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FOCUS25824video13
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FOCUS25824video13
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T00H08M38S
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https://cadmoreoriginalmedia.blob.core.windows.net/d9659159-3115-4f3f-808a-1ac7fa37c4c4/13. 25-17.mp4?sv=2019-02-02&sr=c&sig=7kIqrkVWBPiw3E621qB1YelsD00Kc57DrrhOY53eBzI%3D&st=2026-05-13T19%3A52%3A24Z&se=2026-05-13T21%3A57%3A24Z&sp=r
Upload Date:
2025-12-03T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
SPEAKER: The following is a case presentation—laminoplasty:
SPEAKER: importance of preserving C2 and C7 attachments. Clinical history. The patient was in his 40s with multilevel cervical stenosis with myelopathy. He worked as a hairdresser and noticed clumsiness of his hands without other signs of myelopathy. On physical exam, he had hyperreflexia and bilateral Hoffmann's signs. He had no neck pain.
SPEAKER: His preoperative imaging shows multilevel cervical spondylosis at C3–4, C4–5, C5–6, and, to a lesser extent, at C6–7 on the sagittal T2-weighted MR image. Below the MR image are standing cervical radiographs in neutral position, flexion, and extension. These radiographs demonstrate no instability and no overt kyphosis of the cervical spine.
SPEAKER: So diagnostic considerations. The patient has clinical evidence for myelopathy in the context of multilevel degenerative cervical spondylosis without OPLL. Preoperative flexion and extension radiographs were done that demonstrated no evidence for instability. Also, baseline cervical radiographs did not demonstrate any kyphosis. The patient was therefore considered an appropriate candidate for laminoplasty.
SPEAKER: So the plan for treatment was laminoplasty C3–6 performed with C7 dome laminoplasty. The goal of surgery was to preserve motion and to reduce myelopathy and enable the patient to return to work as a hairdresser. The risks of laminoplasty include axial neck pain in a small proportion of patients, delayed instability, kyphosis, C5 palsy, infection, and CSF leak. As the case unfolded, the patient did very well after surgery and returned to work in less than 4 weeks.
SPEAKER: He did have problems with neck pain following surgery that partially responded to physical therapy. After 5 years, he developed progressive myelopathy in addition to worsening neck pain. Postoperative imaging at that time demonstrated evidence for instability and kyphosis. As you see in this T2- weighted MR image, the kyphosis is greatest at the C5–6 level, although there appears to be satisfactory decompression of the spinal cord at all levels.
SPEAKER: Initially, the patient had a satisfactory outcome. He returned to work as a hairdresser with satisfactory reduction of myelopathy symptoms. However, he developed progressive neck pain and progressive myelopathy after 5 years. He underwent a revision decompression and fusion, but was only able to work part-time as a hairdresser and did so with chronic neck pain. The final radiographic outcome, a posterior lateral fusion, was done at C2–3, C3–4, C4–5, C5–6, and C6–7.
SPEAKER: C2 pars screws were placed, C3–6 lateral mass screws were placed, and C7 pedicle screws were placed.
SPEAKER: The final construct shows some return of cervical lordosis with normal SVA less than 2 cm. Analysis of the complication. Opportunities for improvement. The key opportunity for improvement in this case was to preserve the muscular attachments at C2 and at C7. In addition, a C3 laminectomy or a C3 dome laminoplasty would avoid the axial neck pain that can result from the C3 spinous process rubbing against the C2 spinous process, particularly when patients are in extension.
SPEAKER: It is essential to recognize that the modern literature strongly argues that axial neck pain and kyphosis can be prevented by paying attention to preserving the muscular attachments at C2 and at C7. So what did this case teach us? Intellectually, it is important to recognize that the extensor muscles of the cervical spine must remain attached to C2 and to C7.
SPEAKER: Without these attachments, the extensor function of the semispinalis cervicis is compromised and kyphosis can result, as it did in this case. Obtaining postoperative cervical flexion-extension radiographs at 1 and 2 years after laminoplasty might permit earlier detection of kyphosis. Earlier treatment in this case might have reduced the progression of myelopathy and might have allowed the patient to return to full-time work.
SPEAKER: From a technical perspective, it is important to pay close attention to the preservation of muscular attachments, which we'll demonstrate in the next video. So in the video, again, C3 laminectomy with preservation of C2 muscle attachment, C4–6 laminoplasty.
SPEAKER: We are now exposed in the midline. We carefully identify the spinous process: C3–4, C5–6, and the most rostral portion of C7. Once we've confirmed our levels, then we can start the subperiosteal dissection. And this dissection now is at the C4, C5, and C6 levels. You can see where C7 is on the video. The muscles have not been detached from the spinous process, and at C2, more rostrally, there is a preservation of the muscular attachments.
SPEAKER: We're now fully exposed. You can see the spinous process of C3, C4, C5, C6, and C7. We first start with a partial laminectomy at C7, and we start working here with the M8 cutting drill and now crossing over the midline. You'll notice that we have removed interspinous muscular attachments between C6 and C7. This is enabling us to get that exposure and get the decompression done down to the ligamentum flavum.
SPEAKER: We're working just carefully here with the M8 cutting burr, and we extend that to section as we cross over the midline here to the level of the neural foramen at the proximal portion of the C6–7 facet joint. Again, careful decompression both on the right side and on the left side, so that we have a full decompression of the thecal sac at this level. You can see the ligamentum flavum exposed, and we'll just continue carefully to make certain that we have the lateral extent of our decompression.
SPEAKER: Some bony bleeding is sometimes expected, and we'll use some bone wax here in just a moment to stop that bony bleeding. And we'll have the decompression done at the C7 level, as you can see here. Next, we will turn our attention to a C3 laminectomy and C2 muscle preservation, as you'll see right here.
SPEAKER: We're working with the M8 cutting burr, at the gutters, both on the right side, as you see here, and on the left side, which has been drilled already, and carefully working down to the ligamentum flavum, disconnecting the bone, and getting ready to mobilize it. Once we have this dissection done, we can take a curette underneath the lamina, and you can see here carefully elevating the C3 lamina, just dissecting underneath that ligamentum flavum, being cognizant of where the thecal sac is so that there's no compression of the thecal sac.
SPEAKER: As we perform this maneuver, we can then safely remove the C3 lamina, disconnecting it from the ligamentum flavum and getting a full decompression at that C3 level. So you now see the result of the operation: C3 laminectomy; C4, C5, and C6 laminoplasty plates; and a full decompression of the thecal sac at the C3 rostral level, as well as at the C7 caudal level. And you can see the muscular attachments nicely preserved to the C7 spinous process more caudally.
SPEAKER: And that concludes the laminoplasty operation with preservation of the muscular attachments at C2 and at C7.
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