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Laminoplasty alone as surgical treatment is contraindicated in patients with rigid cervical kyphosis of > 13 degrees as shown in Figure D. When evaluating patients with cervical myelopathy, it is critical to evaluate the sagittal alignment of the cervical spine. This is best done on lateral cervical spine films in neutral, flexion, and extension. By obtaining flexion and extension films, one can determine if the kyphotic deformity is rigid or not. Two angles should be measured, the C2-7 kyphotic angle, and the local kyphotic angle. If patients have significant kyphosis, the spinal cord is draped over the anterior compressive elements, and a posterior approach alone, such as a laminoplasty, is not effective. Suda et al. showed that local kyphosis was the most crucial risk factor for poor surgical outcomes with laminoplasty alone. They recommend when patients have local kyphosis exceeding 13 degrees, anterior decompression should be performed with an attempt to correct the deformity, followed by posterior decompression in some cases. Expansive laminoplasty alone should be avoided in patients with local kyphosis greater than 13 degrees. Chiba et al. reviewed the long-term results of open-door laminoplasty for cervical myelopathy in patients with ossification of the posterior longitudinal ligament. They found patients with preoperative kyphosis had lower recovery rates than those with straight and lordotic alignments. Illustration A and B show the methodology of how to measure the C2-C7 kyphotic angle and the local kyphosis angle. The C2-7 angle is determined by tangential lines on the posterior edge of the C2 and C7 body on lateral radiographs in neutral position. The local kyphosis angle is determined by tangential lines on the posterior edge of the vertebral bodies that flank the kyphotic segment. Illustration C shows the treatment algorithm of cervical myelopathy. Incorrect Answers: Answer 1, 2, 3, 5: The mainstay of treatment in most patients with multi-level disease would be laminectomy with posterior fusion (if kyphosis is <10 degree) or a combined anterior and posterior approach (if kyphosis is >10 degrees).
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