View/Download PDF
Original Article
2019
:10;
219
doi:
10.25259/SNI_518_2019
CROSSMARK LOGO Buy Reprints
PDF

Minimally invasive cervical laminectomy for spondylotic myelopathy in medically fragile patients

Department of Neurological Surgery, Oregon Health & Science University, and Operative Care Division Portland Veterans Administration Hospital, Portland, Oregon, US,
Department of Medicine, Division of Hospital Medicine, Oregon Health & Science University, Portland, Oregon, US.
Corresponding author: Donald A. Ross, Department of Neurological Surgery, Oregon Health & Science University, 3303 SW Bond Avenue, Mail Code CH8N, Portland, Oregon 97239, US. rossdo@ohsu.edu
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Ross DA, O’Glasser AY. Minimally invasive cervical laminectomy for spondylotic myelopathy in medically fragile patients. Surg Neurol Int 2019;10:219.

Abstract

Background:

Cervical spondylotic myelopathy often affects elderly and fragile patients who are not optimal candidates for major surgical procedures. Here, we report patients previously judged not suitable for cervical surgery, who were successfully treated with minimally invasive (MI) cervical decompressions without complications.

Methods:

Retrospectively, we reviewed medically fragile patients (e.g., too many comorbidities), previously deemed unsuitable for surgery who successfully tolerated MI cervical decompressions. The accompanying preoperative comorbidities, surgical risks, complications, and neurological outcomes were assessed.

Results:

Three male patients, with a mean age of 73 years, exhibited an average preoperative modified Japanese Orthopedic Association (mJOA) score of 8. The preoperative Charlson comorbidity indices, the Elixhauser comorbidity indices (respectively averaging 5.7 and 5.7 points, the preoperative Edmonton fragility index (average 12 points), and national surgical quality improvement program risks were calculated. Surgical times averaged 185 min and patients were followed for an average of 11.3 months. No patient had any immediate or delayed postoperative complications. The length of hospital stay was 1 day for each patient. The postoperative mJOA scores averaged 11, which was clinically significant. Further, the postoperative magnetic resonance imaging obtained approximately 3 months postoperative demonstrated adequate cord decompression.

Conclusion:

Medically fragile patients with significant cervical spondylotic myelopathy but major comorbidities precluding major surgery successfully underwent MI cervical decompressions.

Keywords

Cervical spondylotic myelopathy
Elderly
Medically fragile
Minimally invasive cervical decompression

INTRODUCTION

In the elderly with cervical spondylotic myeloradiculopathy, data demonstrate relatively high posterior cervical fusion (10.5%) or combined anterior and posterior cervical surgery (9.02%) complication rates. Furthermore, many elderly patients are medically fragile with other major comorbidities which increase the risk of major cervical surgery. For example, inadequate bone density potentiates higher pseudarthrosis rates, whereas compromised nutrition may result in poor healing, wound breakdown, and infection. Here, however, minimally invasive (MI) cervical laminectomy may prove beneficial. To better evaluate this, we studied three high-risk elderly patients for whom we performed MI cervical laminectomies for myelopathy due to cord compression.

METHODS

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study, formal consent is not required, the study was approved by the institutional review board with a waiver of authorization.

The senior author performed all three MI spine decompressive procedures through an 18 mm tubular retractor using a 5 mm smooth diamond drill for bone removal. Pre- and postoperative modified Japanese Orthopedic Association (mJOA) were reviewed.[7] Patients were assigned Charlson comorbidity index (CCI) scores,[2] Elixhauser comorbidity index (ECI) scores,[3] and Edmonton frailty scale (EFS) scores[8] based on the review of electronic medical records. In addition, National Surgical Quality Improvement Program (NSQIP) scores were calculated to estimate surgical risks (American College of Surgeons NSQIP).[1] Patients were followed postoperatively and underwent postoperative cervical magnetic resonance imaging (MRI) approximately 3 months after surgery. The characteristics of the three identified cases are shown in Table 1. The mean age of the three males was 73 years. The mean preoperative mJOA score was 8, CCI was 5.7, ECI was 5.7, and EFS was 12. NSQIP risk calculations are shown in Figure 1.

Table 1:: Three case mean demographic (all male), pre- and postoperative indices and scores, and risk, operative and examination data.
Figure 1:: Case #1, pre (a) and postoperative (b) cervical sagittal T2-weighted magnetic resonance imaging (MRI) scans show good decompression at C5-C6. Case #2, pre (c) and postoperative (d) cervical sagittal T2-weighted MRI scans show good decompression at C4-C5. Case #3, pre (e) and postoperative (f) cervical axial T2-weighted MRI scans show good decompression at C2-C3.

RESULTS

No patient had any immediate or delayed postoperative complications. The length of stay was 1 day for each patient. Two patients returned to the skilled nursing facility in which they were living preoperatively and one went home.

Post-operative mJOA scores averaged 11, a statistically significant improvement, and patients were followed for a mean interval of 11.3 months. Three-month postoperative MRI scans showed good cord decompression and no need for further surgery [Figure 1].

DISCUSSION

The postoperative courses for the three cases presented were less complicated than predicted by the CCI, the ECI, the EFS, and NSQIP risk calculators. Therefore, MI decompression may result in better than predicted outcomes than the presumably open surgeries used to calibrate currently available risk assessment tools.

MI laminectomy is performed through a 2 cm incision resulting in minimal blood loss, less postoperative pain than open surgery, fewer wound complications vs. open procedures (e.g., such as no infection or cerebrospinal fluid leaks),[6] and less systemic stress than open surgery.[4] MIS surgery is associated with lower infection rates vs. open surgery as reported in several studies.[5,6]

CONCLUSION

We conclude that the three medically fragile patients we presented here with major comorbidities, who were not candidates for larger cervical procedures, benefitted from MI cervical laminectomy. Current surgical risk assessment tools may not be appropriate for MI spine procedures.

Acknowledgments

The authors thank Shirley, McCartney, Ph.D., for editorial assistance.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflict of interest.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms.

REFERENCES

  1. , , , , , , . Development and evaluation of the universal ACS NSQIP surgical risk calculator: A decision aid and informed consent tool for patients and surgeons. J Am Coll Surg. 2013;217:833-420
    [Google Scholar]
  2. , , , . A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation. J Chronic Dis. 1987;40:373-83
    [Google Scholar]
  3. , , , . Comorbidity measures for use with administrative data. Med Care. 1998;36:8-27
    [Google Scholar]
  4. , , , . Less systemic cytokine response in patients following microendoscopic versus open lumbar discectomy. J Orthop Res. 2005;23:406-11
    [Google Scholar]
  5. , , . Does minimally invasive spine surgery minimize surgical site infections? Asian Spine J. 2016;10:1000-6
    [Google Scholar]
  6. . Complications of minimally invasive, tubular access surgery for cervical, thoracic, and lumbar surgery. Minim Invasive Surg. 2014;2014:451637
    [Google Scholar]
  7. , , , , , , . Predicting the minimum clinically important difference in patients undergoing surgery for the treatment of degenerative cervical myelopathy. Neurosurg Focus. 2016;40:E14
    [Google Scholar]
  8. , , , . Preoperative frailty score for 30-day morbidity and mortality after cranial neurosurgery. World Neurosurg. 2017;107:959-65
    [Google Scholar]
Show Sections