Novel Approach in Posterior Cervical Laminoplasty: Integrating Spinous Process Sutures with Intermittent Titanium Miniplates

Novel Approach in Posterior Cervical Laminoplasty: Integrating Spinous Process Sutures with Intermittent Titanium Miniplates | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Novel Approach in Posterior Cervical Laminoplasty: Integrating Spinous Process Sutures with Intermittent Titanium Miniplates Shuai Zhao, Ying-Jin Sun, Geng-Ao Wen, Shang Qiu, Cheng Li, Shuo Feng, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3926218/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective This study aimed to assess the clinical effectiveness of using intermittent titanium miniplates at C4 and C6 in conjunction with adjacent spinous process sutures for lifting and fixation during posterior cervical unilateral open-door laminoplasty. Methods We retrospectively analyzed the clinical data of 24 patients with ossification of the posterior longitudinal ligament who underwent this surgery. We assessed the Japanese Orthopaedic Association (JOA) score, visual analog scale (VAS) score, and the incidence of axial symptoms preoperatively. Additionally, we measured cervical curvature angle (CCA), range of motion (ROM), effective sagittal diameter (ESD), and the effective narrowest area (ENA) of the spinal canal both before and after surgery. All patients were followed up for a minimum of 1 year. Results At the final follow-up, significant improvements were observed in JOA scores and VAS scores compared to preoperative values. There was a significant improvement in postoperative ENA and ESD. There were no statistically significant differences in CCA and ROM at the final follow-up compared to preoperative values. Axial symptoms developed in 7 cases (29.2%, 7/24) postoperatively. Conclusions Integrating spinous process sutures with intermittent titanium miniplates not only reduces patient costs but also improves clinical outcomes in posterior unilateral open-door decompression of cervical laminae. Health sciences/Diseases Health sciences/Medical research ossification of the posterior longitudinal ligament open-door laminoplasty axial symptoms cervical curvature Figures Figure 1 Figure 2 Figure 3 1 Introduction Posterior cervical unilateral open-door laminoplasty (PCUDL) stands as an effective treatment for cervical spinal stenosis arising from cervical ossification of the posterior longitudinal ligament (OPLL) 1–3 . Various fixation methods have been employed to maintain the open position following decompression in PCUDL. Notably, separate suture suspension fixation was abandoned in clinical practice due to silk thread's potential to damage soft tissues, leading to unstable fixation and the risk of door closure 4 . While anchor fixation offered increased reliability compared to separate sutures, it remained susceptible to door shaft breakage and reclosure 5 . The posterior screw-rod system, although dependable, faced criticism for its impact on the physiological curvature and mobility of the cervical spine 6,7 . The introduction of titanium miniplates marked a significant advancement, offering secure fixation with less interference in cervical mobility, making them a popular choice in clinical settings 8–10 . However, clinical experience revealed challenges when attempting to place nails on the small C3 lateral block and spinous process. Additionally, the high cost of titanium miniplates raised concerns about the economic burden on patients when using them for fixation on each decompressed vertebral plate. This prompted the exploration of a fixation method that could securely hold the structure in place while reducing the number of titanium miniplates required. As a result, we treated patients with cervical spine OPLL by employing C4 and C6 intermittent titanium miniplates in combination with adjacent spinous process sutures for lifting and fixation during decompression in posterior cervical unilateral open-door laminoplasty. This approach not only achieved positive clinical outcomes but also significantly reduced patients' medical expenses, as reported below. 2 Materials and methods 2.1 Patients We conducted a retrospective study at our hospital, spanning from December 2015 to September 2022, focusing on patients with ossification of the multisegmental (≥ 3 segments) cervical posterior longitudinal ligament. This study explored the surgical approach of posterior cervical unilateral open-door decompression involving segments C3-C7. The procedure included the use of interrupted titanium miniplates for C4 and C6, complemented by the lifting and fixation of adjacent spinous processes in C3, C5, and C7 using interspinous sutures. The inclusion criteria were as follows: ( 1 ) clinical imaging data (including X-ray, CT, and MRI) confirming spinal canal stenosis due to ossification of the multisegmental (≥ 3 segments) cervical posterior longitudinal ligament, and ( 2 ) patients presenting clinical symptoms attributable to cervical spinal canal stenosis, such as lower limb weakness, gait instability, sensation of stepping on cotton, tendon hyperreflexia, and similar manifestations. Exclusion criteria encompassed the following: ( 1 ) craniocerebral injury and upper motor neuron injury, and ( 2 ) follow-up duration of less than 12 months. A total of 24 patients were included in this study, including 19 males and 5 females, aged from 43 to 73 years (60.46 ± 7.83 years). The study follows the ethical principles outlined in the Declaration of Helsinki and its subsequent amendments. Patients and their families comprehended the study's details, willingly provided informed consent, and the study received approval from Ethics Committee of the Affiliated Hospital of Xuzhou Medical University. All methods used followed relevant regulations. 2.2 Surgical technique The patient was positioned in the prone orientation following general anesthesia. Shoulder and head support braces were employed, and standard sterilization and draping procedures were performed. An incision was made at the midpoint of the posterior neck to provide complete exposure of the bilateral laminae spanning from C3 to C7. The lamina exhibiting severe symptoms was designated as the "open-door" side. Bone grooves, positioned 3mm from the inner edge of the bilateral lamina, were created using a grinding drill. Subsequently, the lamina was efficiently opened, progressing from the cortical bone to the dural sac. In the contralateral lamina, the V-shaped bone groove was used as the hinge on the side of the door shaft, and the lamina was lifted to the side of the door shaft. Titanium miniplates of suitable dimensions were chosen to secure the spinous processes and laminae of C4 and C6, followed by reinforcement using self-tapping screws. After drilling the root of the spinous process of C3, C5 and C7, the suture was used to pass through the bone hole and fixed at the upper hole of the spinous process fixation part of the adjacent C4 or C6 titanium miniplate to form an oblique upward pulling force (Fig. 1 , Fig. 2 ). After irrigating the incision, the excess bone was implanted into the bone groove on the side of the C3-C7 door shaft and around the facet joint, and the facet joint was covered with gelatin sponge to the back of the lamina. Finally, the incision was sutured and the operation was completed. Postoperatively, patients underwent follow-up evaluations at 1 month, 3 months, and 6 months. Subsequently, annual follow-up assessments were conducted for a minimum of 1 year. 2.3 Clinical evaluation Preoperative, 3-month postoperative, and final follow-up assessments of spinal cord function were conducted using the Japanese Orthopaedic Association (JOA) spinal cord score. The rate of neurological function improvement was determined using the formula: Recovery Rate (%) = (Postoperative JOA - Preoperative JOA) / (17 - Preoperative JOA) × 100% 11 . From the postoperative period to the final follow-up, all patients were monitored for axial symptoms. The primary indications included neck and back pain, often accompanied by soreness, distension, and stiffness. Neck pain symptoms were assessed using the visual analog scale (VAS), with a VAS score > 3 indicative of the presence of axial symptoms 12 . 2.4 Imaging evaluation outcomes During preoperative and final follow-up evaluation, C2 to C7 was measured by Cobb method to evaluate cervical curvature angle (CCA) on lateral cervical radiographs and cervical range of motion (ROM) on flexion-extension dynamic cervical radiographs​ 13–15 . The effective sagittal diameter (ESD) and the effective narrowest area (ENA) of the spinal canal were quantified using preoperative CT scans, as well as at the 3-month postoperative and final follow-up (Fig. 3 ). 2.5 Statistical analysis Statistical analysis was conducted using SPSS 26.0 software. Count data were presented as percentages (%), while measurement data were reported as ( \(\overline{X}\) ± SD). Statistical significance was determined using Student's t-test and repeated measures analysis of variance. Differences were considered statistically significant at P < 0.05. 3 Results 3.1 Clinical evaluation outcomes There was a significant difference in JOA score at 3 months after surgery and at the final follow-up compared with that before surgery. The JOA score at the final follow-up was better than that at 3 months after surgery, and the difference was statistically significant (Table 1 ). The improvement rate of neurological function at the final follow-up was 75.29% ±14.79%. Table 1 Comparison of preoperative and postoperative JOA, VAS, ESD and ENA results Preop 3 months postop Final follow-up F value P value JOA score 8.79 ± 1.79 13.75 ± 1.45 14.87 ± 1.48 164.119 < 0.001 VAS score 5.25 ± 1.33 2.42 ± 1.38 1.29 ± 1.00 110.305 < 0.001 ESD (mm) 6.25 ± 1.75 10.58 ± 1.54 10.32 ± 1.53 555.179 < 0.001 ENA (mm 2 ) 96.46 ± 23.467 212.38 ± 30.64 207.71 ± 31.53 493.122 < 0.001 Data are expressed in \(\overline{X}\) ± SD . JOA, Japanese Orthopaedic Association; VAS, visual analog scale; ESD, the effective sagittal diameter; ENA, the effective narrowest area; Preop, preoperative; Postop, postoperative. VAS score at 3 months after surgery and at the final follow-up were significantly better than preoperative score (p < 0.05), and VAS score at the final follow-up were better than at 3 months after surgery (p < 0.05) (Table 2 ). By 3 months after surgery, 7 patients had developed axial symptoms (29.2%, 7/24), which were treated with NSAIDs. By the time of the final follow-up, most of the patients' symptoms had resolved, except for one patient who still had residual axial pain. Table 2 Comparison of preoperative and postoperative CCA and ROM results Preop Final follow-up t value P value CCA (°) 18.64 ± 5.11 17.55 ± 5.26 0.730 0.469 ROM (°) 35.33 ± 6.32 37.73 ± 5.81 0.347 0.730 Data are expressed in \(\overline{X}\) ± SD . CCA, Cervical curvature angle; ROM, range of motion 3.2 Imaging evaluation outcomes The results of CCA and ROM measured postoperatively on cervical lateral radiographs were similar to those preoperatively, and the differences were not statistically significant (p > 0.05) (Table 2 ). At the last follow-up, the patient was still able to maintain CCA and ROM approximating the preoperative level at the final follow-up. The ESD and ENA of the spinal canal measured on CT at 3 months postoperatively and at the final follow-up were significantly better than preoperatively (p 0.05) (Table 1 ). This shows that the fixing method we use is reliable, and there is no rebound or reclosing on the open side of the door. 4 Discussion Cervical Ossification of the Posterior Longitudinal Ligament (OPLL) is a prevalent condition in spinal surgery. OPLL reduces the effective cervical spinal canal volume, resulting in pressure on the dura mater or nerve roots, leading to lower limb weakness and a sensation of walking on cotton. Expansive laminoplasty procedures, including posterior unilateral open-door decompression and cervical laminectomy with screw-rod internal fixation, are the primary treatments for symptomatic OPLL. Compared to the latter, unilateral open-door decompression offers advantages such as shorter operation times, reduced bleeding, and improved range of motion (ROM) and physiological cervical curvature 16 . Posterior unilateral open-door laminoplasty for the cervical spine has been widely adopted by spinal surgeons since its initial introduction in 1977 3 . However, initial procedures presented certain challenges, including postoperative axial pain and door reclosure. The occurrence of door reclosure can be as high as 34%, significantly impacting the outcomes of the procedure 17 . To address door reclosure, a solution involves utilizing a suture suspension method. This method entails suturing and securing the spinous process to surrounding soft tissues such as the facet joint capsule. Nevertheless, this approach has limitations, including unreliable fixation, substantial damage to the joint capsule and surrounding soft tissues, and a relatively high reclosure rate 18 . Subsequently, O'Brien 19 introduced the concept of a rigid door shaft, emphasizing the significance of reliable fixation to prevent door reclosure. This involved implanting autogenous bone particles into the interlaminar space on the door shaft side after screw fixation, promoting bone healing. Although this method reduced the incidence of reclosure, it lacked fixed support on the door side, leading to potential issues such as door shaft fracture, reclosure, and epidural scar adhesion, resulting in dural compression. In 2004, Heller et al 20 proposed the use of titanium miniplate internal fixation, which involved placing a titanium miniplate at the junction of the open-door side to ensure reliable fixation. This approach allowed patients to engage in early functional exercises while wearing a neck brace, significantly reducing the risk of door reclosure or a decrease in door angle following surgery. Consequently, due to its dependable fixation, titanium miniplates have become extensively utilized in posterior unilateral open-door decompression of the cervical spine. In previous posterior cervical surgeries, we observed that certain patients had smaller C3 lateral mass and spinous process sizes compared to those below them. This situation, compounded by the presence of osteoporosis, could result in issues with unstable screw fixation during surgery. Furthermore, the use of titanium miniplates to fix the entire C3 to C7 segment, while providing increased stability and reliability, can substantially increase the economic burden on patients due to the high cost of titanium miniplates. Currently, various scholars have proposed different recommendations regarding the specific quantity and placement of titanium miniplates following posterior unilateral open-door decompression of the cervical spine. Ji et al 21 found no significant difference in therapeutic efficacy between intermittent fixation of C3, C5, and C7 and continuous fixation of C3 to C7. However, concerning operation time, intraoperative blood loss, and operational costs, three titanium miniplates proved superior to five titanium miniplates. In our study, we found that the open-door side could be reliably stabilized during the operation by placing titanium miniplates and screws in C4 and C6, followed by lifting and securing them through sutures of adjacent spinous processes. Additionally, in the comparison between the results at 3 months post-surgery and the final follow-up, we identified no statistically significant differences in the effective sagittal diameter and the effective area of the cervical canal. Thus, controversy persists regarding the location and quantity of intermittent titanium miniplate fixations. To alleviate the financial burden on patients and address the issue of C3 anatomical characteristics, we performed segmental decompression and fixation from C3 to C7 for individuals with OPLL. After exposing the adjacent spinous processes of C3, C5, and C7, we created holes at the root of the spinous processes. Non-absorbable sutures were then passed through these bone holes and lifted obliquely before being secured to the C4 and C6 titanium miniplates. Intraoperatively, we observed that the fixation of the door shaft was reliable. Subsequent follow-up revealed that the door on the open side remained open during the cervical CT scans performed 3 months after surgery and at the final follow-up. Furthermore, bony fusion was observed in the slots on the side of the open door during the 3-month reexamination. At the last follow-up, the cervical curvature angle (CCA) and range of motion (ROM) of the cervical vertebrae from C2 to C7 did not significantly differ from their pre-surgery values. Additionally, the measurements of effective sagittal diameter (ESD) and effective narrowest area (ENA) of the cervical spinal canal taken before surgery remained stable throughout the follow-up period. This highlights the effectiveness of the intermittent fixation technique using only C4 and C6 titanium miniplates combined with sutures on adjacent spinous processes for stabilization and fixation. In fact, this approach has demonstrated superiority over the use of 3 or 5 titanium miniplates, particularly in some respects 21 . Axial pain is a common complication following posterior unilateral open-door cervical vertebrae surgery, with numerous contributing factors. Literature reports suggest that factors such as postoperative cervical stability, ROM, damage to cervical facet joints caused by internal fixation materials, and injury to the cervical posterior ligament complex may underlie axial pain 22–25 . In our study, although we limited the use of titanium miniplates to C4 and C6 to minimize facet joint damage, some patients still experienced postoperative axial pain. Furthermore, seven patients exhibited varying degrees of posterior cervical stiffness and axial pain three months after surgery. We suspect that prolonged cervical brace use and intraoperative soft tissue manipulation may be contributing factors. We provided instructions for patients to use non-steroidal analgesics and engage in appropriate cervical exercises, leading to significant relief in six patients. However, one patient did not experience satisfactory pain relief, and we plan to conduct further follow-up in subsequent studies. This study has certain limitations. The small sample size and the relatively short duration of follow-up necessitate continued observation to determine whether reclosure of the open-door side becomes an issue over an extended follow-up period. Furthermore, in real-world clinical practice, not all patients are suitable candidates for the use of titanium miniplates in conjunction with adjacent spinous process sutures. Decision-making should be individualized and based on each patient's specific circumstances. 5 Conclusion This study provides valuable insights into the clinical efficacy of intermittent titanium miniplate usage in conjunction with adjacent spinous process sutures in the unilateral open-door posterior cervical approach. This technique emerges as a viable treatment option for cervical spondylosis, offering benefits not only in terms of cost reduction for patients but also in achieving positive clinical outcomes, including pain relief, neurological improvement, and radiological stability. Declarations Author Contribution Z.S. and S.YJ. did the study, analyzed the data, and wrote the manuscript. W.GA. was responsible for drawing. Q.S., L.C., F.S. and Y.F. were involved in the design, data management, and analysis of the study. F.S. and Y.F. made significant contributions to the conception and design of the study, and critically revised the manuscript. All authors read and approved the final manuscript. References Tsuyama, N. Ossification of the posterior longitudinal ligament of the spine. Clin. Orthop. 71–84 (1984). Kimura, I., Shingu, H. & Nasu, Y. Long-term follow-up of cervical spondylotic myelopathy treated by canal-expansive laminoplasty. J. Bone Joint Surg. Br. 77, 956–961 (1995). 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[Effect of penetration of mini-plate lateral mass screws into facet joint on axial symptoms in cervical laminoplasty]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi Zhongguo Xiufu Chongjian Waike Zazhi Chin. J. Reparative Reconstr. Surg. 27, 1324–1330 (2013). Yeh, K.-T. et al. Expansive open-door laminoplasty secured with titanium miniplates is a good surgical method for multiple-level cervical stenosis. J. Orthop. Surg. 9, 49 (2014). Li, D., Hai, Y., Meng, X., Yang, J. & Yin, P. Posterior open-door laminoplasty secured with titanium miniplates vs anchors: a comparative study of clinical efficacy and cervical sagittal balance. J. Orthop. Surg. 14, 401 (2019). Qi, Q. et al. Is Mini-Plate Fixation Superior to Suture Suspensory Fixation in Cervical Laminoplasty? A Meta-Analysis. World Neurosurg. 93, 144–153 (2016). Yonenobu, K., Abumi, K., Nagata, K., Taketomi, E. & Ueyama, K. Interobserver and intraobserver reliability of the japanese orthopaedic association scoring system for evaluation of cervical compression myelopathy. Spine 26, 1890–1894; discussion 1895 (2001). Yang, L. et al. Modified plate-only open-door laminoplasty versus laminectomy and fusion for the treatment of cervical stenotic myelopathy. Orthopedics 36, e79-87 (2013). Lee, S.-H. et al. The influence of thoracic inlet alignment on the craniocervical sagittal balance in asymptomatic adults. J. Spinal Disord. Tech. 25, E41-47 (2012). Suk, K.-S. et al. Sagittal alignment of the cervical spine after the laminoplasty. Spine 32, E656-660 (2007). Chen, C. et al. Clinical and Radiographic Outcomes of Modified Unilateral Open-door Laminoplasty with Posterior Muscle-Ligament Complex Preservation for Cervical Spondylotic Myelopathy. Spine 44, 1697–1704 (2019). Ahsan, M. K. et al. Open-door Laminoplasty for Multilevel Cervical Spondylotic Myelopathy and Ossification of the Posterior Longitudinal Ligament (OPLL) using Titanium Reconstruction Miniplate and Screws. Mymensingh Med. J. MMJ 26, 558–568 (2017). M, M. et al. Risk factors for closure of lamina after open-door laminoplasty. J. Neurosurg. Spine 9, (2008). Chen, H. et al. Clinical and radiography results of mini-plate fixation compared to suture suspensory fixation in cervical laminoplasty: A five-year follow-up study. Clin. Neurol. Neurosurg. 138, 188–195 (2015). O’Brien, M. F., Peterson, D., Casey, A. T. & Crockard, H. A. A novel technique for laminoplasty augmentation of spinal canal area using titanium miniplate stabilization. A computerized morphometric analysis. Spine 21, 474–483; discussion 484 (1996). Park, A. E. & Heller, J. G. Cervical laminoplasty: use of a novel titanium plate to maintain canal expansion–surgical technique. J. Spinal Disord. Tech. 17, 265–271 (2004). Ji, W. et al. Comparing clinical outcomes of using 3 versus 5 titanium miniplates in laminoplasty for multilevel cervical myelopathy: A prospective cohort study. J. Orthop. Transl. 20, 67–72 (2020). Zhang, X. et al. Factors associated with postoperative axial symptom after expansive open-door laminoplasty: retrospective study using multivariable analysis. Eur. Spine J. Off. Publ. Eur. Spine Soc. Eur. Spinal Deform. Soc. Eur. Sect. Cerv. Spine Res. Soc. 29, 2838–2844 (2020). Qu, L., Li, Z., Wang, X., Yuan, L. & Li, C. Axial symptoms after conventional and modified laminoplasty: a meta-analysis. World Neurosurg. S1878-8750(23)01354–2 (2023) doi: 10.1016/j.wneu.2023.09.086 . Li, F. H. et al. Incidence and Outcomes of C5 Palsy and Axial Pain After Open-Door Laminoplasty or Laminectomy and Fusion: A Meta-Analysis. World Neurosurg. 128, e1002–e1009 (2019). Ono, A. et al. The relationship between the anatomy of the nuchal ligament and postoperative axial pain after cervical laminoplasty: cadaver and clinical study. Spine 37, E1607-1613 (2012). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3926218","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":273089142,"identity":"b3d8c433-6d91-48bd-a875-6ae9db849040","order_by":0,"name":"Shuai Zhao","email":"","orcid":"","institution":"Affiliated Hospital of Xuzhou Medical College","correspondingAuthor":false,"prefix":"","firstName":"Shuai","middleName":"","lastName":"Zhao","suffix":""},{"id":273089143,"identity":"c5138e25-8477-474a-b9ca-4d35cede7ebe","order_by":1,"name":"Ying-Jin Sun","email":"","orcid":"","institution":"Affiliated Hospital of Xuzhou Medical 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laminoplasty.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3926218/v1/820e0dd7b75f29a4e3147cf9.jpg"},{"id":51236467,"identity":"75080adf-9d69-4327-96bc-4d802cf0e104","added_by":"auto","created_at":"2024-02-16 16:41:01","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":163317,"visible":true,"origin":"","legend":"\u003cp\u003eI An intraoperative demonstration of this procedure.\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3926218/v1/748a3bd05e98d61bf4dd0ccd.jpg"},{"id":51236469,"identity":"c42fb2a6-db7c-4d71-b8e2-8ddd4568ee2f","added_by":"auto","created_at":"2024-02-16 16:41:02","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":329958,"visible":true,"origin":"","legend":"\u003cp\u003eCT scan was used to quantify the effective sagittal diameter (ESD) and the effective narrowest area (ENA) of the spinal canal.\u003c/p\u003e","description":"","filename":"figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3926218/v1/f8039ca08039f85108457777.jpg"},{"id":55909289,"identity":"861946ac-d0ce-4860-80a8-cee8b113d17f","added_by":"auto","created_at":"2024-05-06 07:34:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":716518,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3926218/v1/4196f1b5-a543-47c6-81ee-48ae1cbfb2bd.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Novel Approach in Posterior Cervical Laminoplasty: Integrating Spinous Process Sutures with Intermittent Titanium Miniplates","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003ePosterior cervical unilateral open-door laminoplasty (PCUDL) stands as an effective treatment for cervical spinal stenosis arising from cervical ossification of the posterior longitudinal ligament (OPLL)\u003csup\u003e1\u0026ndash;3\u003c/sup\u003e. Various fixation methods have been employed to maintain the open position following decompression in PCUDL. Notably, separate suture suspension fixation was abandoned in clinical practice due to silk thread's potential to damage soft tissues, leading to unstable fixation and the risk of door closure\u003csup\u003e4\u003c/sup\u003e. While anchor fixation offered increased reliability compared to separate sutures, it remained susceptible to door shaft breakage and reclosure\u003csup\u003e5\u003c/sup\u003e. The posterior screw-rod system, although dependable, faced criticism for its impact on the physiological curvature and mobility of the cervical spine\u003csup\u003e6,7\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe introduction of titanium miniplates marked a significant advancement, offering secure fixation with less interference in cervical mobility, making them a popular choice in clinical settings\u003csup\u003e8\u0026ndash;10\u003c/sup\u003e. However, clinical experience revealed challenges when attempting to place nails on the small C3 lateral block and spinous process. Additionally, the high cost of titanium miniplates raised concerns about the economic burden on patients when using them for fixation on each decompressed vertebral plate.\u003c/p\u003e \u003cp\u003eThis prompted the exploration of a fixation method that could securely hold the structure in place while reducing the number of titanium miniplates required. As a result, we treated patients with cervical spine OPLL by employing C4 and C6 intermittent titanium miniplates in combination with adjacent spinous process sutures for lifting and fixation during decompression in posterior cervical unilateral open-door laminoplasty. This approach not only achieved positive clinical outcomes but also significantly reduced patients' medical expenses, as reported below.\u003c/p\u003e"},{"header":"2 Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Patients\u003c/h2\u003e \u003cp\u003eWe conducted a retrospective study at our hospital, spanning from December 2015 to September 2022, focusing on patients with ossification of the multisegmental (\u0026ge;\u0026thinsp;3 segments) cervical posterior longitudinal ligament. This study explored the surgical approach of posterior cervical unilateral open-door decompression involving segments C3-C7. The procedure included the use of interrupted titanium miniplates for C4 and C6, complemented by the lifting and fixation of adjacent spinous processes in C3, C5, and C7 using interspinous sutures.\u003c/p\u003e \u003cp\u003eThe inclusion criteria were as follows: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) clinical imaging data (including X-ray, CT, and MRI) confirming spinal canal stenosis due to ossification of the multisegmental (\u0026ge;\u0026thinsp;3 segments) cervical posterior longitudinal ligament, and (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) patients presenting clinical symptoms attributable to cervical spinal canal stenosis, such as lower limb weakness, gait instability, sensation of stepping on cotton, tendon hyperreflexia, and similar manifestations. Exclusion criteria encompassed the following: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) craniocerebral injury and upper motor neuron injury, and (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) follow-up duration of less than 12 months.\u003c/p\u003e \u003cp\u003eA total of 24 patients were included in this study, including 19 males and 5 females, aged from 43 to 73 years (60.46\u0026thinsp;\u0026plusmn;\u0026thinsp;7.83 years). The study follows the ethical principles outlined in the Declaration of Helsinki and its subsequent amendments. Patients and their families comprehended the study's details, willingly provided informed consent, and the study received approval from Ethics Committee of the Affiliated Hospital of Xuzhou Medical University. All methods used followed relevant regulations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Surgical technique\u003c/h2\u003e \u003cp\u003eThe patient was positioned in the prone orientation following general anesthesia. Shoulder and head support braces were employed, and standard sterilization and draping procedures were performed. An incision was made at the midpoint of the posterior neck to provide complete exposure of the bilateral laminae spanning from C3 to C7. The lamina exhibiting severe symptoms was designated as the \"open-door\" side. Bone grooves, positioned 3mm from the inner edge of the bilateral lamina, were created using a grinding drill. Subsequently, the lamina was efficiently opened, progressing from the cortical bone to the dural sac. In the contralateral lamina, the V-shaped bone groove was used as the hinge on the side of the door shaft, and the lamina was lifted to the side of the door shaft. Titanium miniplates of suitable dimensions were chosen to secure the spinous processes and laminae of C4 and C6, followed by reinforcement using self-tapping screws. After drilling the root of the spinous process of C3, C5 and C7, the suture was used to pass through the bone hole and fixed at the upper hole of the spinous process fixation part of the adjacent C4 or C6 titanium miniplate to form an oblique upward pulling force (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). After irrigating the incision, the excess bone was implanted into the bone groove on the side of the C3-C7 door shaft and around the facet joint, and the facet joint was covered with gelatin sponge to the back of the lamina. Finally, the incision was sutured and the operation was completed. Postoperatively, patients underwent follow-up evaluations at 1 month, 3 months, and 6 months. Subsequently, annual follow-up assessments were conducted for a minimum of 1 year.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Clinical evaluation\u003c/h2\u003e \u003cp\u003ePreoperative, 3-month postoperative, and final follow-up assessments of spinal cord function were conducted using the Japanese Orthopaedic Association (JOA) spinal cord score. The rate of neurological function improvement was determined using the formula: Recovery Rate (%) = (Postoperative JOA - Preoperative JOA) / (17 - Preoperative JOA) \u0026times; 100%\u003csup\u003e11\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eFrom the postoperative period to the final follow-up, all patients were monitored for axial symptoms. The primary indications included neck and back pain, often accompanied by soreness, distension, and stiffness. Neck pain symptoms were assessed using the visual analog scale (VAS), with a VAS score\u0026thinsp;\u0026gt;\u0026thinsp;3 indicative of the presence of axial symptoms\u003csup\u003e12\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Imaging evaluation outcomes\u003c/h2\u003e \u003cp\u003eDuring preoperative and final follow-up evaluation, C2 to C7 was measured by Cobb method to evaluate cervical curvature angle (CCA) on lateral cervical radiographs and cervical range of motion (ROM) on flexion-extension dynamic cervical radiographs​\u003csup\u003e13\u0026ndash;15\u003c/sup\u003e. The effective sagittal diameter (ESD) and the effective narrowest area (ENA) of the spinal canal were quantified using preoperative CT scans, as well as at the 3-month postoperative and final follow-up (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Statistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was conducted using SPSS 26.0 software. Count data were presented as percentages (%), while measurement data were reported as (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\overline{X}\\)\u003c/span\u003e\u003c/span\u003e\u0026plusmn; SD). Statistical significance was determined using Student's t-test and repeated measures analysis of variance. Differences were considered statistically significant at P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"3 Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Clinical evaluation outcomes\u003c/h2\u003e \u003cp\u003eThere was a significant difference in JOA score at 3 months after surgery and at the final follow-up compared with that before surgery. The JOA score at the final follow-up was better than that at 3 months after surgery, and the difference was statistically significant (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The improvement rate of neurological function at the final follow-up was 75.29% \u0026plusmn;14.79%.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of preoperative and postoperative JOA, VAS, ESD and ENA results\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreop\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 months postop\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFinal follow-up\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eF value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJOA score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e8.79\u0026thinsp;\u0026plusmn;\u0026thinsp;1.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e13.75\u0026thinsp;\u0026plusmn;\u0026thinsp;1.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e14.87\u0026thinsp;\u0026plusmn;\u0026thinsp;1.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e164.119\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e5.25\u0026thinsp;\u0026plusmn;\u0026thinsp;1.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e2.42\u0026thinsp;\u0026plusmn;\u0026thinsp;1.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e1.29\u0026thinsp;\u0026plusmn;\u0026thinsp;1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e110.305\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eESD (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e6.25\u0026thinsp;\u0026plusmn;\u0026thinsp;1.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e10.58\u0026thinsp;\u0026plusmn;\u0026thinsp;1.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e10.32\u0026thinsp;\u0026plusmn;\u0026thinsp;1.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e555.179\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eENA (mm\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e96.46\u0026thinsp;\u0026plusmn;\u0026thinsp;23.467\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e212.38\u0026thinsp;\u0026plusmn;\u0026thinsp;30.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e207.71\u0026thinsp;\u0026plusmn;\u0026thinsp;31.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e493.122\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eData are expressed in \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\overline{X}\\)\u003c/span\u003e\u003c/span\u003e \u0026plusmn; \u003cem\u003eSD\u003c/em\u003e.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eJOA, Japanese Orthopaedic Association; VAS, visual analog scale; ESD, the effective sagittal diameter; ENA, the effective narrowest area; Preop, preoperative; Postop, postoperative.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eVAS score at 3 months after surgery and at the final follow-up were significantly better than preoperative score (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and VAS score at the final follow-up were better than at 3 months after surgery (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). By 3 months after surgery, 7 patients had developed axial symptoms (29.2%, 7/24), which were treated with NSAIDs. By the time of the final follow-up, most of the patients' symptoms had resolved, except for one patient who still had residual axial pain.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of preoperative and postoperative CCA and ROM results\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreop\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFinal follow-up\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003et value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCCA (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e18.64\u0026thinsp;\u0026plusmn;\u0026thinsp;5.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e17.55\u0026thinsp;\u0026plusmn;\u0026thinsp;5.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.730\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.469\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eROM (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e35.33\u0026thinsp;\u0026plusmn;\u0026thinsp;6.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e37.73\u0026thinsp;\u0026plusmn;\u0026thinsp;5.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.347\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.730\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eData are expressed in \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\overline{X}\\)\u003c/span\u003e\u003c/span\u003e \u0026plusmn; \u003cem\u003eSD\u003c/em\u003e.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eCCA, Cervical curvature angle; ROM, range of motion\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Imaging evaluation outcomes\u003c/h2\u003e \u003cp\u003eThe results of CCA and ROM measured postoperatively on cervical lateral radiographs were similar to those preoperatively, and the differences were not statistically significant (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). At the last follow-up, the patient was still able to maintain CCA and ROM approximating the preoperative level at the final follow-up.\u003c/p\u003e \u003cp\u003eThe ESD and ENA of the spinal canal measured on CT at 3 months postoperatively and at the final follow-up were significantly better than preoperatively (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and the difference was not statistically different during the postoperative follow-up (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). This shows that the fixing method we use is reliable, and there is no rebound or reclosing on the open side of the door.\u003c/p\u003e \u003c/div\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eCervical Ossification of the Posterior Longitudinal Ligament (OPLL) is a prevalent condition in spinal surgery. OPLL reduces the effective cervical spinal canal volume, resulting in pressure on the dura mater or nerve roots, leading to lower limb weakness and a sensation of walking on cotton. Expansive laminoplasty procedures, including posterior unilateral open-door decompression and cervical laminectomy with screw-rod internal fixation, are the primary treatments for symptomatic OPLL. Compared to the latter, unilateral open-door decompression offers advantages such as shorter operation times, reduced bleeding, and improved range of motion (ROM) and physiological cervical curvature\u003csup\u003e16\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003ePosterior unilateral open-door laminoplasty for the cervical spine has been widely adopted by spinal surgeons since its initial introduction in 1977\u003csup\u003e3\u003c/sup\u003e. However, initial procedures presented certain challenges, including postoperative axial pain and door reclosure. The occurrence of door reclosure can be as high as 34%, significantly impacting the outcomes of the procedure\u003csup\u003e17\u003c/sup\u003e. To address door reclosure, a solution involves utilizing a suture suspension method. This method entails suturing and securing the spinous process to surrounding soft tissues such as the facet joint capsule. Nevertheless, this approach has limitations, including unreliable fixation, substantial damage to the joint capsule and surrounding soft tissues, and a relatively high reclosure rate\u003csup\u003e18\u003c/sup\u003e. Subsequently, O'Brien\u003csup\u003e19\u003c/sup\u003e introduced the concept of a rigid door shaft, emphasizing the significance of reliable fixation to prevent door reclosure. This involved implanting autogenous bone particles into the interlaminar space on the door shaft side after screw fixation, promoting bone healing. Although this method reduced the incidence of reclosure, it lacked fixed support on the door side, leading to potential issues such as door shaft fracture, reclosure, and epidural scar adhesion, resulting in dural compression. In 2004, Heller et al\u003csup\u003e20\u003c/sup\u003e proposed the use of titanium miniplate internal fixation, which involved placing a titanium miniplate at the junction of the open-door side to ensure reliable fixation. This approach allowed patients to engage in early functional exercises while wearing a neck brace, significantly reducing the risk of door reclosure or a decrease in door angle following surgery. Consequently, due to its dependable fixation, titanium miniplates have become extensively utilized in posterior unilateral open-door decompression of the cervical spine.\u003c/p\u003e \u003cp\u003eIn previous posterior cervical surgeries, we observed that certain patients had smaller C3 lateral mass and spinous process sizes compared to those below them. This situation, compounded by the presence of osteoporosis, could result in issues with unstable screw fixation during surgery. Furthermore, the use of titanium miniplates to fix the entire C3 to C7 segment, while providing increased stability and reliability, can substantially increase the economic burden on patients due to the high cost of titanium miniplates. Currently, various scholars have proposed different recommendations regarding the specific quantity and placement of titanium miniplates following posterior unilateral open-door decompression of the cervical spine. Ji et al\u003csup\u003e21\u003c/sup\u003e found no significant difference in therapeutic efficacy between intermittent fixation of C3, C5, and C7 and continuous fixation of C3 to C7. However, concerning operation time, intraoperative blood loss, and operational costs, three titanium miniplates proved superior to five titanium miniplates. In our study, we found that the open-door side could be reliably stabilized during the operation by placing titanium miniplates and screws in C4 and C6, followed by lifting and securing them through sutures of adjacent spinous processes. Additionally, in the comparison between the results at 3 months post-surgery and the final follow-up, we identified no statistically significant differences in the effective sagittal diameter and the effective area of the cervical canal. Thus, controversy persists regarding the location and quantity of intermittent titanium miniplate fixations.\u003c/p\u003e \u003cp\u003eTo alleviate the financial burden on patients and address the issue of C3 anatomical characteristics, we performed segmental decompression and fixation from C3 to C7 for individuals with OPLL. After exposing the adjacent spinous processes of C3, C5, and C7, we created holes at the root of the spinous processes. Non-absorbable sutures were then passed through these bone holes and lifted obliquely before being secured to the C4 and C6 titanium miniplates. Intraoperatively, we observed that the fixation of the door shaft was reliable. Subsequent follow-up revealed that the door on the open side remained open during the cervical CT scans performed 3 months after surgery and at the final follow-up. Furthermore, bony fusion was observed in the slots on the side of the open door during the 3-month reexamination. At the last follow-up, the cervical curvature angle (CCA) and range of motion (ROM) of the cervical vertebrae from C2 to C7 did not significantly differ from their pre-surgery values. Additionally, the measurements of effective sagittal diameter (ESD) and effective narrowest area (ENA) of the cervical spinal canal taken before surgery remained stable throughout the follow-up period. This highlights the effectiveness of the intermittent fixation technique using only C4 and C6 titanium miniplates combined with sutures on adjacent spinous processes for stabilization and fixation. In fact, this approach has demonstrated superiority over the use of 3 or 5 titanium miniplates, particularly in some respects\u003csup\u003e21\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAxial pain is a common complication following posterior unilateral open-door cervical vertebrae surgery, with numerous contributing factors. Literature reports suggest that factors such as postoperative cervical stability, ROM, damage to cervical facet joints caused by internal fixation materials, and injury to the cervical posterior ligament complex may underlie axial pain\u003csup\u003e22\u0026ndash;25\u003c/sup\u003e. In our study, although we limited the use of titanium miniplates to C4 and C6 to minimize facet joint damage, some patients still experienced postoperative axial pain. Furthermore, seven patients exhibited varying degrees of posterior cervical stiffness and axial pain three months after surgery. We suspect that prolonged cervical brace use and intraoperative soft tissue manipulation may be contributing factors. We provided instructions for patients to use non-steroidal analgesics and engage in appropriate cervical exercises, leading to significant relief in six patients. However, one patient did not experience satisfactory pain relief, and we plan to conduct further follow-up in subsequent studies.\u003c/p\u003e \u003cp\u003eThis study has certain limitations. The small sample size and the relatively short duration of follow-up necessitate continued observation to determine whether reclosure of the open-door side becomes an issue over an extended follow-up period. Furthermore, in real-world clinical practice, not all patients are suitable candidates for the use of titanium miniplates in conjunction with adjacent spinous process sutures. Decision-making should be individualized and based on each patient's specific circumstances.\u003c/p\u003e"},{"header":"5 Conclusion","content":"\u003cp\u003eThis study provides valuable insights into the clinical efficacy of intermittent titanium miniplate usage in conjunction with adjacent spinous process sutures in the unilateral open-door posterior cervical approach. This technique emerges as a viable treatment option for cervical spondylosis, offering benefits not only in terms of cost reduction for patients but also in achieving positive clinical outcomes, including pain relief, neurological improvement, and radiological stability.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eZ.S. and S.YJ. did the study, analyzed the data, and wrote the manuscript. W.GA. was responsible for drawing. Q.S., L.C., F.S. and Y.F. were involved in the design, data management, and analysis of the study. F.S. and Y.F. made significant contributions to the conception and design of the study, and critically revised the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eTsuyama, N. Ossification of the posterior longitudinal ligament of the spine. Clin. 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Axial symptoms after conventional and modified laminoplasty: a meta-analysis. World Neurosurg. S1878-8750(23)01354\u0026ndash;2 (2023) doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.wneu.2023.09.086\u003c/span\u003e\u003cspan address=\"10.1016/j.wneu.2023.09.086\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi, F. H. \u003cem\u003eet al.\u003c/em\u003e Incidence and Outcomes of C5 Palsy and Axial Pain After Open-Door Laminoplasty or Laminectomy and Fusion: A Meta-Analysis. World Neurosurg. 128, e1002\u0026ndash;e1009 (2019).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOno, A. \u003cem\u003eet al.\u003c/em\u003e The relationship between the anatomy of the nuchal ligament and postoperative axial pain after cervical laminoplasty: cadaver and clinical study. Spine 37, E1607-1613 (2012).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"ossification of the posterior longitudinal ligament, open-door laminoplasty, axial symptoms, cervical curvature","lastPublishedDoi":"10.21203/rs.3.rs-3926218/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3926218/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThis study aimed to assess the clinical effectiveness of using intermittent titanium miniplates at C4 and C6 in conjunction with adjacent spinous process sutures for lifting and fixation during posterior cervical unilateral open-door laminoplasty.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe retrospectively analyzed the clinical data of 24 patients with ossification of the posterior longitudinal ligament who underwent this surgery. We assessed the Japanese Orthopaedic Association (JOA) score, visual analog scale (VAS) score, and the incidence of axial symptoms preoperatively. Additionally, we measured cervical curvature angle (CCA), range of motion (ROM), effective sagittal diameter (ESD), and the effective narrowest area (ENA) of the spinal canal both before and after surgery. All patients were followed up for a minimum of 1 year.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAt the final follow-up, significant improvements were observed in JOA scores and VAS scores compared to preoperative values. There was a significant improvement in postoperative ENA and ESD. There were no statistically significant differences in CCA and ROM at the final follow-up compared to preoperative values. Axial symptoms developed in 7 cases (29.2%, 7/24) postoperatively.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eIntegrating spinous process sutures with intermittent titanium miniplates not only reduces patient costs but also improves clinical outcomes in posterior unilateral open-door decompression of cervical laminae.\u003c/p\u003e","manuscriptTitle":"Novel Approach in Posterior Cervical Laminoplasty: Integrating Spinous Process Sutures with Intermittent Titanium Miniplates","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-16 16:40:57","doi":"10.21203/rs.3.rs-3926218/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"98f38e15-2b19-4df1-8a0a-ac1c948eca39","owner":[],"postedDate":"February 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":28789195,"name":"Health sciences/Diseases"},{"id":28789196,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2024-05-06T07:34:20+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-16 16:40:57","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3926218","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3926218","identity":"rs-3926218","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}