Orthopedic surgeons in Japan use laminoplasty to manage cervical myelopathy approximately 10 times more frequently than surgeons in the United States, who prefer anterior procedures, according to Byron Stephens, M.D., an associate professor in the Department of Orthopedic Surgery at Vanderbilt University Medical Center.
In a recent study, Stephens and Vanderbilt colleagues compared U.S. operative management strategies for cervical myelopathy versus that of Japan. Additionally, they measured the prevalence of laminoplasty in treating myelopathy in the U.S.
“Laminoplasties offer equally robust clinical outcomes as other surgical techniques, including laminectomy and fusion and anterior cervical discectomy and fusion (ACDF), in treating cervical myelopathy,” Stephens said. “It also offers several unique advantages, such as preserving cervical motion and avoiding fusion-related complications.”
Given these benefits, laminoplasty would be expected to become a more commonly performed surgery in America; however, as Stephens explained “failure to adopt laminoplasty into routine clinical practice should warrant further investigation into reasons why.”
Two National Datasets
The researchers reviewed a group of 16,084 patients from the American College of Surgeons National Surgical Quality Improvement Program database and 389,872 patients from the Japanese Diagnosis Procedure Combination database, examining records from 2007 to 2015.
Data was collected from patients with diagnoses of spondylosis with myelopathy or disk herniation with myelopathy. The proportion of surgeries performed in Japan versus the United States was then compared using linear regression modeling.
“Laminoplasties offer equally robust clinical outcomes as other surgical techniques. It also offers several unique advantages, such as preserving cervical motion and avoiding fusion-related complications.”
The researchers found that in the United States, ACDF was the most common procedure used to address cervical myelopathy and was performed on 9,864 patients, or 61 percent of the study population. In contrast, laminoplasty was the most performed surgery for cervical myelopathy in Japan, at 165,494 patients, or 43 percent. That compares to just 4 percent of United States study subjects undergoing laminoplasty for cervical myelopathy.
Significantly, the percentage of surgeries in each category remained steady over the eight-year period – even though overall numbers rose.
“One major reason for the discrepancy is a relative lack of training in the United States for laminoplasty, although this has been changing recently,” Stephens said. “Another reason is the cultural demand for non-fusion surgery in Japan, which I personally believe will grow in the U.S.”
Stephens also acknowledged that there are significant economic incentives for fusion surgeries in the United States, which could also contribute to the low rate of laminoplasty performed by United States surgeons.
“Increase in utilization will primarily come through educational efforts of training programs, but also through increased patient awareness.”
“Increase in utilization will primarily come through educational efforts of training programs, but also through increased patient awareness,” Stephens said. “Increasing reimbursement for laminoplasty, which is a more technically demanding procedure, would also even the playing field and create incentive to perform a surgery that has been shown to have equivalent or even better clinical outcomes to fusion.”
Solidifying the Benefits
Given the benefits of laminoplasty, the findings of this study should prompt orthopedic surgeons to examine their own practice to ensure that they are achieving optimal results for patients, and to prompt institutions to evaluate their training curriculum to ensure that trainees receive suitable exposure to laminoplasty.
“Longer-term follow-up studies demonstrating the durability of laminoplasty and potential reduction in symptomatic adjacent segment operation would be helpful in solidifying the benefit of this non-fusion surgical option,” Stephens concluded.