The Spine Journal 9 (2009) 426–430

Letters to the Editor

Laminoplasty: a review of its role in compressivecervical myelopathy

To the Editor:

I have read the article by Hale et al. [1] with great interest.I want to applaud the authors’ great work in organizing theavailable literature into a logical and clear article. However,I would like to differ from the authors regarding the open-door laminoplasty procedure, in that it is better not to re-move the spinous processes during a classic open-doorlaminoplasty.

Expansive open-door laminoplasty refers to theHirabayashiexpansive open-door laminoplasty reported by Hirabayashiet al. in 1981 [2]. In the review of Hale et al., they demonstratedthis procedure in four steps: (1) after the spinous processes areremoved; (2) bone troughs are created at both laminae-lateralmass junctions using a high-speed burr; (3) the trough is left in-complete on the contralateral side; and (4) the hemi-lamina iselevated and fixed to the ipsilateral facet or surrounding muscu-lature with sutures, maintaining patency of the canal. The pro-cedure is indicated in Fig. 1 of Hale et al.’s article [1]. This wasthe method described initially [2,3]; however, it is not necessar-ily the current practice for a standard Hirabayashi expansiveopen-door laminoplasty according to recent literature and clin-ical practice, especially regarding spinous process removal.The procedure has evolved or improved, and is accepted bymost spine surgeons nowadays. Hirabayashi et al. [4] docu-mented four key points for open-door laminoplasty in 1999.One of these points is the preservation of the supraspinousand interspinous ligaments together with the spinous processesto maintain cervical lordosis, which play an important role inposterior decompression surgery in making dorsal shift of thespinal cord effective. If the spinous process is removed, itmay be difficult for surgeons to preserve the supraspinous lig-ments and prevent the slippage and loosening of sutures aroundthe spinous process and adjacent joint capsules because of thelimited length left after removal of the process. The slippageand loosening of sutures may inevitably result in spring-backor closure of the open-door and cervical restenosis. This opin-ion is also recommended by other authors [5].

References

[1] Hale JJ, Gruson KI, Spivak JM. Laminoplasty: a review of its role in

compressive cervical myelopathy. Spine J 2006;6(6 Suppl):289S–98S.

[2] Hirabayashi K, Miyagawa J, Satomi K, Maruyama T, Wakano K.

Operative results and postoperative progression of ossification among

1529-9430/09/$ – see front matter � 2009 Elsevier Inc. All rights reserved.

patients with ossification of cervical posterior longitudinal ligament.

Spine 1981;6:354–64.

[3] Hirabayashi K, Watanabe K, Wakano K, Suzuki N, Satomi K, Ishii Y.

Expansive open-door laminoplasty for cervical spinal stenotic myelop-

athy. Spine 1983;8:693–9.

[4] Hirabayashi K, Toyama Y, Chiba K. Expansive laminoplasty for mye-

lopathy in ossification of the longitudinal ligament. Clin Orthop Relat

Res 1999;359:35–48.

[5] Steinmetz MP, Resnick DK. Cervical laminoplasty. Spine J 2006;6(6

Suppl):274S–81S.

Hai-Qiang Wang, MDXi’an, People’s Republic of China

doi:10.1016/j.spinee.2008.07.009

Reply:

We would like to thank Dr. Wang for his generally positivecomments regarding our review article on the role of cer-vical laminoplasty in the surgical treatment of compressivecervical myelopathy. We certainly agree that our Figure 1,representing the ‘‘Hirabayashi-type’’ (open-door) lamina-plasty is based on the initial description of the procedure.It is reprinted from a previous critical review of lamina-plasty, including the figure legend. In the text of the article,we do note that ‘‘Hirabayashi advocated stay sutureswithin the spinous process and paraspinal muscles.,’’but we agree that we could have been more descriptiveof his later modification within the text. It should also benoted that, to the best of our knowledge, this later modifi-cation is based on expert opinion and personal experience,not on any evidence-based comparison of techniques andmodifications.

The purpose of our article was to present the two ba-sic canal opening techniques and their clinical results,not to be specific regarding each modification of bothtypes of procedures. As an example, many plate applica-tions have been described, with or without interveningbone graft, skipping levels, etc, and the description ofeach of these various modifications were considered be-yond the scope and purpose of the review. Some sur-geons performing the open-door technique still prefer toremove the bulk of the spinous process, regardless ofthe method of open-door fixation, to decrease the dead-space created by the laterally displaced spinous pro-cesses. Definite clinical benefit of retention of the inter-spinous and supraspinous tissues (more muscle thanligament) is yet to be shown.