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15 May 2024: Clinical Research  

Comparative Analysis of Postoperative Sagittal Balance in Expansive Open-Door Laminoplasty versus Laminectomy with Fusion for Multilevel Ossification of Posterior Longitudinal Ligament: A Retrospective Study

Xudong Ma12ABCDEF, Zhen Yu3BC, Duoyue Wu4CDE, Yan Huang1ABCDEF*

DOI: 10.12659/MSM.943057

Med Sci Monit 2024; 30:e943057




BACKGROUND: This single-center study included 80 patients with multilevel cervical ossification of the posterior longitudinal ligament (OPLL) and aimed to compare postoperative sagittal balance following treatment with expansive open-door laminoplasty (LP) vs total laminectomy with fusion (LF).

MATERIAL AND METHODS: Data of 80 patients with multilevel OPLL treated with LP vs LF between January 2017 and January 2022 were retrospectively analyzed. The basic data, cervical sagittal parameters, and clinical outcomes of the patients were counted in the preoperative and postoperative periods, and complications were recorded. Forty patients underwent LP and 40 underwent LF. Cervical sagittal parameters were compared between and within the 2 groups. Clinical outcomes and complications were compared between the 2 groups.

RESULTS: At last follow-up, the postoperative C2-C7 Cobb angel, T1 slope (T1S), and C7 slope (C7S) were significantly higher in the LF group than in the LP group (P<0.001). C2-C7 SVA (cSVA) was slightly higher in the LF group (P>0.05) and significantly higher in the LP group (P<0.05). The incidence of postoperative complications in the LP group was significantly lower than in the LF group (P=0.02). The postoperative scores on the Visual Analog Scale (VAS), Neck Disability Index (NDI), and Japanese Orthopedic Association (JOA) were significantly improved in both groups (P<0.001).

CONCLUSIONS: Both procedures had good outcomes in neurological improvement. After posterior surgery, the cervical vertebrae all showed a tilting forward. Compared to LP, LF may change cervical balance in Cobb angel, T1S. LF has better efficacy in improving cervical lordosis compared with LP. Patients with high T1 slope after surgery may has more axial pain.

Keywords: Cervical Vertebrae, Spinal Canal, Neurosurgery


The posterior longitudinal ligament starts from the dorsal aspect of the C2 vertebrae, and its main function is to protect the stability of the cervical spine from excessive flexion and extension activities [1]. The pathophysiological basis of ossification posterior longitudinal ligament (OPLL) is the proliferation of spindle cells that produce collagenous fibers, which accumulate over time and finally become bone [2]. The diagnosis of multilevel OPLL is defined as ossification of more than 3 segments on imaging. The pathogenesis of OPLL is unclear, and epidemiology shows that family inheritance is a major factor leading to development of OPLL [3]. Studies [4–7] have shown that OPLL has a male-to-female ratio of 2: 1 to 3: 1 and is most common in people 50–60 years old, with a 15–20% prevalence of spinal disorders in the 60+ age group. Progression of OPLL often involves progressive neurological deterioration and typical symptoms of nerve compression, such as numbness and loss of muscle strength in the limbs [8,9]. For those who fail to undergo conservative treatment, we generally recommend surgical treatment, but the best surgical approaches are still debatable [10].

Anterior and posterior procedures have been utilized for treatment of OPLL [11,12]. Anterior surgery, which directly remove the ossified posterior longitudinal ligament to achieve decompression, seem to be a curative solution. Nevertheless, when involving more than 3 ossified segments, anterior surgery is more challenging to address the ossification and tends to alter the balance of the cervical spine, contributing to cervical instability and pseudoarthrosis development [13,14]. Posterior surgery is commonly used for treating multilevel OPLL due to its greater simplicity and safety [12]. The main posterior procedures are expansive open-door laminoplasty (LP) and total laminectomy with fusion (LF). Both procedures have their own advantages and disadvantages. LP is more effective in relieving neurological symptoms and protecting cervical mobility [11]. Ma et al [15] found that LF has more advantages in improving cervical lordosis, even with a higher rate of neck pain after LF.

Exploration of the cervical balance is ongoing, and it is a necessary factor in maintaining a natural curve [16,17]. Cervical imbalance can lead to development of clinical symptoms such as neck pain, and can affect spinal cord drift [18]. Some researchers [18–20] have suggested that increased C2–C7 SVA (cSVA) and T1 slope (T1S) are associated with poor neurological function. Nonetheless, studies on changes in cervical balance in patients with multilevel OPLL who have undergone LF and LP treatments are lacking.

Therefore, this retrospective study from a single center included 80 patients with multilevel cervical OPLL and aimed to compare postoperative sagittal balance following treatment with LP vs LF from January 2017 to January 2022.

Material and Methods


The First Affiliated Hospital of University of Science and Technology of China’s Ethics Committee approved the study (approval No. 2023-RE-034). This study complied with the ethical standards of the Declaration of Helsinki. Informed consent was waived as this study was retrospective.


We retrospectively examined patients who underwent LP (n=65) or LF (n=75) therapy between January 2017 and January 2022. Patients in the study were (1) those with a combination of mixed and segmental imaging of OPLL, (2) those with ossification lesions of more than 3 levels, (3) those with preoperative C2–C7 Cobb angle on lateral X-ray ranging from 10° to 20°, and (4) those with K-line (+) follow-up. Exclusion criteria were kyphosis or severe neck pain, fractures, malignancy, and thoracic OPLL. Thus, 80 patients were included in this retrospective matched cohort analysis, 40 of whom underwent LP and 40 of whom underwent LF. All major complications following surgery were recorded in each cohort. Some minor complications (eg, constipation, electrolyte imbalance) were not documented.


In this study, 40 patients with a average of 61.3±1.4 years of age underwent LP surgery (26 males and 14 females) with devices such as connecting rods and screws supplied by Beijing FULE Technology Development Company. A total of 40 patients (29 men and 11 women), averaging 59.5±1.6 years in age, underwent LF surgery using the Y-type plate and screws supplied by Beijing FULE Technology Development Company.

: Patients were in a prone position with cranium upwards 30 degrees (Figure 2A). In sequence, the vertebral lamina was exposed. The side with the worst symptoms was the open side and the other was the hinge side, severing the spinous process to prevent open laminae from closing again. On the open side (Figure 2B), we used a thin rongeur to cut off the vertebral plate along the medial pedicle, showing the dura, so that the spinal canal was enlarged. On the hinge side (Figure 2C), a grinding drill was applied to remove the cortical bone along the lateral margin of the lamina, which formed the shape of the bone groove and left only the cancellous bone and inner cortex. After removing yellow ligaments, laminae were pushed laterally towards the hinge side to create an “open door” and then fixed with a Y-shaped plate (Figure 2D). To determine satisfactory screw placement, C-arm machine fluoroscopy was used. The width of the opening door was approximately 12 mm, which was enough to obtain sufficient space for spinal cord drift. Later, a negative-pressure drain was placed, the incision was closed, and the area was fasten with a neck brace for 3 months.

: Under anesthesia in the prone position (Figure 2A), the lamina and lateral joints were exposed. The pre-curved rods and screws were put in place (Figure 2E). To assess internal fixation and to determine satisfactory screw placement, C-arm machine fluoroscopy was used. The lamina was excised to fully expose the dural sac (Figure 2F). Drainage remained positioned, and the incision was sealed with tiered sutures. A cervical brace was used to immobilize for 3 months.


The intensity of pain was evaluated using the Visual Analog Scale (VAS). The Neck Disability Index (NDI) and Japanese Orthopedic Association (JOA) scores were used to measure neurological function before the operation and at the final visit.


Lateral cervical X-ray images was taken for each patient to evaluate cervical sagittal balance. Two orthopedic surgeons not involved in the study measured 4 parameters related to cervical sagittal balance (Figure 4):

The mean values of the measurements were documented.


Counting postoperative complications, the criteria for axial pain are shown in Table 1.


Data were analyzed using SPSS 26.0 for Windows (IBM Corporation, Chicago, IL, USA). All values for the continuous variables were expressed as mean±standard deviation. For continuous variables (eg, age, follow-up time, surgery time, blood loss), the t test was used to assess normally distributed data. For categorical variables, count data, including sex, types of ossification, axial pain, cerebrospinal fluid leakage, and cervical 5 nerve root palsy, were performed using the chi-square test.



Follow-up for a minimum of 24 months was completed by 80 patients, comprising 40 LP and 40 LF cases. The LP group experienced a volume of 84.0±5.3 ml of blood loss, while the LF group experienced 111.3±5.3 ml(P=0.02). On average, the mean duration of surgery in the LP group was 85.4±3.8 minutes, and it was 96.8±4.5 minutes in the LF group (P=0.08). There was no significant difference between LP and LF in terms of follow-up times (31.9 months vs 27.4 months), age, gender, operative segments, or ossification type (Table 2).


At the preoperative visit, there was no significant difference between the LP and LF cohorts in terms of the JOA, VAS, and NDI scores (P>0.05). However, both groups had significant improvements in the scores from preoperative to post-surgery (P=0.000) (Table 3).


None of the preoperative sagittal parameters were significantly different between the 2 groups (P>0.05) (Table 4).

C2–C7 Cobb angel: Comparisons between groups were statistically differences at the final follow-up (16.22±3.30 vs 22.56±3.19).

cSVA: No statistical significance was found between the 2 groups in the last follow- up (2.23±1.032 vs 2.11±1.02).

T1S: There was significant difference between LP and LF groups at the last follow-up (20.57±2.78 vs 23.95±3.49).

C7S: There was a significant difference between LP and LF groups at the last follow-up (18.29±2.51 vs 22.93±2.99).


In the LF cohort, the C2–C7 Cobb, T1 slope, and C7 slope increased significantly at the last follow-up, while there was no difference in the LP cohort (P>0.05). cSVA in the LP group was significantly higher than before surgery (P<0.05), but there was no significant change in the LF group (P>0.05).


A marked divergence (P=0.02) in complication rates between cohorts was observed. In the LP cohort, we recorded 4 complications, including neck pain (axial symptoms), C5 nerve palsy, progressive kyphosis, and revision surgery. Five patients (12.5%) in the LP cohort had neck pain, and 1 patient (2.5%) had C5 nerve palsy. One patient (2.5%) had been diagnosed with progressive kyphosis, and 1 patient (2.5%) underwent revision surgery (Table 5). There were 4 complications (45%) in the LF cohort. Fifteen of these (37.5%) were related to neck pain. Of these patients, 2.5% underwent revision surgery, while the remaining 2.5% were diagnosed with infection, with 1 (2.5%) suffering from C5 nerve palsy. The LP group’s axial symptom rate of 12.5% (5 out of 40) was significantly lower than that of the LF group (37.5%) (P=0.009) (Table 5).


For different types of OPLL, we can perform decompression through the anterior or posterior approaches [11,12,21]. Despite the anterior approach providing more direct decompression, the posterior approach is clinically recommended for the treatment of multilevel OPLL [22]. LP and LF are considered to be effective procedures for multilevel OPLL [23].

The purpose of LP and LF is to improve the neurological symptoms [22,23]. However, with deeper understanding, a growing body of literature emphasizes the importance of cervical balance, which has important implications for the prognosis of patients with OPLL [20,24,25]. In cervical physiologic alignment, decompression by the posterior approach can keep the spinal cord away from the compressed segments to achieve symptomatic relief. Loss of physiologic curvature can affect spinal cord drift toward the dorsal side, resulting in worse clinical symptoms [26,27]. Cervical lordosis not only maintains horizontal gaze, but also reduces the consumption of muscle strength and maintains the overall cervical balance [28]. Kyphosis is associated with poor neurological function, with degeneration of adjacent segments [25]. Therefore, preoperative patient selection and maintenance of postoperative cervical alignment can have a crucial impact on clinical results.

In our study, both groups had normal physiological curvature, with no significant difference before surgery, so the patients were appropriately matched. The LF cohort had greater improvement in lordosis than the LP cohort. This may benefit from the connecting rods of the LF, which not only maximizes the recovery of the cervical curvature, but also increases cervical stability. This is similar to the results of previous studies. Chen et al [29] found that laminectomy not only improved the degree of nerve compression and prognosis of patients, but also improved cervical lordosis. Lee et al [30] also found that the risk of kyphosis after laminectomy was not high, which increased the stability of the spine. The change of lordosis was not obvious after LP, mainly because LP only immobilizes the open side, which is less destructive to the overall osseous structure. Since the preoperative and postoperative Cobb angles were within the normal range, expanding the volume of the spinal canal by opening the door also allowed the spinal cord to drift, accomplishing indirect decompression and improving the patient’s clinical symptoms.

cSVA is used to indicate the cervical sagittal deviation. It can reflect the cervical functional status, and the larger cSVA, the worse the cervical function [31,32]. We found significantly increased cSVA values in both groups. Because of the damage to the posterior cervical column caused by the surgery, the cervical sagittal balance was disrupted. LF has stronger internal fixation than LP, which maximizes the maintenance of cervical lordosis and stability and protects the sagittal balance of the cervical spine. Tang et al [32] found that cSVA could affect the recovery of neurological function, and neurological function deteriorated when cSVA was ≥40 mm. In this study, no deterioration of neurological function occurred in the 2 groups of patients after surgery, probably because cSVA did not exceed 40 mm at the last visit.

T1S, which has been increasingly used to study the cervical sagittal balance, reflects the degree of cervicothoracic junction kyphosis, which is significantly correlated with C7S and C2–C7 Cobb angle [33]. The T1 vertebrae is the “base” of the entire cervical spine, and its shape and orientation have an effect on cervical lordosis. When T1S ≥25 or <13 degree, it is harder to maintain cervical sagittal balance [34]. The elevated T1S can cause a compensatory increase in cervical lordosis, which further leads to cervical imbalance and the need for patients to exert posterior cervical muscle strength to maintain horizontal gaze, thus affecting postoperative outcomes [20,35,36]. However, in this study, the preoperative and postoperative T1S or C7S in both groups were within the normal range, which had little effect on the overall cervical balance. The increased incidence of axial pain in the LF group may be related to the increased T1S due to the depletion of posterior cervical muscle strength.

A marked disparity in the complications of the 2 cohorts was observed. It has been suggested that because of the stripping of soft tissues and the greater amount of bleeding in LF, the rate of postoperative wound infection is higher in LF. The infection rate of LF in this study was 2.5%. Axial symptoms, a common complication of cervical spine surgery, often result in neck pain. Du et al. [37] proposed that maintaining the cervical spine’s natural curvature could reduce the risk of axial symptoms. In our research, we found that the occurrence rate of axial symptoms was 12.5% for LP and 37.5% for LF. As LP is less destructive to posterior tissues than LF, the more opportunity there is for muscle attachment to the bone, the more it may help to minimize postoperative axial pain.

It is crucial to realize a few limitations in this research. It was a retrospective, single-center study with a short follow-up period, and the surgical segments selected were C3–C6 and C3–C7 segments, ignoring the effect of different segments, which may have resulted in selection bias. Future studies should increase the sample size and have longer follow-up. Long-term comparisons of sagittal balance need to be made in double-blind controlled trials.


Both procedures showed good results in neurological improvement. After posterior surgery, the cervical vertebrae showed a tilting forward. Unlike LP surgery, LF can change cervical balance in Cobb angel and T1S. LF has better efficacy in improving cervical lordosis. Patients with high T1S after surgery tend to have more axial pain.


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