SPINE An International Journal for the study of the spine Publish Ahead of Print

DOI: 10.1097/BRS.0000000000002257

Surgical outcomes of posterior spinal fusion alone using cervical pedicle screw

constructs for cervical disorders associated with athetoid cerebral palsy

Kei Watanabe, MD, PhD,※ Toru Hirano, MD, PhD,※ Keiichi Katsumi, MD, PhD,※ Masayuki
Ohashi, MD, PhD,※ Hirokazu Shoji, MD,※ Akiyoshi Yamazaki, MD, PhD,※※ Tomohiro
Izumi, MD, PhD,※※ Kazuhiro Hasegawa, MD, PhD,† Takui Ito, MD, PhD,‡ Naoto Endo,
MD, PhD※

※
Department of Orthopedic Surgery, Niigata University Medical and Dental General
Hospital, Niigata City, Niigata, Japan
※※
Department of Orthopedic Surgery, Spine Center, Niigata Central Hospital
†
Niigata Spine Surgery Center, Kameda Daiichi Hospital
‡
Department of Orthopedic Surgery, Niigata City General Hospital

Address correspondence to:

Kei Watanabe, MD, PhD

Department of Orthopedic Surgery,

Niigata University Medical and Dental General Hospital

1-757 Asahimachi Dori, Chuo-ku, Niigata City, Niigata, 951-8510, Japan.

Phone: +08-25-227-2272

Fax: +08-25-227-0782

E-mail: [email protected]

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 The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work.

No relevant financial activities outside the submitted work.

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 Abstract

Study design: Retrospective case series.

Objective: To investigate clinical outcomes after posterior spinal fusion (PSF) using cervical

pedicle screw (CPS) constructs for cervical disorders associated with athetoid cerebral palsy

(CP).

Summary of Background Data: Traditionally, most patients with cervical myelopathy

associated with CP have required combined anterior and posterior fusion to achieve solid

stability against severe involuntary movement.

Methods: Thirty-one CP patients with cervical disorders who underwent PSF alone with a

minimum 2-year follow-up (mean 58 months) were analyzed. All patients were treated with

PSF using CPS constructs with or without decompression procedures. The average number of

fused segments was 5.1 (range, 1 to 10 segments), and a halo jacket was applied in 16

patients for at least 2 months after surgery. Clinical outcomes using the Japanese Orthopaedic

Association scoring system (JOA score) and walking ability, radiographic sagittal alignment,

fusion status, surgery-related complications were evaluated.

Results: The JOA score improved from 8.3 points preoperatively to 10.9 points at the final

follow-up (p<0.05). While no patients experienced deterioration in their walking ability

postoperatively, 10 patients were unable to walk at the final follow-up. Sagittal alignment,

including C0-2 angle, C2-7 angle, and local alignment in fused segments, was maintained

postoperatively. Twenty-five patients achieved fusion at the final follow-up (fusion rate:

81%), and 5 patients with non-union required additional surgery. With regard to

complications, 5 patients encountered postoperative upper extremity palsy.

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 Conclusions: The CPS construct is amenable to achieve a relatively high fusion rate without

correction loss, and good clinical outcomes can be achieved with a posterior single approach

for CP patients. In the future, efforts should be made to make appropriate decisions regarding

the fusion area, take preventative measures against postoperative upper extremity palsy, and

simplify external orthoses after surgery, especially with the use of a halo jacket.

Key words: athetoid cerebral palsy, posterior fusion, pedicle screw, cervical spine,

myelopathy

Level of Evidence: 4

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 Introduction

Because involuntary movements associated with athetoid cerebral palsy (CP) result in severe

degenerative change in the cervical spine, cervical myelopathy can occur at a relatively

young age.1 The surgical treatments for this condition include posterior decompression

procedures such as laminectomy or laminoplasty; however, none of them have yielded

satisfying long-term results due to progressive intervertebral instability or kyphotic

malalignment that leads to worsening symptoms.2,3 Several spinal arthrodesis procedures,

including anterior spinal fusion (ASF) with or without instrumentation,4-6 posterior fusion

using rod-wiring techniques,4,7,8 and circumferential fusion,4,9 have been introduced.

Nevertheless, involuntary neck movements by the patient and insufficiency of biomechanical

stability lead to the risk of non-union, progression of kyphosis, bone graft dislodgement, or

perioperative respiratory complications. In 1994, Abumi et al. first reported the use of

cervical pedicle screw (CPS) fixation for traumatic or nontraumatic lesions,10,11 and CPSs

biomechanically provided superior stability in multilevel fixation under axial, torsional, and

flexural loading compared with other types of anchors.12 CPSs have been widely used as a

strong anchor for various types of cervical disorders, including degenerative disease, spinal

tumors, trauma, and destructive disorders related to hemodialysis or rheumatoid arthritis.

We hypothesized that the CPS construct can lead to a higher fusion rate against severe

degenerative lesions with involuntary movement, and in 2000, we introduced posterior spinal

fusion (PSF) using CPS constructs to treat cervical disorders associated with athetoid CP. The

purpose of this study was to investigate the clinical outcomes after PSF alone using CPS

constructs for cervical disorders associated with athetoid CP.

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 Methods

This study was approved by an internal review board (SPIRB 1385). Thirty-four consecutive

patients with cervical compressive disorders in the subaxial region that was associated with

CP who underwent PSF using pedicle screw constructs beginning in 2000 at one of the two

hospitals with which the author is affiliated were included. Those with upper cervical lesions

alone who underwent occipito–C2 or C1–C2 decompression and fusion were excluded from

the analysis. Two patients who underwent combined anterior spinal fusion and one who was

moved to a distant place were excluded, and 31 patients, with a minimum 2 year-follow-up

(mean, 58 months, range, 24-156) were therefore enrolled for the analyses.

The clinical data are summarized in Table 1, and there were 19 men and 12 women, with

an average age of 51 years (range 33–65). Their diagnoses were atlantoaxial subluxation

(AAS) concomitant with cervical spondylotic myelopathy (CSM) or radiculopathy (CSR) in

the subaxial region in 8 patients, CSM alone in 13, and cervical spondylotic myelo-

radiculopathy (CSMR) in 10. Twelve patients out of the 31 had received previous cervical

spine surgery, including anterior spinal fusion and laminoplasty.

We investigated clinical outcomes, radiographic sagittal alignment, fusion status,

complications related to surgery, and adjacent disease that required additional revision

surgery. Clinical outcomes were assessed using the Japanese Orthopaedic Association

scoring system (JOA score; scored from 0 to 17 points)13 preoperatively, highest score

postoperatively, and at final follow-up. Walking ability was likewise assessed preoperatively,

3 months postoperatively and at final follow up using the following grading system: grade 1:

independent walking, 2: dependent walking (requiring cane/brace for ambulation), 3: unable

to walk (requiring a wheelchair). Sagittal alignment included the C0-2 angle (the angle

between McGregor’s line and the lower endplate of C2), C2-7 angle (the angle between the

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 lower endplate of C2 and the lower endplate of C7), and sagittal fused angle within the fused

segments (the angle between the upper endplate of the uppermost fused vertebra/McGregor’s

line and the lower endplate of the lowermost fused vertebra) seen on lateral radiograph with

the patient in a neutral position, all of which were evaluated preoperatively, 3 months

postoperatively, and at final follow-up. A positive value indicated lordosis on radiographic

assessment. The fusion status was defined as continuous trabecula on computed tomography

(CT) and a range of motion of ≤ 3° seen on flexion-extension lateral radiographs.

Surgical procedure and postoperative external immobilization

Our surgical strategy indicated that posterior instrumented fusion with CPS constructs should

be used to treat cervical disorders in patients with CP, but a lateral mass screw was used

simultaneously in 11 patients, a transarticular screw was used in 4, and a lamina screw was

used in 3, due to a narrow pedicle channel or anomalous course of the vertebral arteries, as

seen on preoperative CT angiography.14 CPSs were inserted using the guidance of a CT-

based navigation system (StealthStation; Medtronic Inc., Minneapolis, MN) in 2005 and

after, while CPSs were inserted using the guidance of lateral fluoroscopy before 2005. With

regard to CPS insertion techniques using the CT based navigation system, a small pedicle

probe was inserted into the pedicle under single-level registration in the cervical spine and

multilevel registration in the thoracic spine. With regard to free hand techniques, a small

pedicle probe was inserted into the pedicle under the guide of a radiograph image intensifier

using a lateral view to confirm the direction and insertion depth according to previously-

described techniques.10,11 When magnetic resonance imaging (MRI) showed spinal canal

stenosis with cervical cord compression, posterior decompression procedures, including

laminoplasty (n=16) for patients undergoing a primary posterior cervical procedure or

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 laminectomy (n=12) for additional decompression procedure after a previous laminoplasty,

were combined. When a patient complained of radiating pain in an upper extremity,

coexisting with foraminal stenosis at the corresponding disc level seen on preoperative MRI,

microsurgical foraminotomy and removal of both the inferior and superior articular processes

(n=12) were also combined. Regarding bone graft material, monocortical iliac strut grafts

with morselized cancellous autografts were used at the craniocervical junction, and

morselized cancellous iliac or local autografts were placed posterolaterally in subaxial region.

The fusion area included all segments with severe degenerative changes, such as loss of

disc height and osteophyte formation in uncovertebral or facet joints, and the mean fused

segments was 5.8 segments (range, 1-10) in these subjects. PSF extending to occipital bone

was indicated for either irreducible AAS or severe degenerative change in occiput-C1 joint,

and PSF extending to C1 for reducible AAS based on the preoperative extension radiograph

and CT. The initial procedures in patients with subaxial lesions were posterior cervical fusion

for 12 patients and posterior cervico-thoracic fusion extending to either T1, T2 or T3 for 12

patients with degenerative changes at the cervicothoracic junction. As for patients with both

AAS and subaxial lesions, posterior occipito-cervical (O-C) fusion was done in 1 patient, and

occipito-thoracic (O-T) fusion extending to either T1 or T2 was done in 6 patients with

degenerative change at the cervicothoracic junction.

With regard to the subaxial cervical alignment, we aimed to connect the rods according to

the neutral alignment seen on preoperative lateral radiographs, and avoided excessive

kyphosis correction to prevent iatrogenic root entrapment due to foraminal narrowing. With

regard to the upper cervical alignment, to prevent dysphagia, we paid special attention not to

stabilize C0–C2 at a C0-2 angle smaller than that of neutral alignment.

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 With regard to external immobilization after surgery, we used halo immobilization in 16

patients and a simple cervical collar in 8, and 7 did not have external immobilization. The

entire period of external immobilization, for both cervical collar and halo immobilization,

was 5.1 months on average (range, 2-12).

Statistical analysis

Statistical comparisons of the radiographic parameters before and after surgery were

calculated using the nonparametric Wilcoxon signed-rank test or chi-square test, and p values

< 0.05 were considered statistically significant. StatView-J 5.0 (Abacus Concepts, Berkeley,

CA, USA) was used for all statistical analyses.

Results

Participants

The clinical data of the participants and some of their outcomes, including fusion status and

postoperative complications, are summarized in Table 1.

Radiographic sagittal alignment and clinical outcome

The clinical outcomes are summarized in Table 2. With regard to clinical outcomes, the JOA

score improved from 8.3 points preoperatively to 10.9 points at the final follow-up (p < 0.05).

Regarding walking ability, grades 1, 2, and 3 were seen in 10, 5, and 16 patients,

respectively, preoperatively; and grades 1, 2, and 3 were seen in 12, 9, and 10 patients,

respectively, at the final follow-up. Although no patients experienced deterioration in their

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 walking ability grade after surgery, 10 patients with preoperative grade 3 out of 16 were

unable to walk at the final follow-up. The C0-2 angle, C2-7 angle, and sagittal fused angle

within the fused segments were maintained from 18.8°, 0.0°, and 5.5°, respectively,

preoperatively, to 24.0°, -3.5°, and 3.0°, respectively, at the final follow-up (for all

comparisons, p > 0.05).

Fusion status

Twenty-five patients achieved solid bony union (fusion rate: 81%), demonstrated on plain

radiographs and CT images. Six patients (19%) who underwent multilevel fusion with 5 or

more segments demonstrated non-union: at the uppermost instrumented vertebral (UIV) level

in 4 patients and lowermost instrumented vertebral (LIV) level in 3 (one patient showed non-

union at both locations). Three patients out of 4 with non-union at the UIV level, who

demonstrated rod breakage or C1-2 transarticular screw breakage in the craniocervical

junction, and 2 out of 3 with non-union at the LIV level, who demonstrated C7 CPS breakage

or T3 pedicle screw pull-out, required revision fusion surgery. Two patients out of 5 who

underwent O-T fusion showed rod breakage in the craniocervical junction or lower cervical

region, despite halo jacket application for 2 months after O-T fusion.

Complications related to surgery

Complications related to the surgery occurred in 9 patients (29%), which included transient

dysphagia after O-C fusion that required swallowing rehabilitation (n=1), surgical site

infection that required debridement (n=2), malposition of a lateral mass screw requiring

screw removal (n=1), and paralysis of the upper extremities (n=5). With regard to paralysis of

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 the upper extremities, 4 patients had unilateral C5 palsy and 1 had bilateral C6+C7 palsy.

While 2 patients who received additional foraminal decompression experienced full recovery

of the palsy, 2 patients out of 3 without additional interventions still had C5 palsy at the final

follow-up.

Adjacent disease that required additional revision surgery

Seven patients (23%) out of total 31 patients presented with adjacent diseases with recurrent

myelopathy after previous ASF or posterior upper cervical fusion with a mean interval of 8

years 11 months (range: 3 years, 7 months to 21 years, 10 months). Two patients (8%) out of

24 required additional extended fusion surgeries after primary PSF with intervals of 2 years,

10 months and 9 years, 8 months during the follow-up period. The corresponding levels were

C1/2 in 2 patients, C4/5 in 3, C5/6 in 2, and C6/7 in 1.

Illustrative case

A 58-year old woman suffered from numbness and motor weakness of an upper extremity.

Plain radiographs showed multilevel disc degeneration (Figure 1 A), MRI showed spinal

canal stenosis at C5/6 and C6/7, and an intramedullary T2-weighted high intensity area

without canal stenosis was seen at C3/4 (Figure 1 B). Preoperative CT images showed

multilevel disc degeneration as well as foraminal stenosis from C4 to T1 (Figure 1 C).

Although she underwent PSF (C2-T1), laminoplasty (C5-7), and foraminotomy (left C5/6 and

C6/7) as an initial surgery, the patient experienced motor palsy in the C6 and C7 segments

bilaterally. She received additional surgery, including fusion that was extended to T2 and

extensive foraminotomy (left C4/5 and bilateral C5/6 to C7/T1), by sufficient removal of both

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 the superior and inferior articular processes. Although her motor weakness gradually

recovered and she could return to activities of daily life, her JOA score deteriorated from 15

points preoperatively to 10 points at 5 years follow-up (Figure 1 D, E).

Discussion

We investigated the clinical outcomes of PSF with CPS constructs for cervical disorders

associated with athetoid CP. The results of this study indicate that careful preoperative

evaluation of thin-slice CT angiography to check the patient’s bone structure and vertebral

artery, as well as posterior spinal fusion alone using CPS constructs, can achieve good

clinical outcomes for CP patients with cervical compressive myelopathy/radiculopathy.

However, one third of the subjects in this study were unable to walk at the final follow-up;

therefore, early detection of myelopathic symptoms before losing walking ability and early

intervention are desirable before the progression of myelopathy.

Use of CPS for CP patients

Cervical spondylotic myelopathy or radiculopathy associated with CP is caused by

involuntary excessive movement, in addition to degeneration associated with aging, which

demands the most secure CPS construct.15 However, surgeons must be aware of the potential

risks of screw misplacement, which could cause vertebral artery, nerve root, or spinal cord

injury. There have been several reports showing that the pedicle perforation rate ranges

between 6.7% and 30%.16-18 Kato et al. reported on the morphological characteristics of the

cervical spine in patients with CP, and observed frequent pedicle sclerosis, a wide transverse

angle, and lateral mass deformity, which were associated with a higher risk of critical

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 breach.19 Hence, careful preoperative study of thin-slice CT angiography during preoperative

planning is recommended to confirm that the pedicle channel diameter is wide enough and

the anomalous vertebral artery exists.14 In addition, the use of modern surgery-supporting

technologies, such as a navigation system, is recommended to facilitate accurate screw

placement with safety.20-22

Decision making about the fusion area

No consensus exists on the fusion area of spinal fusion surgery for CP patients with cervical

disorders. In the present study, adjacent diseases were present in 7 patients who required

revision surgeries, which were frequently observed in C1/2 or the mid-cervical (from C4/5 to

C5/6) regions. Ohnari et al. reported a 25% incidence of atlantoaxial subluxation after

anterior/posterior combined fusion for subaxial lesions at a minimum of 5 years follow-up;9

in the present study 2 patients had atlantoaxial subluxation as the adjacent disease. Although

surgeons must also pay attention to adjacent disease in the upper cervical region, localized

cervical fusion is usually indicated, except for in the upper cervical region. When longer

fusion is performed for CP patients with voluntary movement, the possibility of non-union,

such as rod fracture and screw pull-off, might be increased. If the neurological symptoms

severely deteriorate in certain cases, the dramatic recovery of symptoms would be difficult,

according to the results of the present study. Therefore, we basically extended instrumented

fusion beyond the levels that radiographically demonstrated disc or facet degeneration and

foraminal stenosis in order to minimize the risk of adjacent diseases.

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 Preventive measures of postoperative upper extremity palsy

Postoperative C5 palsy has been reported in great numbers as one of the clinically serious

complications of posterior cervical surgery. Previous reports demonstrated higher incidences

of postoperative C5 palsy after posterior decompression surgeries that are concomitant with

instrumented fusion,23-25 and mentioned that C5 nerve root compression might be due to

iatrogenic foraminal stenosis, especially after increased lordosis or reduction of

spondylolisthesis at the C4/5 level. Although nerve root compression might occasionally

occur, this is not clinically significant, except for C5 or C8 nerve root compression that

causes dropped shoulder or finger. In the present study, C5 palsy occurred in all patients with

postoperative upper extremity palsy, except for one patient with bilateral upper extremity

palsy in multiple segments (the illustrative case), and physicians must pay attention to C4/5

levels with potential foraminal stenosis due to degeneration. Therefore, we recommend

preventive measures as follows: 1. Excessive correction of sagittal alignment should be

avoided to prevent iatrogenic foraminal stenosis; 2. Prophylactic foraminotomy should be

performed, combined with sufficient removal of both the inferior and superior articular

processes;26 and 3. Lateral mass screws connected to a rod with off-set connectors should be

used, or CPS insertion should be skipped, especially for the C4/5 segment, in order not to

unintentionally pull the vertebra backward and cause narrowing of the neural foramen.

External immobilization in CP patients

Ueda et al. reported that muscle release of the neck extensor and sternocleidomastoid muscles

concomitant with laminoplasty is effective for cervical myelopathy associated with CP in

simplifying external immobilization and improving JOA scores compared with laminoplasty

alone.27 Furuya et al. reported that serial intramuscular injection of botulinum toxin

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 concomitant with posterior decompression and instrumented fusion effectively omits the need

for the use of a halo jacket.28 However, the long term effects of these measures against

muscle athetosis have been unclear, and a partnership with specialists in botulinum toxin

injection is necessary, which is not an ordinary situation. Moreover, previous reports showed

that combined anterior and posterior fusion or posterior fusion alone using CPS constructs

without the use of a halo jacket for the treatment of cervical myelopathy that is associated

with CP has good outcomes.9,15 However, these surgeries are mainly indicated only for

subaxial lesions. Although a halo jacket for patients with subaxial lesions was discontinued

after 2009, in the present study, 2 patients had non-union at the UIV (C0/2) and LIV (C6/7)

levels, even after halo jacket application. Therefore, we believe that the use of rigid external

immobilization, including a halo jacket, is critical, especially for patients who undergo O-C/T

fusions with 5 or more fused segments, since craniocervical junction is a critical region for

non-union. Moreover, severe involuntary movement might be another indication for rigid

external immobilization; however, the judgment on the procedure was based on the surgeon’s

subjective experience.

This study has some limitations. First, the number of patients with CP was limited due to

the relative rarity of this condition; however, we believe that the present study had a larger

case series than previous reports. Second, we could not examine the relationship between the

surgical outcomes and the severity of involuntary movements, since objective assessment of

athetosis is difficult.

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 Conclusion

Although good outcomes were achieved in our study, preventive measures against non-union

and postoperative upper extremity palsy should be established. Since one third of the subjects

in this study were unable to walk at the final follow-up, early intervention is desirable before

the progression of myelopathic symptoms.

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 Figure legends

Figure 1. A 58-year old female experienced motor palsy in the C6 and C7 segments
bilaterally after initial posterior spinal fusion (C2-T1), and required an additional extensive
foraminotomy (left C4/5 and bilateral C5/6 to C7/T1). A: Preoperative plain radiographs
demonstrated severe spondylosis in the subaxial regions, but no atlantoaxial instability was
seen on functional radiographs. B: T2-weighted sagittal magnetic resonance image
demonstrated severe spinal cord compression at C5/6 and C6/7, and intramedullary signal
change without canal stenosis at C3/4. C: Sagittal reconstruction computed tomography
images demonstrated severe degenerative changes in the subaxial region and foraminal
stenosis (arrows) due to osteophyte of the uncovertebral joints and superior articular joints.
D: T2-weighted sagittal magnetic resonance image demonstrating decompression of the
spinal cord at 5 years follow-up. E: Plain radiograph demonstrating maintenance of C2-7
alignment and bony fusion without implant failure.

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 Table 1: Summary of clinical data for the 31 study cases

Case Age/ Diagnos fusion Decompression procedure Other anchors Bone graft Previous op. Additional op. External Fusion Postop. Follow-up
Sex is level orthosis status complication (mon.)

1 57/M CSM C4-T2 ― ― local bone Laminoplasty ― ― + ― 30

ASF(C4-6)
PSF(C1/2)
2 42/M CSMR C4-5 fora.rt.C4/5 ― iliac bone ASF(C3/4) PSF(C2-T2) + ― + ― 104
fora.lt.C5/6/7/T1

3 56/M CSM C3-7 laminectomyC3-7 ― local bone ― ― ― + rt. C5 palsy 156

4 48/M CSM C2-T1 ― ― iliac bone + local ASF(C3/4) ― halo jacket C7/T1 ― 24
bone non-union

5 46/F CSM C2-5 ― LMS iliac bone PSF(C0-2) ― halo jacket + LMS 66
(bil.C3-5) malposition

6 56/M AAS+ C0-T1 laminectomyC1 + ― iliac bone + ― ― halo jacket + ― 108

CSM laminoplastyC3-7 β-TCP5g

7 49/F CSM C3-6 laminoplastyC3-6 ― iliac bone + local ― ― halo jacket + ― 24

bone

8 53/F CSM C2-7 laminoplastyC3,C4 ― iliac bone + local ― ― halo jacket + ― 72

bone

9 42/M CSM C2-7 laminoplastyC3 + ― iliac bone ― ― halo jacket + ― 70

partial laminectomyC2,C4

10 45/F CSM C2-7 laminoplastyC4-6 ― iliac bone + local ― ― Collar + ― 60

bone

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11 65/M AAS+ C1-7 laminoplastyC5,C6 ― iliac bone + local ― ― ― + ― 38
CSMR bone

12 57/M CSMR C2-T2 laminectomyC2-5 + LMS iliac bone + local PSF(C0-2) ― ― + dysphagia 33
fora.bil.C4/5 (lt.C3, bil.C5) bone

13 54/M CSM C2-7 laminoplastyC3-5 ― iliac bone + local ― ― halo jacket + ― 42

bone + collar

14 47/F CSMR C2-T1 laminectomyC6,C7 LMS local bone laminoplasty ― halo jacket + SSI 54
(bil.C5,C6) fora.lt.C6/7
15 33/M CSM C2-7 laminoplastyC4-6 + LMS iliac bone + local laminoplasty PSF(C6-T3) halo jacket C6/7 ― 45
laminectomyC3 (bil.C4,lt.C5) bone non-union

16 53/M CSMR C2-7 laminoplastyC4-6 + ― iliac bone + local ― ― ― + lt. C5 palsy 36

fora.bil.C5/6 bone

17 48/F CSMR C2-T1 laminoplastyC3-7 + ― iliac bone + local ― ― Collar + ― 54

fora.lt.C4/5/6/7 bone

18 51/M CSMR C2-T2 laminoplastyC3-7 + ― iliac bone + local ― ― Collar + ― 48

fora.bil.C4/5,C7/T1, rt.C5/6 bone

19 58/F CSMR C2-T2 laminectomyC3-7 + LMS iliac bone + local ― ― Collar + bil.C5,6 palsy 48
fora.lt.C4/5, bil.C5/6/7/T1 (lt.C3,C4) bone

20 50/M AAS+ C1-7 laminectomyC4,5 + TAS iliac bone + local laminoplasty PSF(C0-2) ― C1/2 rt. C5 palsy 36
CSMR fora.lt.C5/6/7, bil.C4/5, C7/T1 (bil.C1-2) bone non-uniom

21 51/M CSM C2-T1 laminectomyC3-5,6/7 LS iliac bone + local ― ― halo jacket + ― 36

(lt.C2) bone

22 55/M AAS+ C0-T2 laminectomy C1 + ― iliac bone + local laminoplasty PSF(C0-2) halo jacket + C0/2 SSI 24
CSM fora.bil.C4/5 bone total contact non-union

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23 60/M CSMR C2-T1 laminoplastyC3-7 + LMS iliac bone + local ― ― Collar C2/3 ― 25
fora.lt.C7/T1 (bil.C3, lt.C6) bone +β-TCP2g non-union

24 58/F AAS+ C0-T1 laminectomyC1 LMS (rt.C3,C6, iliac bone + local ― ― halo jacket + ― 24
CSM lt.C4,C5) bone

25 62/F AAS+ C0-5 ― TAS iliac bone laminoplasty Collar + ― 48

CSM (Lt.C4-5)

26 44/M CSMR C3-T1 laminoplastyC3-6 + LMS local bone + ― ― halo jacket + ― 102
fora.rt.C3/4, lt.C4/5, bil.C5/6 (rt.C3,C4,C5) β-TCP2g + collar

27 45/F CSM C3-T3 laminoplastyC5-7 TAS iliac bone + local ― ― halo jacket + ― 98
(rt.C4-5,C6-7) bone + collar

28 55/F AAS+ C0-T3 ― TAS(rt.C5-6) iliac bone + local Laminoplasty PSF(C0-2) Collar C0/2,T2/3 ― 96
CSM LS(rt.C2,C3) bone +β-TCP2g ASF(C5-7) PSF(T2-7) non-union

29 42/M AAS+ C0-T1 laminectomyC1,C6,7 LMS(lt.C4,C5) iliac bone + local laminectomy ― halo jacket + ― 102
CSM LS(lt.C2) bone +β-TCP5g + collar

30 62/M CSMR C2-T3 laminoplastyC3-6 + LMS(lt.C5) local bone ― PSF(C0-2) + Collar + rt. C5 palsy 38
fora.rt.C5/6/7,bil.C4/5 fora.rt.C4/5

31 57/F CSM C0-T2 laminoplastyC4-6 + LMS (bil.C3,C4, iliac bone + local PSF(C1/2) halo jacket + ― 36
fora.rt.C4/5/6 lt.C5) bone + collar

Abbreviations: fora.; foraminotomy, LMS; lateral mass screw, TAS; transarticular screw, LS; lamina screw, SSI; surgical site infection

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Table 2: Summary of clinical results for the 31 study cases

Preop. Postop. Final P value

JOA score mean (SD), point 8.3 (3.5) 10.9 (3.0) 10.0 (2.9) 0.0016
[highest score]
Walking ability 0.0002
Grade 1 [independent walk], case (%) 10 (32) 12 (39) 12 (39)
Grade 2 [dependent walk], case (%) 5 (16) 11 (35) 9 (29)
Grade 3 [unable to walk], case (%) 16 (52) 8 (26) 10 (32)

Radiographic alignment
C0-2 angle mean (SD), ° 18.8 (20.1) 19.3 (17.7) 24.0 (16.3) 0.7704
C2-7 angle mean (SD), ° -0.0 (21.7) -1.6 (16.2) -3.5 (16.6) 0.1744
Sagittal fused angle mean (SD), ° 5.4 (18.7) 2.7 (13.7) 3.0 (13.5) 0.0839

 Statistical analyses were performed in comparison between preop. and final follow-up.

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