The Application Of Evidence-based Medicine In Posterior Approach Surgery For Multi-level Cervical Spondylotic Myelopathy

PART ONE COMPARISON OF CLINICAL OUTCOMES AND SAFETY BETWEEN LAMINECTOMY WITH INSTRUMENTED FUSION AND LAMINOPLASTY FOR THE TREATMENT OF MULTI-LEVEL CERVICAL SPONDYLOTIC MYELOPATHY:A META-ANALYSISOBJECTIVE : Many studies concern about the comparison of posterior laminectomy with instrumented fusion and laminoplasty for the efficacy and safety on multi-level cervical spondylotic myelopathy,but no consensus has been reached concerning which surgical approach is better treatment for MCSM.This study was to compare the efficacy and safety of posterior laminectomy with instrumented fusion and laminoplasty in the treatment of multi-level cervical spondylotic myelopathy.MATERIALS AND METHODS: A systematic search was conducted using the Pub Med,Cochrane Central,the ISI Web of Knowledge Database,EMbase,CMB,CNKI,Wanfang and VIP databases up to December 2017.Studies that compared posterior laminectomy with instrumented fusion and laminoplasty for the treatment of multi-level cervical spondylotic myelopathy were identified.Meta-analyses were performed for preoperative and postoperative Japanese Orthopedic Association(JOA)scores,preoperative and postoperative visual analogue scale(VAS)scores,preoperative and postoperative cervical range of motion(ROM),preoperative and postoperative cervical curvature index(CCI),operation time,blood loss,rates of overall complication,C5 nerve palsy and axial symptoms.RESULTS: A total of 15 studies were included in this meta-analysis.All of the selected studies were of high quality as indicated by the Newcastle-Ottawa scale(NOS).Among 1131 patients,555 underwent laminectomy with instrumented fusion and 576 underwent laminoplasty.The results of the meta-analysis indicated that there is no statistical difference in preoperative and postoperative Japanese Orthopedic Association(JOA)score,preoperative and postoperative visual analogue scale(VAS)scores,preoperative and postoperative cervical curvature index(CCI),preoperative cervical range of motion(ROM)and the rate of axial symptoms between the two groups.However,laminectomy with instrumented fusion group,compared with laminoplasty group,had higher rate of overall complication [RR=1.99,95%CI(1.24,3.21),Z=2.85,P<0.05],higher rate of C5 palsy[RR=2.22,95%CI(1.30,3.80),Z=2.93,P<0.05],smaller postoperative cervical range of motion(ROM)[SMD=-1.51,95%CI(-2.14,-0.88),Z=4.69,P<0.05],more operation time[SMD=0.51,95%CI(0.12,0.90),Z=2.58,P<0.05],and more blood loss[SMD=0.47,95%CI(0.30,0.65),Z=5.26,P<0.05].CONCLUSION: These results suggested that both posterior laminectomy with instrumented fusion and laminoplasty were determined to be effective for multi-level cervical spondylotic myelopathy.However,laminoplasty had certain advantages on larger postoperative cervical range of motion,lower overall complication and C5 palsy rates,less operation time and intraoperative loss of blood.More prospective randomized controlled trials are needed to comfirm the results of this meta-analysis in the future.PART TWO COMPARISON OF ANCHOR SCREW FIXATION AND MINI-PLATE FIXATION IN UNILATERAL EXPANSIVE OPEN-DOOR LAMINOPLASTY FOR MULTI-LEVEL CERVICAL SPONDYLOTIC MYELOPATHY:A META-ANALYSISOBJECTIVE:Many studies compared anchor screw fixation and mini-plate fixation in unilateral expansive open-door laminoplasty for the treatment of multi-level cervical spondylotic myelopathy,but no consensus has been reached concerning which fixation method is better for MCSM.This study was to compare the efficacy and safety of the two different fixation methods applied in single open-door laminoplasty for multi-level cervical spondylotic myelopathy.MATERIALS AND METHODS: A systematic search was conducted using the Pub Med,Cochrane Central,the ISI Web of Knowledge Database,EMbase,CMB,VIP,CNKI,and Wanfang databases up to December 2017.Studies that compared anchor screw fixation and mini-plate fixation in unilateral expansive open-door laminoplasty for the treatment of multi-level cervical spondylotic myelopathy were identified.Meta-analyses were performed for preoperative Japanese Orthopedic Association(JOA)scores,postoperative JOA scores,JOA scores improvement rate,preoperative and postoperative cervical range of motion(ROM),preoperative and postoperative cervical curvature index(CCI),postoperative lamina open angle,operation time,blood loss,rates of C5 nerve palsy and axial symptoms.RESULTS: A total of 12 studies were included in this meta-analysis.All of the selected studies were of high quality as indicated by the Newcastle-Ottawa scale(NOS).Among 809 patients,372 underwent anchor screw fixation and 437 underwent mini-plate fixation.The results of the meta-analysis indicated that there is no statistical difference in preoperative Japanese Orthopedic Association(JOA)score,JOA scores improvement rate,preoperative cervical curvature index(CCI),preoperative cervical range of motion(ROM),the rate of C5 palsy and blood loss between the two different fixation methods.However,compared with mini-plate fixation,anchor screw fixation had higher rate of axial symptoms [RR=1.75,95%CI(1.31,2.35),P<0.05],less postoperative JOA scores [SMD=-0.38,95%CI(-0.62,-0.15),P <0.05],smaller postoperative cervical curvature index(CCI)[SMD=-0.64,95%CI(-0.94,-0.33),smaller postoperative cervical range of motion(ROM)[SMD=-1.11,95%CI(-2.18,-0.04),P <0.05],smaller lamina open angle [SMD=-1.98,95%CI(-3.71,-0.24),P < 0.05],less operation time [SMD=-0.33,95%CI(-0.59,-0.07),P < 0.05].CONCLUSION: Unilateral expansive open-door laminoplasty combined with mini-plate fixation,compared with anchor screw fixation,had advantages on lower rate of axial symptoms,better neurological function recovery,maintaining postoperative cervical range of motion and physiological lordosis,larger radiographic postoperative lamina open angle.More prospective large sample-sized randomized controlled trials are needed to confirm the results of this meta-analysis in the future.