Equipoise for Laminoplasty Versus Fusion for Cervical Spondylotic Myelopathy: Is a Randomized Trial Feasible?

BACKGROUND AND OBJECTIVES: There is global variation and uncertainty regarding the utilization of laminoplasty in the treatment of patients with degenerative cervical spondylotic myelopathy. We asked whether clinical equipoise can be established among cervical spine surgeon experts for a possible trial comparing laminoplasty with fusion. METHODS: Fifty randomly selected cases from a cervical spondylotic myelopathy trial [NCT-02076113] were presented to 26 cervical spine experts to determine the suitability of randomization to laminoplasty vs fusion surgery. A brief clinical vignette, sagittal T2-weighted MRI, and appropriate axial images were reviewed by the experts. Each expert assessed the randomizability of each case and then stated the choice of approach: laminoplasty, fusion (anterior or posterior), arthroplasty, or no surgery. After 6 months, the same 50 cases were reviewed by all experts. RESULTS: Among 50 cases, 46 (92%) were deemed suitable for randomization by a simple majority at both time points. The response rate of the expert panel members was 100% at both time points. Among 2600 surgeon responses over 2 time points, experts stated their choice of approach as laminoplasty in 40% of instances and selected fusion (anterior or posterior) in 57% of cases. Temporal stability of decision-making was high with mean stability = 0.85 (SD = 0.09), indicating that surgeons generally maintained similar treatment decisions over 6 months. A subset (12 experts) of the expert panel who reviewed these 50 cases over 10 years ago demonstrated a significant increase in the preference for laminoplasty from 18% to 40% ( P < .001). CONCLUSION: Among cervical spine experts, laminoplasty utilization has increased over 10 years. Global cervical spine experts demonstrate equipoise for comparing laminoplasty with fusion. The results suggest that a significant proportion of patients with cervical myelopathy would be eligible for a future trial and the results would be likely to affect global practice.