Alternative Procedures for the Treatment of Cervical Spondylotic Myelopathy

Abstract

In Brief Study Design. Systematic review. Objective. To perform an evidence synthesis of the literature assessing the efficacy of arthroplasty, oblique corpectomy without fusion, and skip laminectomy to treat symptomatic cervical spondylotic myelopathy (CSM). Summary of Background Data. Traditionally, patients with symptomatic cervical spinal cord compression due to degenerative disease have been treated with anterior or posterior approaches or both. Recent reports suggest that there are several nontraditional management strategies that merit attention. The anterior procedures include decompression and anterior reconstruction with an artificial disc and oblique corpectomy without fusion. A posterior option is decompression, using the skip laminectomy technique. Methods. We conducted a systematic search in MEDLINE and the Cochrane Collaboration Library for literature published through October 15, 2012, on human studies published in the English language containing abstracts to answer the following key questions: (1) Is there evidence that artificial disc replacement after neural decompression results in equal or improved outcomes compared with anterior cervical decompression and fusion for CSM? (2) Describe the outcomes of oblique corpectomy without fusion for CSM? (3) Is there evidence that skip laminectomy results in equal or improved outcomes compared with laminoplasty for CSM? Results. The initial literature search yielded 141 unique, potentially relevant citations, which were evaluated against the inclusion/exclusion criteria set a priori. A total of 10 studies were selected for inclusion. For question 1, 2 studies suggested that neurological outcomes favored artificial disc replacement compared with anterior cervical decompression and fusion, whereas functional and pain outcomes were inconsistently reported. For question 2, 5 reported case series suggested favorable neurological, functional, and pain outcomes associated with oblique corpectomy in subjects with CSM, compared with the pretreatment condition. For question 3, 3 studies comparing laminoplasty with skip laminectomy suggested similar neurological outcomes between treatment groups, although functional and pain outcomes were inconsistently reported. Conclusion. A paucity of high-quality literature exists regarding treatment outcomes associated with arthroplasty, oblique corpectomy without fusion, and skip laminectomy for symptomatic CSM. Comparative prospective studies with long-term follow-up and standardized outcome measures are needed to assess treatment outcomes associated with these alternative techniques appropriately. Evidence-Based Clinical Recommendations. Recommendation 1. No recommendation can be made from comparative literature regarding treatment outcomes comparing ADR with ACDF for CSM. Overall Strength of Evidence. Insufficient Strength of Recommendation. Strong Recommendation 2. No recommendation can be made from comparative literature regarding treatment outcomes comparing laminoplasty with skip laminectomy for CSM. Overall Strength of Evidence. Low Strength of Recommendation. Strong Summary Statements. Oblique corpectomy is an option in selected cases of CSM. It should not be considered a first-line treatment strategy because of the relatively high morbidity associated with this procedure. A systematic review of the literature was performed to assess the efficacy of arthroplasty, oblique corpectomy without fusion, and skip laminectomy for cervical spondylotic myelopathy. The authors found a relative lack of high-quality data comparing these so-called “alternative” techniques with standard surgical decompression with or without fusion.