What is the recommended treatment approach for a patient undergoing a cervical laminectomy?

Cervical Laminectomy: Treatment Approach

For patients undergoing cervical laminectomy, the recommended treatment approach is laminectomy with posterior fusion, particularly for severe multilevel cervical kyphosis, as this approach provides better neurological recovery (2.0 Nurick grades improvement) compared to laminectomy alone (0.9 Nurick grades). 1

Patient Selection and Indications

• Cervical laminectomy is appropriate for:

  • Congenital or acquired stenosis
  • Multilevel spondylosis
  • Ossification of the posterior longitudinal ligament (OPLL)
  • Ossification of the yellow ligament (OYL) 2

• Careful patient selection is critical:

  • Older individuals (>70 years) with prohibitive comorbidities or fixed long-term neurological deficits may not be good candidates 2
  • Patients with symptoms for less than one year tend to have better outcomes 1

Surgical Approach Selection

Laminectomy with Fusion vs. Laminectomy Alone

• Laminectomy with posterior fusion is strongly recommended over laminectomy alone due to:
  • Significantly lower risk of postoperative kyphosis (7% vs 24%) 1
  • Better neurological recovery (2.0 vs 0.9 Nurick grades) 1
  • Laminectomy alone has a complication rate of 14-47% 1

Alternative: Laminoplasty

• Laminoplasty is an alternative non-fusion decompression procedure with specific indications:
  • Most appropriate for patients with multilevel stenosis 3
  • Patients should have preserved sagittal alignment 3
  • Minimal to no axial neck pain related to spondylosis 3
  • Contraindicated in patients with significant preoperative neck pain, kyphotic alignment, or substantial instability 3
  • Recommended for CSM or OPLL with expected recovery rate of 55-60% using JOA scale 4

Two-Stage Approach

• For severe multilevel cervical kyphosis, a two-stage surgical approach (anterior followed by posterior) is recommended:
  • Provides greater degree of correction than anterior-alone approach
  • Higher rate of postoperative neurological deterioration and complications 1

Perioperative Management

• To optimize surgical outcomes and limit perioperative morbidity:
  • Utilize awake intubation and positioning
  • Implement continuous intraoperative somatosensory-evoked potential monitoring 2
  • Regular postoperative neurological assessments
  • Physical therapy for gait training and strengthening 1

Factors Affecting Outcomes

• Functional improvement may be limited by:

  • Duration of symptoms (better outcomes when <1 year)
  • Severity of stenosis
  • Severity of myelopathy
  • Poorly controlled diabetes 4
  • Advanced age (conflicting evidence) 4

• Long-term outcomes:

  • Patients over 65 years often show good short-term results but greater long-term deterioration
  • Factors associated with deterioration include advanced age (>70 years), severe original myelopathy, and recent trauma 2
  • Late neurologic deterioration can occur in approximately 22% of OPLL patients (average 8 years after surgery) and in some CSM patients (average 11 years after surgery) 5

Complications to Monitor

• Potential complications include:
  • C5 palsy
  • Infection
  • Hardware failure 1
  • Complex cervical deformity surgery carries a 24.4% risk of major complications including dysphagia, deep wound infection, and new C5 motor deficit 1
  • Adjacent segment disease requiring long-term surveillance 1

By following these recommendations and carefully selecting appropriate patients, cervical laminectomy with fusion can effectively address multilevel cervical pathology with improved neurological outcomes and reduced risk of postoperative complications.