentage of the sum of the four segments divided by line segment A (Figure 1). Cervical range of motion was measured using the Cobb method for C2-C7 in flexion and extension on radiographs (Figure 2). These measurements were performed over three times by one of the authors and an independent experienced musculoskeletal radiologist to reduce the intra- and inter observer bias.

Main outcome measures
There were (1) JOA for cervical spondylotic myelopathy (JOA score); (2) recovery rate; (3) cervical curvature index as described by Ishihara; (4) cervical range of motion.

Statistical analysis
Statistical analyses were performed using SPSS 18.0 software. An independent samples t-test was used to assess statistical significance of changes between last follow-up and preoperative parameters in two groups. A value of P < 0.05 was considered statistically significant.

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

讨论

Multi-segmental CSM is a common disorder because of the multi-segmental spinal cord compression caused by CSM, ossification of the posterior longitudinal ligament, multi-segment cervical stenosis and ligamentum flavum hypertrophy, and symptoms include sensory disturbances in the extremities, clumsiness of the hands, gait disturbances, and urinary dysfunction[2]. Many orthopedic surgeons prefer a posterior cervical approach, including laminectomy or laminoplasty, to treat multi-segmental CSM. Laminectomy is the earliest way to decompress the spinal cord by removing spinous process, lamina and ligamentum flavum in patients with multi-segmental cervical compressive myelopathy[15]. Laminoplasty has been performed since 1973 in Japan, and has been proved to be an effective and safe treatment to
widen the spinal canal without removing the dorsal elements of the cervical spine for multi-segmental CSM[16-17].

In this study, we used JOA scores and recovery rate for the assessment of neurological function. The JOA score is a simple scoring system that accurately reflects neurological and functional status[1]. The preoperative and final follow-up JOA scores were 9.23±1.56/13.51±1.16 in laminoplasty group, 9.03±1.44/13.60±1.28 in laminectomy group, respectively. The JOA scores were significantly improved after surgery. In two groups, the better neurological improvement was obtained. Both procedures have been proven safe and effective[18-19]. The posterior cervical approach achieves the therapeutic effect by direct and indirect decompression of the spinal cord. Direct decompression is achieved by removal or elevation of the posterior compressive bone and infolding of the ligamentum flavum. Indirect decompression of the anterior aspect of the spinal cord is achieved by posterior drift of the spinal cord[20, 21]. It was previously believed that whether a sufficient expansion of the spinal canal with an effective spinal cord drift was achieved would directly affect the outcome of these posterior treatments[22]. The recovery rate was 55.6±10.49 % in laminoplasty group, 57.6±13.38 % in laminectomy group in final follow-up, and there were no statistically significant differences between two groups (P < 0.001). The neurological recovery was excellent in 4 (6.2%, laminoplasty group), 6 (11.5%, laminectomy group) patients, good in 44 (67.7%, laminoplasty group, 30 (57.7%, laminectomy group) fair in 17 (26.1%, laminoplasty group), 16 (30.8%, laminectomy group) and there were no poor cases in two groups. The JOA score and recovery rate that objective measure of neurological improvement did not differ between the two groups, thus suggesting equal efficacy of both procedures.

From a biomechanical point of view, open-door laminoplasty with unilateral mass screw fixation and laminectomy with bilateral mass screw fixation are similar. The preoperative and final follow-up cervical curvature index was 14.72±6.08%/14.28±5.38% in laminoplasty group, 13.88±4.31%/13.27±4.20% in laminectomy group, respectively. The cervical range of motion decreased from 36.66±6.76/36.29±7.75 (laminoplasty group/laminectomy group) preoperatively to 26.90±6.06/27.14±6.43 (laminoplasty group/laminectomy group) at the final follow-up (P < 0.001). No significant difference in the final follow-up cervical curvature index and range of motion was found between two groups. In both techniques, the muscles are widely dissected and ligamentous structures transected. The lamina is removed or opened. During this procedure, damage to surrounding tissue might occur. Successful treatment of multi-segmental CSM requires adequate decompression, restoration of the normal curvature and reconstruction of the cervical stability. Recently, lateral mass screws fixation has become optimal preferred option for stabilizing the cervical spine and preventing kyphotic deformity when multi-segmental decompression is required[23-24]. The accuracy of screw trajectory, screw length, technique of insertion, vertebral level, and size of the lateral mass have been reported to affect the relative safety of lateral mass screw placement[25]. Duan et al [26] pointed out that posterior fixation could provide immediate stability to the cervical spine after laminectomy by reinforcing the posterior tension band, which attempted to prevent the loss of cervical lordosis and promote early neurological recovery. Ample biomechanical experiments suggested that lateral mass screws could provide rigid fixation to the multiple cervical planes: flexion stability increased 92%, extension stability increased 60% and rotation stability also improved greatly[23]. In our study, plain radiographs had shown that posterior grafted bones had completely fused by 3 months postoperatively, and cervical curvature remained excellent without cervical curvature changes or instrument failures in the final follow-up. This further confirmed that lateral mass screw fixation can effectively restore and maintain the normal cervical lordosis, providing a stable biomechanical environment for neurological recovery. Moreover, grafted bone fusion plays an important role in preventing the screw/rod breakage or failure at the bone-metal interface with loosening of the screws in bone. In our study, there were no patients who developed lateral mass fracture, screw/rod breakage or pullout. We observed that there were cervical osteophytes or even osteophyte bridging in these patients through cervical radiographs. This may play a major role affecting the cervical range of motion after surgery. Although there was some loss of cervical range of motion, it did not influence neurologic recovery. Patients did not experience great difficulties in performing daily activities in the follow-up.

In this study, we can observe that the pain in neck/shoulder is mild after surgery. We consider the reason may be that fusion with lateral mass screw fixation provide immediate stability to the cervical spine and remain excellent cervical curvature after surgery, and the neck muscles are symmetrically sutured with the other side and finally ankylose in the form of a scar. This allows them to reach a balance of the flexor and extensor muscle strengths. The mechanism of C5 nerve root palsy after posterior decompression is unknown. The possible reason of C5 palsy is that the spinal cord drift-back and subsequent tethering effects on nerve roots. In addition, if the spinal cord has drift-back, the forward force given by the posterior structures (facet joint, laminae, and ligamentum flavum) will damage the C5 nerve root. Reconstruction of the cervical lordosis and adequate posterior decompression (especially of the neural foramina) contribute to decrease the incidence of C5 root palsy. In the study, there was no C5 palsy occurring in any patient because of the removal of the inside edge of facet joints, which provided enough space to drift back for the nerve roots and stabilization of the cervical spine. We believe that both appropriate curvature restoration and enough nerve foramina decompression may play an important role in reducing the incidence of C5 palsy.

The present study showed that open-door laminoplasty with unilateral mass screw fixation and laminectomy with bilateral mass screw fixation were effective surgical strategies in restoring normal cervical alignment, and obtaining excellent neurological recovery. The posterior decompression can remove the pathological changed tissue witch pressured on the nerve tissue, and some neurological function can be recovered after surgery. The results of this study show that no statistically significant difference was found in final follow-up functional results between two groups. The indications of cervical posterior operation: (1) congenital multi-segmental cervical stenosis (≥ 3 segments); (2) multi-segmental spinal cord compression because of ossification of the posterior longitudinal ligament; (3) ligamentum flavum hypertrophy and ossification; (4) various factors, such as cervical degenerative and injuries, contributed to cervical spondylotic myelopathy; (5) spinal cord compression after anterior approaches. Lateral mass screw fixation might play an important role in preventing loss of postoperative cervical curvature and decreasing the incidence of complications such as axial symptoms and C5 root palsy. Although there was some loss of cervical range of motion, patients did not experience great difficulties in performing daily activities in the follow-up. The results of the current study suggest that this posterior decompression with lateral mass screw fixation may be a safe and effective treatment for multi-segment cervical spondylotic myelopathy. There is a need for randomized controlled studies with long-term follow-up to confirm and clarify these results.

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

颈椎后路植入物固定修复多节段脊髓型颈椎病：可改善症状但降低了颈椎活动度

Cervical posterior implant fixation for multi-segment cervical spondylotic myelopathy: improves symptoms but diminishes cervical range of motion

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