AAOS Comprehensive Orthopaedic Review 4: Print + Ebook (AAOS - American Academy of Orthopaedic Surgeons)

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Section 2 | Spine

b. Neck pain • Because no arthrodesis is performed, lami noplasty should not be used to manage painful spondylosis. • Controversy remains regarding whether neck pain associated with laminoplasty reflects new-­ onset postoperative symptoms or simply the persistence of preoperative spondylotic pain. c. Loss of motion • Motion loss may be related to facet joint injury with spontaneous stiffening or fusion or to alterations in tissue and muscle integ rity after posterior surgical exposure. • Prolonged postoperative immobilization can contribute to the problem. • Placing bone graft along the hinge side to assist in healing of the hinge may result in undesired intersegmental fusion or stiffen ing. Inadequate irrigation of bone dust can result in autofusion. • The most common complication follow ing laminoplasty is loss of extension—this can be minimized by (1) ensuring adequate decompression between laminae to prevent impingement and checking extension range of motion intraoperatively; (2) irrigating all bone dust; (3) avoiding laminoplasty of C3; and (4) meticulously closing the muscles. L. Considerations in the patient with preoperative kyphosis a. Drift back occurs reliably in a lordotic or neutral cervical spine but not in the setting of substantial kyphosis. b. Absence of lordosis is not an absolute contraindi cation to laminoplasty. • In patients with kyphosis who have compressive lesions arising posteriorly, laminoplasty also may achieve direct decompression. • In patients with kyphosis with extremely tight cervical stenosis, laminoplasty can be considered as a first-stage procedure, with subsequent ante rior surgery performed if necessary. • If there is less than 15° of focal kyphosis, lami noplasty may still work. M. Combined anterior and posterior surgery 1. Combined anterior and posterior surgery is strongly recommended in patients with multilevel postlaminectomy kyphosis. 2. When multilevel corpectomy is performed to decompress the cord, because of the preexisting

TABLE 3 Laminoplasty Techniques Open Door

French Door Hinge is created unilaterally Hinge is created bilaterally Opening is performed on the opposite lateral mass– laminar junction Opening is performed in the midline

b. Opening the laminoplasty increases the space available for the spinal cord, which drifts away from compression lesions into the space created; it can then be held patent with the bone (autologous spinous process or rib allograft), sutures, suture anchors, or specifi cally designed plates. 3. Advantages over anterior surgery a. Laminoplasty is generally a safer and techni cally easier procedure to perform than mul tilevel anterior corpectomy, particularly in patients with severe stenosis or OPLL that requires resection, because indirect decom pression is performed. b. Laminoplasty is a motion-preserving procedure. • No fusion is required, so all fusion-related complications are eliminated. • Pseudarthrosis is avoided in patients at high risk for this complication, such as patients with diabetes, elderly patients, those who smoke, and chronic steroid users. c. Laminoplasty does not preclude a later anterior procedure. If the patient has persistent stenosis after laminoplasty, focal anterior decompres sions can be performed subsequently at the needed levels. 4. Complications a. Postoperative segmental root-level palsy • This complication occurs in 5% to 12% of patients. • Although other roots also can be affected, the palsy most commonly affects the C5 root, resulting in deltoid and biceps weakness. • Palsies tend to be motor dominant, although sensory dysfunction and radicular pain also can occur. • Palsy can occur at any time from immedi ately postoperatively to 20 days later, com plicating what otherwise appears to be a successful spinal cord decompression.

2 | Spine

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AAOS Comprehensive Orthopaedic Review 4

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