Virginia Spine Institute

An Option for Some Patients with Cervical Myelopathy

By Brian R. Subach, M.D.

A cervical laminaplasty is a procedure performed by spinal surgeons designed to take the pressure off the spinal cord while maintaining both the stability and flexibility of the spine. It appears that such a procedure may avoid some of the complications associated with simple laminectomy (removal of the bones and ligaments on the back of the spine). A laminectomy works well to decompress the spinal canal in patients with normal alignment (lordosis) and normal motion in flexion (forward bending) and extension (backward bending). A laminectomy, by virtue of the removal of the ligaments stabilizing the back of the spine, may predispose the patient to further problems down the road. Such problems include neck pain, headaches, and abnormal neck position.

laminaplasty Cervical myelopathy is a neurologic syndrome in which the spinal cord is compressed or pinched by degenerative osteosrthritis or possibly a fracture or disc herniation. Pressure on the cord causes actual damage as well as progressive problems due to restricted blood flow, leading to possible future deterioration. The cervical spinal cord compression is characterized by numbness or weakness in the arms, legs, or hands. Difficulty with fine motor skills such as sewing, writing, or picking up small objects often occurs. Problems with walking and bladder function may also bring this problem to the attention of the physician and patient.

On examination by the physician, neurological findings often include long-tract signs such as spasticity, hyperreflexia, and clonus. A Babinski response and Hoffman sign may also be present.

Once identified, the intervention for cervical myelopathy is generally surgical decompression from either an anterior (front of the neck) or posterior (back of the neck) approach. Physical therapy may help with balance or strength, however it is unlikely to halt the deterioration of function. The goal of surgery is to halt clinical deterioration and allow for recovery of function. Since it is the spinal cord which is involved, the degree of recovery varies from person to person.

“Laminaplasty is a tremendous breakthrough in cervical surgery.”
– Dr. Brian R. Subach, The Virginia Spine Institute

Anterior decompression involves either removal of degenerative discs and partial removal of vertebral bones with reconstruction using some combination of metal and bone in a procedure called a fusion. Such surgery has risks associated with it. Potential risks associated with multilevel anterior surgery may include:

• spinal cord injury from insertion of an instrument into a severely compressed spinal canal

• esophageal injury

• dysphagia (swallowing difficulties) from esophageal retraction

• dysphonia (speech problems) from injury to the recurrent laryngeal nerve

• vertebral artery injury from lateral decompression.

Dysphagia following lengthy anterior decompression is more common than previously believed, and may be particularly problematic in elderly patients by interfering with nutrition.

Posterior decompression typically involves a cervical laminectomy, removal of the bony part of the spine to decompress the spinal cord and exiting nerve roots to the arms, avoids many of the risks associated with anterior surgery. Despite this, laminectomy has several potential drawbacks. These may include neurologic deterioration from insertion of surgical instruments into a narrowed spinal canal as well as the risk of developing forward deformity (kyphosis) of the neck due to removal of the supporting ligaments. For this specific risk, experts have often recommended the use of small screws during surgery to stabilize the cervical bones and make them stronger during the healing process.

In 1938, Japanese spinal surgeons introduced a new procedure called a cervical “laminaplasty” as an alternative to the laminectomy for posterior cervical decompression. Laminaplasty, involving posterior decompression without removal of the lamina, expands the spinal canal by “hinging” the lamina open on one side (see figures). The ligaments remain connected, but the cord has more room. Since that time, laminaplasty has been advocated for cervical stenosis due to other etiologies. Since it allows the spinal cord to move into the open space posteriorly, the procedure requires a lordotic cervical posture (normal alignment).

The advantages of laminaplasty for spinal canal decompression include:

• avoiding some of the risks associated with anterior surgery

• preserving the protective and stabilizing function of the interspinous ligaments

• eliminating the need for fusion because spinal stability is not damaged

• allowing for decompression of both the cord and the nerve roots

Disadvantages include a slightly reduced range-of-motion and increased risk of neck pain, as well as potential injury to the C5 nerve root during the procedure. This is thought to occur as a result of traction on the nerve root as the spinal bones shift. And the spinal cord mores into a more open area.

The main problem for the surgeon tends to be keeping the spinal canal open after the surgery is complete. Some techniques have been reported for keeping the hinged “door” of the lamina open. The most widely used is the method described by Hirabayashi, in which a suture is passed around the facet capsule at each level on the hinged side of the laminaplasty and then around the spinous process. At the Virginia Spine Institute, we utilize a series of new titanium mini-plates which we find to be stronger and more predictable than the suture method.

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