Is laminoplasty at C4, C5, and C6 recommended for a patient with spinal stenosis, cervical region, and symptoms of numbness, tingling, and difficulty walking?

Laminoplasty at C4-C6 for Cervical Stenosis with Myelopathy

Laminoplasty at C4-C6 cannot be recommended until flexion-extension radiographs with quantitative measurement of segmental motion are obtained, as the presence of grade 1 anterolisthesis at multiple levels (C2-C3, C3-C4, C6-C7) raises critical concern for instability that would absolutely contraindicate laminoplasty. 1, 2

Critical Missing Information That Determines Medical Necessity

The American Association of Neurological Surgeons explicitly states that laminoplasty is contraindicated when more than 3mm of motion exists at any level because the procedure provides no stabilization, and excessive motion will lead to progressive kyphosis, late neurological deterioration, and poor outcomes. 1, 2

What Must Be Done Before Approval

You must obtain repeat cervical flexion-extension radiographs with specific quantitative measurement of anterior-posterior translation at each level from C2-C7. 2 The radiologist must measure in millimeters—not just describe "grade 1 anterolisthesis"—the actual translation distance at each vertebral level during flexion and extension. 1, 2

Common pitfall to avoid: Do not proceed based on descriptive terms like "grade 1 anterolisthesis" or "reduces on extension." These qualitative descriptions are insufficient. 2 The fact that anterolisthesis "reduces on extension" does not mean motion is <3mm—it simply means the vertebra moves back, but the total excursion during flexion-extension could easily exceed 3mm. 2

Decision Algorithm Based on Motion Measurement

If Motion ≤3mm at ALL Levels: Laminoplasty IS Appropriate

• The patient meets clinical criteria for surgical intervention: multilevel stenosis (C4-6), documented myelopathy (numbness, tingling, gait disturbance, stumbling), failed conservative therapy (PT, NSAIDs, Robaxin, Ultram, Lyrica), and imaging confirmation of moderate-to-severe stenosis with disc-osteophyte complexes. 1

• Laminoplasty preserves cervical motion (71% ROM preservation vs 48% with standard techniques), avoids fusion-related complications (pseudarthrosis, hardware failure, adjacent segment disease), and provides neurological improvement comparable to fusion procedures. 3

• Expected outcomes include JOA score improvement of 3-6 points, with 60-80% of patients showing neurological recovery. 3, 1

If Motion >3mm at ANY Level: Laminoplasty IS CONTRAINDICATED

• The patient requires laminectomy with posterior fusion instead. 1, 2 The American Association of Neurological Surgeons guidelines state that fusion must be added to laminectomy to prevent late deformity when instability is present. 1

• Multiple-level anterolisthesis patterns (C2-C3, C3-C4, C6-C7 in this patient) strongly suggest global cervical instability that likely exceeds the 3mm threshold. 1

• Performing laminoplasty in the presence of >3mm motion leads to progressive kyphosis, late neurological deterioration, and poor outcomes. 1, 2

Clinical Justification for This Patient (Assuming Stability Confirmed)

This patient demonstrates clear indications for surgical decompression:

• Myelopathic symptoms: Numbness and tingling extending from shoulders to fingers, gait disturbance with stumbling, recent fall with injury—all indicating spinal cord compression. 1

• Failed conservative management: 3 months of physical therapy (which actually exacerbated symptoms), multiple medications (Robaxin, Ultram, NSAIDs, Lyrica) without adequate relief. 1

• Imaging confirmation: CT shows moderate-to-severe disc-osteophyte complexes at C4-5 and C5-6 with moderate canal stenosis, directly corresponding to the symptomatic levels. 1

• Progressive functional decline: Activities of daily living are limited (neck immobility with prolonged sitting, difficulty walking, fall risk). 1

Potential Complications to Discuss

Regardless of whether laminoplasty or laminectomy-with-fusion is ultimately performed:

• C5 nerve root palsy occurs in 7-15% of patients after laminoplasty, typically developing 4-5 days postoperatively, with most patients recovering within 3-6 months. 3, 4 Risk is higher when the C4-5 level shows high T2 signal on MRI (present in all patients who developed C5 palsy in one series). 4

• Axial neck pain develops in 19-60% of patients after laminoplasty, though modified techniques preserving C2-3 muscular attachments significantly reduce this complication. 3

• Loss of cervical range of motion: Expect 29-56% reduction in ROM after laminoplasty, though this is substantially better than the near-complete loss of motion with fusion. 3, 5

• Postoperative kyphosis occurs in 8-10% of patients long-term, but this risk applies primarily when instability exists preoperatively—hence the critical importance of measuring segmental motion. 3

Inpatient Status Justification

Inpatient admission is appropriate for this multilevel cervical decompression procedure due to:

• Need for postoperative neurological monitoring (C5 palsy risk, spinal cord injury surveillance). 3, 4
• Pain management requirements for axial neck pain. 3
• Mobilization assistance given preoperative gait instability. 1
• Standard practice for multilevel cervical spine surgery requiring 2-3 day hospital stay. 5

Bottom line: Request quantitative flexion-extension measurements immediately. If all levels show ≤3mm motion, approve the laminoplasty. If any level shows >3mm motion, deny laminoplasty and require modification to laminectomy with fusion. 1, 2