Effects of Cervical Paravertebral Extensors in Patients with Cervical Ossification of the Posterior Longitudinal Ligament Grouped According to mK-Line

Abstract

Objectives:: The objective of this study was to quantify the morphology, composition, and asymmetry of the paravertebral extensor muscles (PSEMs) in patients with cervical ossification of the posterior longitudinal ligament (OPLL) who had different modified K-line (mK-line) and the minimum interval between the mK-line and OPLL (INT_min) values and to investigate the relationship between PSEMs and symptoms and outcomes following laminoplasty. These original findings elucidated that the atrophy of PSEMs could predict decompression outcomes and provided a theoretical basis for paraspinal muscle rehabilitation.

Methods:: A total of 94 consecutive patients who underwent laminoplasty for OPLL between January 2020 and January 2022 were enrolled in this retrospective study. The relative cross-sectional areas (rCSA), functional cross-sectional areas (rFCSA), and FCSA/CSA ratio of the multifidus (MF), semispinalis cervicalis (SSCe), semispinalis capitis (SSCa), and splenius capitis (SpCa) were measured at the C3–C7 segments on cervical magnetic resonance imaging (MRI). This study compared the differences between the mK-line (+) group and the mK-line (−) group, as well as between the INT_min <4 mm group and the INT_min ≥4 mm group, using the independent t-test or Mann–Whitney test for continuous variables and the χ²-test for categorical variables. The correlations between the PSEMs and symptoms were analyzed using either the Pearson or Spearman correlation coefficient.

Results:: The relative total CSA (rTCSA) of the PSEMs, especially the MF, was significantly smaller in the mK-line (−) group. However, the FCSA/CSA of the right deep extensor muscle (DEM) was larger. The asymmetry of the MF TFCSA/TCSA showed a significant difference between the mK-line groups. In the INT_min <4 mm group, the PSEMs rCSA and rFCSA were significantly smaller, while the bilateral MF TFCSA/TCSA and right SSCe TFCSA/TCSA were larger. The asymmetry of the superficial extensor muscle rCSA was significantly lower in the group with INT_min <4 mm. The postoperative modified Japanese Orthopedic Association score (mJOA) and mJOA recovery rate were positively correlated with the INT_min and DEM rCSA and negatively correlated with the asymmetry of MF FCSA/CSA.

Conclusions:: In patients with mK-line (−) or INT_min <4 mm, the PSEMs were smaller, and the DEM atrophy and composition changes were predominant. The MF asymmetry was higher in patients with mK-lines (−), whereas the SEM atrophy and asymmetry were more prevalent in patients with INT_min <4 mm. The DEM was related to the preoperative and postoperative mJOA scores. DEM-preserving surgery or DEM-specific rehabilitation exercises can improve the recovery of patients with OPLL during the perioperative period. In addition, attention should be paid to the evaluation of the SEM, especially the SpCa at the C3 and C5 levels.

Keywords

Laminoplasty / mK-line / Muscle Atrophy / OPLL / Paravertebral Extensor Muscles

References

[1] Matsunaga S, Sakou T. Ossification of the posterior longitudinal ligament of the cervical spine: etiology and natural history. Spine (Phila Pa 1976). 2012;37(5):E309–E314.

[2] An HS, Al-Shihabi L, Kurd M. Surgical treatment for ossification of the posterior longitudinal ligament in the cervical spine. J Am Acad Orthop Surg. 2014;22(7):420–429.

[3] Taniyama T, Hirai T, Yamada T, Yuasa M, Enomoto M, Yoshii T, et al. Modified K-line in magnetic resonance imaging predicts insufficient decompression of cervical laminoplasty. Spine (Phila Pa 1976). 2013;38(6):496–501.

[4] Taniyama T, Hirai T, Yoshii T, Yamada T, Yasuda H, Saito M, et al. Modified K-line in magnetic resonance imaging predicts clinical outcome in patients with nonlordotic alignment after laminoplasty for cervical spondylotic myelopathy. Spine (Phila Pa 1976). 2014;39(21):E1261–E1268.

[5] Hirai T, Yoshii T, Inose H, Yuasa M, Yamada T, Ushio S, et al. Is modified K-line a powerful tool of surgical decision making for patients with cervical Spondylotic myelopathy? Clin Spine Surg. 2019;32(9):351–356.

[6] Bajouri Z, Telang S, Fresquez Z, Kim M, Gilbert Z, Pickering T, et al. Evaluating changes to the modified K-line using kinematic MRIs. Spine. 2023;48(12):859–866.

[7] Duan Q, Liang G, Chen C, Ye Y, Zheng X, Liang C, et al. Accuracy of realigned K-line for predicting surgical outcomes after Laminoplasty in patients with degenerative cervical myelopathy. Global Spine J. 2023;21925682221150908:1–10.

[8] Moisey LL, Mourtzakis M, Cotton BA, Premji T, Heyland DK, Wade CE, et al. Skeletal muscle predicts ventilator-free days, ICU-free days, and mortality in elderly ICU patients. Crit Care. 2013;17(5):R206.

[9] Cruz-Jentoft AJ, Sayer AA. Sarcopenia. Lancet. 2019;393(10191):2636–2646.

[10] Abbott R, Pedler A, Sterling M, Hides J, Murphey T, Hoggarth M, et al. The geography of fatty infiltrates within the cervical multifidus and semispinalis cervicis in individuals with chronic whiplash-associated disorders. J Orthop Sports Phys Ther. 2015;45(4):281–288.

[11] Fortin M, Dobrescu O, Courtemanche M, Sparrey CJ, Santaguida C, Fehlings MG, et al. Association between Paraspinal muscle morphology, clinical symptoms, and functional status in patients with degenerative cervical myelopathy. Spine (Phila Pa 1976). 2017;42(4):232–239.

[12] Fortin M, Wilk N, Dobrescu O, Martel P, Santaguida C, Weber MH. Relationship between cervical muscle morphology evaluated by MRI, cervical muscle strength and functional outcomes in patients with degenerative cervical myelopathy. Musculoskelet Sci Pract. 2018;38:1–7.

[13] Doi T, Ohtomo N, Oguchi F, Tozawa K, Nakarai H, Nakajima K, et al. Association between deep posterior cervical Paraspinal muscle morphology and clinical features in patients with cervical ossification of the posterior longitudinal ligament. Global. Spine J. 2023;13(1):8–16.

[14] Boyd-Clark LC, Briggs CA, Galea MP. Muscle spindle distribution, morphology, and density in longus colli and multifidus muscles of the cervical spine. Spine (Phila Pa 1976). 2002;27(7):694–701.

[15] Elliott JM, Cornwall J, Kennedy E, Abbott R, Crawford RJ. Towards defining muscular regions of interest from axial magnetic resonance imaging with anatomical cross-reference: part II – cervical spine musculature. BMC Musculoskelet Disord. 2018;19(1):171.

[16] Charest-Morin R, Street J, Zhang H, Roughead T, Ailon T, Boyd M, et al. Frailty and sarcopenia do not predict adverse events in an elderly population undergoing non-complex primary elective surgery for degenerative conditions of the lumbar spine. Spine J. 2018;18(2):245–254.

[17] Naghdi N, Elliott JM, Weber MH, Fehlings MG, Fortin M. Morphological changes of deep extensor neck muscles in relation to the maximum level of cord compression and canal compromise in patients with degenerative cervical myelopathy. Global Spine J. 2022;21925682221136492:1–9.

[18] Gu Y, Wang C, Hu J, Chen Y, Yu W, Wang Z, et al. Association between the cervical extensor musculature and the demographic features, symptoms, and sagittal balance in patients with multilevel cervical Spondylotic myelopathy. World Neurosurg. 2023;169:e40–e50.

[19] Moroney SP, Schultz AB, Miller JA. Analysis and measurement of neck loads. J Orthop Res. 1988;6(5):713–720.

[20] Jull G, Kristjansson E, Dall'Alba P. Impairment in the cervical flexors: a comparison of whiplash and insidious onset neck pain patients. Man Ther. 2004;9(2):89–94.

[21] Moskven E, Bourassa-Moreau E, Charest-Morin R, Flexman A, Street J. The impact of frailty and sarcopenia on postoperative outcomes in adult spine surgery. A systematic review of the literature. Spine J. 2018;18(12):2354–2369.

[22] Verdijk LB, Snijders T, Drost M, Delhaas T, Kadi F, van Loon LJ. Satellite cells in human skeletal muscle; from birth to old age. Age (Dordr). 2014;36(2):545–547.

[23] Correa-de-Araujo R, Harris-Love MO, Miljkovic I, Fragala MS, Anthony BW, Manini TM. The need for standardized assessment of muscle quality in skeletal muscle function deficit and other aging-related muscle dysfunctions: a symposium report. Front Physiol. 2017;8:87.

[24] Passias PG, Segreto FA, Bortz CA, Horn SR, Frangella NJ, Diebo BG, et al. Fatty infiltration of cervical spine extensor musculature: is there a relationship with cervical sagittal balance? Clin Spine Surg. 2018;31(10):428–434.

[25] Mitsutake T, Sakamoto M, Chyuda Y, Oka S, Hirata H, Matsuo T, et al. Greater cervical muscle fat infiltration evaluated by magnetic resonance imaging is associated with poor postural stability in patients with cervical Spondylotic radiculopathy. Spine (Phila Pa 1976). 2016;41(1):E8–E14.

[26] Thakar S, Mohan D, Furtado SV, Sai Kiran NA, Dadlani R, Aryan S, et al. Paraspinal muscle morphometry in cervical spondylotic myelopathy and its implications in clinicoradiological outcomes following central corpectomy: clinical article. J Neurosurg Spine. 2014;21(2):223–230.

[27] Patwardhan AG, Khayatzadeh S, Havey RM, Voronov LI, Smith ZA, Kalmanson O, et al. Cervical sagittal balance: a biomechanical perspective can help clinical practice. Eur Spine J. 2018;27(Suppl 1):25–38.

[28] Khayatzadeh S, Kalmanson OA, Schuit D, Havey RM, Voronov LI, Ghanayem AJ, et al. Cervical spine muscle-tendon unit length differences between neutral and forward head postures: biomechanical study using human cadaveric specimens. Phys Ther. 2017;97(7):756–766.

[29] Lin S, Lin T, Wu Z, Chen G, Shangguan Z, Wang Z, et al. Does the asymmetry and extension function of the preoperative cervical paraspinal extensor predict postoperative cervical sagittal deformity in patients who undergo modified laminoplasty? Spine J. 2022;22(12):1953–1963.

[30] Paliwal M, Weber KA, Smith AC, Elliott JM, Muhammad F, Dahdaleh NS, et al. Fatty infiltration in cervical flexors and extensors in patients with degenerative cervical myelopathy using a multi-muscle segmentation model. PloS One. 2021;16(6):e0253863.

[31] Liu X, Tan B, Xiao B, Zou X, Liu S. Modified K-line for making decisions regarding the surgical approach in patients with K-line (−) OPLL. Orthopaedic Surg. 2021;13(4):1351–1358.

[32] Koshimizu H, Sakai Y, Harada A, Ito S, Ito K, Hida T. The impact of sarcopenia on cervical spine sagittal alignment after cervical Laminoplasty. Clin Spine Surg. 2018;31(7):E342–E346.

[33] Wen BT, Liu BG. Association between changes in sagittal X-ray measurements and neck extensor muscle atrophy after cervical Laminoplasty. Neurochirurgie. 2020;66(6):442–446.

[34] Huang Z, Bai Z, Yan J, Zhang Y, Li S, Yuan L, et al. Association between muscle morphology changes, cervical spine degeneration, and clinical features in patients with chronic nonspecific neck pain: a magnetic resonance imaging analysis. World Neurosurg. 2022;159:e273–e284.

[35] Wang H, Zhang L. Expansion of Spinal Canal with lift-open Laminoplasty: a new method for compression cervical myelopathy. Orthopaedic Surg. 2021;13(5):1673–1681.

[36] Machino M, Yukawa Y, Hida T, Ito K, Nakashima H, Kanbara S, et al. Cervical alignment and range of motion after laminoplasty: radiographical data from more than 500 cases with cervical spondylotic myelopathy and a review of the literature. Spine (Phila Pa 1976). 2012;37(20):E1243–E1250.

[37] O'Leary S, Falla D, Elliott JM, Jull G. Muscle dysfunction in cervical spine pain: implications for assessment and management. J Orthop Sports Phys Ther. 2009;39(5):324–333.

[38] Rivard J, Unsleber C, Schomacher J, Erlenwein J, Petzke F, Falla D. Activation of the semispinalis cervicis and splenius capitis with cervical pulley exercises. Musculoskelet Sci Pract. 2017;30:56–63.

[39] Nie C, Chen K, Zhu YU, Song H, Lyu F, Jiang J, et al. Comparison of time-dependent resistance isometric exercise and active range of motion exercise in alleviating the sensitization of postoperative axial pain after cervical laminoplasty. Musculoskelet Sci Pract. 2022;62:102669.

RIGHTS & PERMISSIONS

2023 2023 The Authors. Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.