Joseph Riina and David G. Schwartz

Goals of Surgical Treatment

1. Decompression of multilevel cervical spinal stenosis

2. Maintenance of cervical stability after decompression

Diagnosis

Diagnostic tests include anteroposterior (AP), lateral, flexion, and extension radiographs, magnetic resonance imaging (MRI), and computed tomography (CT)/myelogram. Physical findings include difficulty with gait and long tract signs, including positive Hoffman’s sign, up-going toes with Babinski, inverted radial reflex, spasticity, difficulty with fine motor activities, decreased sensation, loss of bowel and bladder control, hyporeflexia at the level of compression, hyperreflexia below the lesion, and clonus.

Indications for Surgery

1. Cervical canal compression extending over three or more levels

2. Neutral or lordotic cervical spine

3. Opacification of posterior longitudinal ligament

Contraindications

1. Cervical kyphosis, which does not allow the spinal cord to shift posteriorly and adequately decompress

2. Cervical instability as defined by translation of more than 3 mm from flexion to extension; or increased angular motion

Advantages of Open Door Laminoplasty

1. Decreased surgical morbidity, few complications, no need for rigid internal fixation or rigid postoperative immobilization

2. Maintains spinous processes and laminae, which provide protection and stability

3. Retention of the ligamentum flavum, which acts as a tension band increasing stability

4. Short operative time with minimal blood loss

5. Improved postoperative imaging because of less hardware

6. No risk of pseudarthrosis or graft dislodgment

7. No risk of injury to the esophagus, trachea, or recurrent laryngeal nerve

Disadvantages of Open Door Laminoplasty

1. Unable to use in kyphotic spine

2. Approach more painful postoperatively

Advantages of Multilevel Laminectomy

1. Wide decompression

2. Able to image cervical spine postoperatively

Disadvantages of Multilevel Laminectomy

Rotational instability that presents as cervical kyphosis, swan neck deformity, or multilevel subluxation (usually occurs within 8 months to 2 years).

Advantages of Multilevel Corpectomy

1. Direct decompression including discs, osteophytes, and bone spurs

2. Less postoperative pain

Disadvantages of Multilevel Corpectomy

1. Risk of dural injury when removing large bony osteophytes, or ossification of the posterior longitudinal ligament (OPLL)

2. Need for rigid internal fixation

3. Decreased fusion rates for multilevel corpectomy

4. Increased complication rate, including injury to the esophagus, trachea, and recurrent laryngeal nerve, and swallowing difficulty

5. Graft dislodgment

Open Door Laminoplasty Procedure

Preoperative Planning

1. Choice of levels: MRI for soft tissue evaluation (beware: MRI has the tendency to overcall the amount of stenosis). CT scan/myelogram for more accurate bony stenosis evaluation. All levels of compression should be addressed, and decompression should include the normal level above and the normal level below.