Approach For Cervical Spondylotic Myelopathy Research Articles

Cervical spondylotic myelopathy and radiculopathy: a stepwise approach and comparative analysis of surgical outcomes: a narrative review of recent literature.

Selecting the optimal surgical treatment for multilevel cervical spondylotic myelopathy and radiculopathy significantly affects symptom improvement, postoperative prognosis, and quality of life. Proper patient selection and precise surgical execution are crucial for achieving successful outcomes, considering the favorable natural course of cervical radiculopathy. Several factors must be considered, including the number of affected segments, spinal alignment, kyphosis degree, stiffness, and surgeon expertise, when determining the surgical approach for cervical spondylotic myelopathy. An anterior approach is commonly used in cases that involve fewer than three segments with mild kyphosis, whereas posterior laminoplasty or anterior cervical discectomy and fusion (ACDF) are effective for cases with more than three segments with maintained lordosis. Both the degree of stiffness and spinal cord compression need to be considered for cases with kyphotic deformity. ACDF may be suitable when anterior structures are the primary source of compression and mild kyphosis is present. The decision between laminoplasty or laminectomy and fusion depends on the kyphosis degree for multilevel compression with kyphosis. An evaluation of cervical rigidity is required for severe kyphosis, and posterior laminectomy and fusion may be effective for flexible kyphosis, whereas a staged posterior-anterior-posterior approach may be required for rigid kyphosis to address both deformity and neural compression. This review summarizes recent research and presents illustrative cases of optimal surgical decision-making for various cervical spondylotic radiculopathy and myelopathy presentations.

Analysis of Short-Term Prognostic Factors of Posterior Single Open-Door Laminoplasty in Patients with Cervical Spondylotic Myelopathy.

Posterior cervical expansive open-door laminoplasty (ELAP) is one of the main methods for the treatment of multilevel cervical spondylotic myelopathy (CSM). However, some patients are vulnerable to developing complications such as kyphosis and axial symptoms after ELAP, potentially facing adverse prognosis following the procedure. At present, there are few reports on the short-term prognostic factors in Chinese patients with CSM after undergoing ELAP. The main objectives of this study are to investigate the efficacy of ELAP in the treatment of CSM and to analyze the short-term prognostic factors. This study is a retrospective study. A total of 98 patients with CSM who received ELAP surgery in The First People's Hospital of Tongxiang City from May 2021 to October 2022 were selected as the study participants. The clinical efficacy of the ELAP was evaluated using visual analog scale (VAS), Japanese Orthopedic Association (JOA) score, and assessments based on imaging indicators. All patients were followed up for 1 year postoperatively. The short-term prognosis was analyzed according to JOA improvement rate, and the short-term prognostic factors were analyzed using multivariate logistic regression. The JOA scores of 98 CSM patients at 1 year after operation were significantly higher than those before operation (p < 0.001), and their postoperative VAS score were significantly lower than those before operation (p < 0.001). The postoperative cervical curvature (p < 0.001), sagittal diameter of cervical spinal canal (p < 0.001) and distance between vertebral body and posterior edge of spinal cord (p < 0.001) were significantly improved relative to the corresponding preoperative values. There was no significant difference in cervical 2-7 Cobb angle before and after operation (p = 0.979). Multivariate logistic regression analysis showed that age (p < 0.001), course of disease (p < 0.001) and preoperative JOA score (p < 0.001) were independent risk factors affecting the short-term prognosis in CSM patients. ELAP is a safe and effective therapeutic approach for CSM, whose short-term prognosis is related to age, course of disease and preoperative JOA score.

Patients May Return to Work Sooner After Laminoplasty: Occupational Outcomes of the Cervical Spondylotic Myelopathy Surgical Trial.

Return-to-work (RTW) is an important outcome for employed patients considering surgery for cervical spondylotic myelopathy (CSM). We conducted a post hoc analysis of patients as-treated in the Cervical Spondylotic Myelopathy Surgical Trial, a prospective, randomized trial comparing surgical approaches for CSM to evaluate factors associated with RTW. In the trial, patients were randomized (2:3) to either anterior surgery (anterior cervical decompression/fusion [ACDF]) or posterior surgery (laminoplasty [LP], or posterior cervical decompression/fusion [PCDF], at surgeon's discretion). Work status was recorded at 1, 3, 6, and 12 months postoperatively. For patients working full-time or part-time on enrollment, time to RTW was compared across as-treated surgical groups using discrete-time survival analysis. Multivariate logistic regression was used to assess predictors of RTW. Clinical outcomes were compared using a linear mixed-effects model. A total of 68 (42%) of 163 patients were working preoperatively and were analyzed. In total, 27 patients underwent ACDF, 29 underwent PCDF, and 12 underwent LP. 45 (66%) of 68 patients returned to work by 12 months. Median time to RTW differed by surgical approach (LP = 1 month, ACDF = 3 months, PCDF = 6 months; P = .02). Patients with longer length-of-stay were less likely to be working at 1 month (odds ratio 0.51; 95% CI, 0.29-0.91; P = .022) and 3 months (odds ratio 0.39; 95% CI, 0.16-0.96; P = .04). At 3 months, PCDF was associated with lower Short-Form 36 physical component summary scores than ACDF (estimated mean difference [EMD]: 6.42; 95% CI, 1.4-11.4; P = .007) and LP (EMD: 7.98; 95% CI, 2.7-13.3; P = .003), and higher Neck Disability Index scores than ACDF (EMD: 12.48; 95% CI, 2.3-22.7; P = .01) and LP (EMD: 15.22; 95% CI, 2.3-28.1; P = .014), indicating worse perceived physical functioning and greater disability, respectively. Most employed patients returned to work within 1 year. LP patients resumed employment earliest, while PCDF patients returned to work latest, with greater disability at follow-up, suggesting that choice of surgical intervention may influence occupational outcomes.

Application and Advantages of the Trans-Unco-Discal (TUD) Approach for Cervical Spondylotic Myelopathy and Radiculopathy: Classification and Modification of Surgical Technique Based on the Location of Spinal Cord and/or Nerve Root Compression.

Purpose: We assess the application and advantages of modifying the trans-unco-discal (TUD) approach which we underwent for cervical myelo-radiculopathy. We present the surgical techniques of the modified TUD approach. Materials and Methods: The material was 180 cases where anterior cervical decompression (ACD) was performed by the modified TUD approach. We classified the material into four groups based on the location of the nerve root and/or spinal cord compression: I, compression of the root at intervertebral foramen (IVF); II, compression of the posterior margin of the vertebral body; III, compression of the IVF and posterior margin of the vertebral body; IV, compression of the bilateral IVF and posterior margin of the vertebral body. We applied the modified TUD approach to these four types. We present the surgical procedures and techniques for the modified TUD approach. The Japanese orthopedic association (JOA) score and neuroradiological alignment were examined. Results: The improvement rate of the JOA score was 78.4% at 6 months post-surgery and 77.5% in the most recent examinations. By the modified TUD approach, compressive lesions of the spinal cord and/or nerve roots were removed, and good alignment was acquired and sustained. Conclusions: ACD by the modified TUD approach safely achieved appropriate decompression for the spinal cord and/or nerve roots, and the patients had a high improvement rate and good alignment. Complications were less common than with other surgical procedures. If the TUD approach and endoscopic approaches can be combined, their application to new area is anticipated.

Cervical disc arthroplasty for magnetic resonance-evident cervical spondylotic myelopathy: comparison with anterior cervical discectomy and fusion.

Anterior cervical discectomy and fusion (ACDF) is a standard surgical approach for cervical spondylotic myelopathy (CSM) caused by disc herniations. Although cervical disc arthroplasty (CDA) has become, in the past decade, a viable alternative to ACDF in selected patients, the differences among patients with CSM treated with CDA and ACDF remain elusive. The effectiveness of motion preservation devices in CSM is also unclear. Adult patients who underwent 1- or 2-level CDA or ACDF between 2007 and 2021 were retrospectively reviewed. Patients whose preoperative T2-weighted MRI demonstrated increased intramedullary signal intensity (IISI) were included and analyzed for the following: comparison of the length of IISI on pre- and postoperative MR images as well as range of motion (ROM) at the indexed levels between the CDA and ACDF groups. Measurement for clinical outcomes included the visual analog scale (VAS) of the arm and neck, the Neck Disability Index, and modified Japanese Orthopaedic Association scores. Perioperative clinical data were also compared between the two groups. A total of 122 patients were allocated to the CDA group and 108 to the ACDF group, with mean follow-ups of 46.6 and 39.0 months, respectively. Patients in the CDA group were younger than those in the ACDF group (47.64 ± 12.40 vs 61.73 ± 12.25 years, p < 0.001) (mean ± SD). The ACDF group had more 2-level surgery compared to the CDA group (p = 0.002). Both groups had significant regression of IISI on postoperative MRI compared to that of preoperative imaging (CDA: 1.23 ± 0.84 to 0.28 ± 0.39 cm; ACDF: 1.07 ± 0.60 to 0.37 ± 0.42 cm; both p < 0.001). The decrease in the length of IISI was similar between the two groups (p = 0.058). The postoperative ROM was well preserved in the CDA group (superior to ACDF, which yielded minimal ROM postoperatively). Both the CDA and ACDF groups demonstrated improvement in Neck Disability Index and modified Japanese Orthopaedic Association scores at 24 months postoperatively. The CDA group had significant improvements on VAS scores, whereas the improvement did not reach significance for the ACDF group at 24 months postoperatively. Significant shortening of IISI on T2-weighted MRI was demonstrated after both CDA and ACDF. At 24 months postoperatively, all clinical outcomes demonstrated improvement after both strategies, except that the VAS score was not significantly improved for ACDF. Therefore, CDA is a safe and effective option for patients with MR-evident CSM.

Cervical Oblique Corpectomy: Revitalizing the Underused Surgical Approach With Step-By-Step Simulation in Cadavers.

Recently, the World Federation of Neurosurgical Societies Spine committee recommended that additional research on cost-benefit analysis of various surgical approaches for cervical spondylotic myelopathy be carried out and their efficacy with long-term outcomes be compared. Unfortunately, it is highly probable that the oblique corpectomy (OC) will not be included in cost-benefit investigations due to its infrequent application by neurosurgeons dealing with the spine. In this cadaveric study, head and necks of 5 adult human cadavers stained with colored latex and preserved in 70% alcohol solution were dissected under a table-mounted surgical microscope using 3× to 40× magnifications. The OC approach was performed to simulate real surgery, and the neurovascular structures encountered during the procedure and their relations with each other were examined. Oblique corpectomy was performed unilaterally, although neck dissections were performed bilaterally on 10 sides in all 5 cadavers. At each stage of the dissection, multiple three-dimensional photographs were obtained from different angles and distances. For an optimal OC, both the anterior spinal cord must be sufficiently decompressed and sufficient bone must be left in place to prevent instability in the cervical spine. Oblique corpectomy is a valid and potentially low cost alternative to other anterior and posterior approaches in the surgical treatment of cervical spondylotic myelopathy. However, meticulous cadaver studies are essential before starting real surgical practice on patients in order to perform it effectively and to avoid the risks of the technique.

Comparison of Clinical Outcomes and Sagittal Alignment After Different Levels of Anterior Cervical Discectomy and Fusion in Patients With Cervical Spondylotic Myelopathy: From One-level to Three-level.

A nonrandomized and prospective study. The aim of this study was to compare clinical outcomes and sagittal alignment after one-level, two-level, and three-level anterior cervical discectomy and fusion (ACDF) in patients with cervical spondylotic myelopathy (CSM). ACDF is a widely used surgical approach for CSM. It remains controversial regarding to whether corrected lordosis can be maintained over time after different levels ACDF. A total of 175 patients with cervical spondylotic myelopathy who underwent ACDF were enrolled in this retrospective study. The neurofunctional assessment was performed with the Japanese Orthopedic Association (JOA) score and the recovery rate of JOA score. Radiographic parameters included C2-C7 lordosis, fused segments lordosis, T1 slope, the cervical sagittal vertical axis (cSVA). Patients with more fusion levels had more operative time and blood loss and higher rate of complications. All patients showed a larger cervical lordosis than that preoperatively and the restored lordosis increased with more segments involved. The restored lordosis had little change during the whole follow-up in one-level and two-level group. CL decreased from 25.65 ± 9.31° on the third postoperative day to 20.25 ± 10.03° at the final follow-up in three-level group (P = 0.001). Only T1 slope in three-level increased significantly from preoperative 26.55 ± 9.36° to 29.06 ± 7.54° on the third postoperative day (P = 0.011) and decreased to 26.89 ± 7.22° (P = 0.043) at final follow-up. The JOA score all increased significantly at the last follow-up in each group, but the recovery rate of the JOA score in each group was similar (P = 0.096). ACDF with different levels had similar postoperative clinical outcomes. Three-level ACDF has an apparent advantage in restoring lordosis, a poor ability to maintain lordosis, and a higher incidence of complications compared to one-level or two-level ACDF.Level of Evidence: 3.

Value of Surgery and Nonsurgical Approaches for Cervical Spondylotic Myelopathy: WFNS Spine Committee Recommendations.

Cervical spondylotic myelopathy (CSM) is a common cause of adult spinal cord dysfunction. Although the therapeutic options for moderate to severe CSM patients have been established well, the existing guidelines for therapeutic decisions in mild cases of CSM are unclear. We present a review of literature on conservative treatment and surgery for CSM and suggest general recommendations applicable in various clinical presentations and in different geographic locations across the globe, with due considerations to available resources and locally prevalent practices.

Operative outcomes of patients with cervical spondylotic myelopathy at Cipto Mangunkusumo National Central Hospital 2014-2016

Introduction: Cervical spondylotic myelopathy (CSM) is the most common type of myelopathy with cervical spondylosis as the underlying disorder. To this date, there has been ongoing debate regarding operative approach in CSM treatment that there is still no established treatment proven superior one over the other. This study aims to investigate the operative outcomes of CSM. Methods: We retrospectively reviewed patients with CSM who had undergone anterior approach and posterior surgery at Cipto Mangunkusumo Hospital, Jakarta, Indonesia, between January 2014 and December 2016. The average followup time was 13-42 months, with an average of 27 months. The clinical data of patients were observed, including age, sex, operation records, pre- and post-operative Japanese Orthopaedic Association (JOA) scores, cervical spine canal stenosis, cervical curvature, and the presence of ossification of the posterior longitudinal ligament. Results: Eight patients (6 male, 2 female) with CSM were enrolled in this study with mean age of 55.6 ± 9 years. Two patients experienced minor complication, and one patient had major complication of Frankel grade decrement and phrenic nerve paralysis that led to prolonged intensive care. The preoperative cervical JOAs of the eight patients were 11.2 ± 2.81 and post operative JOAs were 13.1 ± 3.44. (p< 0.05). Seven patients were satisfied with the outcomes of their surgery. Conclusion: A definite conclusion could not be drawn regarding the most effective surgical approach for CSM. Further studies with larger number of samples and centres are required to investigate the comparison of best treatment choice for CSM.

Bundled payment reimbursement for anterior and posterior approaches for cervical spondylotic myelopathy: an analysis of private payer and Medicare databases.

OBJECTIVE Cervical spondylotic myelopathy (CSM) is a progressive spinal condition that often requires surgery. Studies have shown the clinical equivalency of anterior versus posterior approaches for CSM surgery. The purpose of this study was to determine the amount and type of resources used for anterior and posterior surgical treatment of CSM by using large national databases of clinical and financial information from patients. METHODS This study consists of 2 large cohorts of patients who underwent either an anterior or posterior approach for treatment of CSM. These patients were selected from the Medicare 5% National Sample Administrative Database (SAF5) and the Humana orthopedic database (HORTHO), which is a database of patients with private payer health insurance. The outcome measures were the cost of a 90-day episode of care, as well as a breakdown of the cost components for each surgical procedure between 2005 and 2014. RESULTS A total of 16,444 patients were included in this analysis. In HORTHO, there were 10,332 and 1556 patients treated with an anterior or posterior approach for CSM, respectively. In SAF5, there were 3851 and 705 patients who were treated by an anterior or posterior approach for CSM, respectively. The mean ± SD reimbursements for anterior and posterior approaches in the HORTHO database were $20,863 ± $2014 and $23,813 ± $4258, respectively (p = 0.048). The mean ± SD reimbursements for anterior and posterior approaches in the SAF5 database were $18,219 ± $1053 and $25,598 ± $1686, respectively (p < 0.0001). There were also significantly higher reimbursements for a rehabilitation/skilled nursing facility and hospital/inpatient care for patients who underwent a posterior approach in both the private payer and Medicare databases. In all cohorts in this study, the hospital-related reimbursement was more than double the surgeon-related reimbursement. CONCLUSIONS This study provides resource utilization information for a 90-day episode of care for both anterior and posterior approaches for CSM surgery. There is a statistically significant higher resource utilization for patients undergoing the posterior approach for CSM, which is consistent with the literature. Understanding the reimbursement patterns for anterior versus posterior approaches for CSM will help providers design a bundled payment for patients requiring surgery for CSM, and this study suggests that a subset of patients who require the posterior approach for treatment also require greater resources. The data also suggest that hospital-related reimbursement is the major driver of payments.

Anterior surgical approach for cervical spondylotic myelopathy: clinical and radiological outcomes

Anterior surgical approach for cervical spondylotic myelopathy: clinical and radiological outcomes

Impact of Race and Insurance Status on Surgical Approach for Cervical Spondylotic Myelopathy in the United States: A Population-Based Analysis.

Retrospective cohort study. The aim of the study was to assess factors potentially impacting the operative approach chosen for cervical spondylotic myelopathy (CSM) patients on a nationwide level. CSM is one of the most common spinal disorders treated by spine surgeons, with operative management consisting of three approaches: anterior-only, posterior-only, or combined anterior-posterior. It is unknown whether the operative approach used differs based on patient demographics and/or insurance status. The nationwide inpatient sample from 2001 to 2010 was used for analysis. Admissions having a diagnosis code of 721.1 and a primary procedure code of 81.02/81.03, 81.32/81.33, 81.02/81.03, or 81.32/81.33 (combined anterior and posterior fusion/refusion at C2 or below), and 3.09 (decompression of the spinal canal including laminoplasty) were included. Analysis was adjusted for several variables including patient age, race, sex, primary payer for care, and admission source/type. Multivariate analyses revealed that non-white race (black [odds ratio, OR = 1.39; 95% confidence interval, CI = 1.32-1.47; P < 0.0001], Hispanic [OR = 1.51; 95% CI = 1.38-1.66; P < 0.0001], Asian/Pacific Islander [OR = 1.40; 95% CI = 1.15-1.70; P = 0.0007], Native American [OR = 1.33; 95% CI = 1.02-1.73; P = 0.037]) and increasing age (OR = 1.03; P < 0.0001) were predictive of receiving posterior-only approaches. Female sex (OR = 1.39; 95% CI = 1.34-1.43; P < 0.0001), private insurance (OR = 1.19; 95% CI = 1.14-1.25; P < 0.0001), and nontrauma center admission type (OR = 1.29-1.39; 95% CI = 1.16-1.56; P < 0.0001) were independently predictive of increased likelihood of receiving an anterior-only approach. Hispanic race (OR = 1.35; 95% CI = 1.14-1.59; P = 0.0004) and admission source (another hospital [OR = 1.65; 95% CI = 1.20-2.27; P = 0.0023], other health facility [OR = 1.68; 95% CI = 1.13-2.51; P = 0.011]) were the only variables predictive of increased combined anterior-posterior approaches; Native American race (OR = 0.32; 95% CI = 0.13-0.78; P = 0.013) decreased the likelihood of a combined anterior-posterior approach. Private insurance status, female sex, and white race independently predict receipt of anterior-only CSM approaches, whereasd non-white race (black, hispanic, Asian/Pacific Islander, Native American) and nonprivate insurance predict receiving posterior-only CSM approaches. Given recent literature demonstrating posterior-only approaches as predictive of increased mortality in CSM (Kaye et al, 2015), our findings indicate that for CSM patients, non-white race may significantly increase mortality risk, whereas private insurance status may significantly decrease the risk of mortality. Further prospective study will be needed to more definitively address these issues. 3.

Laminectomy and fusion vs laminoplasty for multi-level cervical myelopathy: a systematic review and meta-analysis.

Surgical approaches for multi-level cervical spondylotic myelopathy (CSM) include posterior cervical surgery via laminectomy and fusion (LF) or expansive laminoplasty (EL). The relative benefits and risks of either approach in terms of clinical outcomes and complications are not well established. A systematic review and meta-analysis was conducted to address this topic. Electronic searches were performed using six databases from their inception to January 2016, identifying all relevant randomized controlled trials (RCTs) and non-RCTs comparing LF vs EL for multi-level cervical myelopathy. Data was extracted and analyzed according to predefined endpoints. From 10 included studies, there were 335 patients who underwent LF compared to 320 patients who underwent EL. There was no significant difference found postoperatively between LF and EL groups in terms of postoperative JOA (P=0.39), VAS neck pain (P=0.93), postoperative CCI (P=0.32) and Nurich grade (P=0.42). The total complication rate was higher for LF compared to EL (26.4 vs 15.4%, RR 1.77, 95% CI 1.10, 2.85, I 2=34%, P=0.02). Reoperation rate was found to be similar between LF and EL groups (P=0.52). A significantly higher pooled rate of nerve palsies was found in the LF group compared to EL (9.9 vs 3.7%, RR 2.76, P=0.03). No significant difference was found in terms of operative time and intraoperative blood loss. From the available low-quality evidence, LF and EL approaches for CSM demonstrates similar clinical improvement and loss of lordosis. However, a higher complication rate was found in LF group, including significantly higher nerve palsy complications. This requires further validation and investigation in larger sample-size prospective and randomized studies.

Clinical Outcome of Anterior vs Posterior Approach for Cervical Spondylotic Myelopathy

Introduction Cervical spondylotic myelopathy is a common cause of neurological morbidity. The decompression of the neural elements is the gold standard procedure for this pathology, but there is still a lot of controversy for the selection of the approach, anterior, posterior or combined. Methods 42 patients were enrolled with the diagnosis of cervical spondylotic myelopathy, the 42 underwent surgery with either anterior or posterior approach at the hospital Centro Médico Nacional de Occidente, Guadalajara, México, a follow up for up to one year was made, comparing the results with the modified score for the Japanese Association of Orthopaedics (mJAO) and the Nurick score. Results Patients were divided into two groups. homogeneity analysis were made, finding similar results between both groups ( p &lt; 0.05) Group A. 19(45%)patients received surgery by an anterior approach (Corpectomy with expandable cage and anterior plate fixation) and group B. 23 (55%)underwent posterior approach, from this 23 patients, 18(43%) had a laminectomy with posterior instrumentation and fusion, and 5 (12%) had a laminoplasty. 38% female patients and 62% male patients, median age was 75 years old. Functional outcomes were measure with the modified score for the Japanesse Association of Orthopaedics (mJAO) for up to one year follow up. Group A had a lower score (x:15.52) compare with group B (x:17.13) (15.52 versus 17.13, p &lt; 0.05. While in the Nurick score Group B got a higher score (x:0.73) compare with group A (x:0.30) (0.73 vs 0.30, p &lt; 0.05). Conclusions The election of the surgical approach in the cervical spondylotic myelopathy should be individualize according to the characteristics of the injured elements, it should be focused in the decompression of the neural elements and the recovery to the sagittal balance. In this study a statistical difference was found according to the mJAO and the Nurick scale in favor of the posterior approach, but the anterior decompression may also have good results according to the one year follow up ( p &lt; 0.05). More studies should be made with a bigger population and a longer follow up

Area under the Curve: Analysis of Approach-Related Recovery Time in 165 Operative Cervical Spondylotic Myelopathy Patients with a 2-Year Follow-Up

Introduction Much debate about postoperative outcomes regarding surgical approaches for cervical spondylotic myelopathy (CSM) exists in the literature with no clear evidence of superiority. We propose a novel method for assessing health-related quality of life (HRQOL) outcomes by taking into account each patient's baseline at postoperative time points and analyzing the “area under the curve” (AUC), a proxy for suffering time. Patients and Methods Post hoc analysis of a prospective, multicenter database of patients with CSM. A total of 165 patients met the following inclusion criteria: symptomatic CSM, age older than 18 years, and 2-year follow-up with modified Japanese Orthopaedic Association (mJOA) and neck disability index (NDI). The anterior approach group (AAG) ( n = 110) and posterior approach group (PAG) ( n = 55) were compared at baseline, 1 year, and 2 years for each HRQOL. This comparison was repeated with normalization, using the patient's baseline as the anchor, followed by an integration and comparison of AUC. Results and Conclusion: For the first time, AUC analysis was applied to evaluating patients with CSM. Nonnormalized HRQOLs demonstrated the AAG started higher and met better standards at all times points compared with the PAG. Normalized mJOA demonstrated the PAG actually did better at 2 years, whereas NDI suggested that the AAG did better, although this was not significant. AUC analysis further supported the superiority of the PAG, with statistical significance at 1 and 2 years' time points, suggesting that patients who undergo the posterior approach may suffer less in the first 2 years of their postoperative course.

Regional Differences in Outcomes of Surgical Treatment for Cervical Spondylotic Myelopathy Outcomes of the AOSpine Multicenter Prospective CSM-I Study

Introduction Cervical spondylotic myelopathy (CSM) is a condition that is commonly seen in those over the age of 50 to 60 years. A progressive increase in the number of patients who present with CSM is expected in the coming decades as the proportion of those over 60 years is anticipated to double by 2050 according to the World Health Organization (WHO). Regional variations in the pattern of presentations, etiology, and surgical management of CSM are likely to be important determinants of outcome of treatment. Here, we report the current presentation and management of CSM in a large prospective international multicenter study (AOSpine CSM-International). Materials and Methods Between 2007 and 2011, all adult patients with imaging-confirmed CSM were enrolled at 16 international high-volume centers. Detailed data on presentation, treatment, and functional outcomes were collected prospectively. The decision on surgical approach, levels decompressed, and use of instrumentation was left to the attending surgeons. Patients with inflammatory, infective, or neoplastic myelopathic etiologies were excluded. Patients were followed-up for up to 24 months. Results Participating centers were based in Asia (AP, n = 150), Europe (E, n = 126), Latin (LA, n = 80), and North America (NA, n = 123). The mean age of the cohort was 56.4 years (range, 22–87 years) and majority of them were males. Patients from AP and LA were significantly younger (53.9 and 54.2 years, respectively) than those from NA and E ( p &lt; 0.0003). The presenting underlying CSM pathology varied between regions ( p &lt; 0.001). Posterior ligamentum flavum hypertrophy was most frequently seen in LA, and OPLL was prevalent in patients in AP (35%) and E (32%). Despite etiological variations, there were no differences in baseline mJOA, Nurick, and NDI scores ( p &lt; 0.1). However, patients in AP scored the highest and those in LA scored the lowest on SF36 PCS, and LA patients had highest SF36 MCS scores ( p &lt; 0.008). Anterior surgical decompression was performed in a majority in Europe (71.43%), AP (61.07%), and NA (56%) but not in LA (33%). Circumferential decompression surgery was rarely performed in NA (4.88%) and E (3.17%). At 24 months, there was significant improvement in overall outcome measures ( p &lt; 0.001) in all regions. Patients in Asia demonstrated the greatest improvement in NDI and SF-36 PCS/MCS and patients in Europe the least. Patients from Europe had lower SF-36 QOL scores and showed less functional improvement in mJOA. NDI score was highest in the AP region. Conclusion There were significant regional variations in etiology of CSM but not at presenting functional status. Anterior cervical approach for CSM was the most common surgical approach worldwide. Surgical decompression achieved statistically significant improvements in mJOA, NDI, Nurick score, and SF36v2 across centers. However, there were variations in the degree of functional improvements gained across the regions.

Anterior approaches for cervical spondylotic myelopathy: which? When? How?

Cervical spondylotic myelopathy is a degenerative disorder with an unfavorable natural history. Surgical treatment options have evolved substantially over time, with both anterior and posterior methods proving successful for certain patients with specific characteristics. Anterior decompression of the spinal canal plus fusion techniques for stabilization has several advantages and some disadvantages when compared to posterior options. Understanding the pros and cons of the approaches and techniques is critical for the surgeon to select the best operative treatment strategy for any given patient to achieve the best outcome. Multiple decision-making factors are involved, such as sagittal alignment, number of levels, shape of the pathoanatomy, age and comorbidities, instability, and pre-operative pain levels. Any or all of these factors may be relevant for a given patient, and to varying degrees of importance. Choice of operative approach will therefore be dependent on patient presentation, risks of that approach for a given patient, and to some degree surgeon experience.

Complex cervical spine surgery at the hospital for special surgery: editorial.

The inaugural complex cervical spine symposium at the Hospital for Special Surgery brought together preeminent thought leaders and innovators in cervical spinal surgery in May of 2013 from around the USA, Europe, and Asia. Topics included advanced cervical spine operative techniques, cervical spine reconstruction, the operative treatment of pediatric cervical spine disorders, deformity, and tumor treatment at the occipitocervical junction. The Keynote Lecture was delivered by Kuniyoshi Abumi, MD, PhD, from Sapporo, Japan, on cervical spine osteotomies and the treatment and reduction of occiptiocervical deformities. Dr. Abumi served as the first president of the Cervical Spine Research Society’s Asia Pacific Division and is widely regarded for developing the technique of subaxial cervical spine pedicle screw instrumentation. Pediatric cervical spine lectures were given by John Dorman’s MD from the Children’s Hospital of Pennsylvania and Daniel Hedequist, MD, from Boston Children’s Hospital. Christoph Seipe, MD, PhD from the Schon Klinik in Munich, Germany, and Roger Hartl, MD, presented their experiences with advanced computer navigation techniques for complex degenerative cervical spine disorders and minimally invasive surgical techniques, respectively. Todd Albert, MD, who has since joined the HSS family as Surgeon-in-Chief, presented techniques for reconstruction of the post-surgical spine, and Edward D. Simmons, MD, presented the experience that he and his father accumulated over several decades with the cervical spine osteotomy that bears his family name, the “Simmon’s osteotomy.” Several controversial topics pertinent to modern cervical surgery were debated by leading experts in their respective fields, ranging from motion preservation surgery using disk replacement devices, the treatment of athletes with critical cervical spinal stenosis, and the optimal surgical approach for cervical spondylotic myelopathy using modern techniques. It was my great privilege both to serve as the director of the HSS Complex Cervical Spine Symposium and as guest editor of the HSS Journal’s cervical spine special issue. This focus issue of the symposium summarizes many of the cutting edge talks, debate sessions, and expert techniques given by surgeons at the symposium.

Posterior surgical treatment of cervical spondylotic myelopathy: review article.

Cervical spondylosis is now recognised as the leading cause of myelopathy and spinal cord dysfunction worldwide. Chronic spinal cord compression results in chronic inflammation, cellular apoptosis, and microvacular insufficiency, which are thought to the biologic basis for cervical spondylotic myelopathy (CSM). Our purpose was to address the key principles of CSM, including natural history and presentation, pathogenesis, optimal surgical approach, results and complication rates of posterior surgical approaches for CSM so that the rationale for addressing CSM by a posterior approach can be fully understood. We conducted a systematic search of PubMed/MEDLINE and the Cochrane Collaboration Library for literature published through February 2014 to identify articles that evaluated CSM and its management. Reasons for exclusion included patients with ossification of the posterior longitudinal ligament (OPLL), patients with degenerative disc disease without CSM, and patients with spine tumor, trauma and infection. Meeting abstracts/proceedings, white articles and editorials were additionally excluded. The search strategy yielded 1,292 articles, which was reduced to 52 articles, after our exclusion criteria were introduced. CSM is considered to be a surgical disorder due to its progressive nature. There is currently no consensus in the literature whether multilevel spondylotic compression is best treated via an anterior or posterior surgical approach. Multilevel CSM may be safely and effectively treated using a posterior approach, either by laminoplasty or with a laminectomy and fusion technique.

Surgical management of cervical spondylotic myelopathy

Cervical spondylotic myelopathy (CSM) is emerging as the most common cause of spinal cord dysfunction in the elderly worldwide. In the past decade, our understanding of the biomechanics of the spine has improved along with advances in spinal instrumentation and this has led to significant changes in the surgical management of CSM. This review will discuss the indications, advantages and limitations of different operative approaches as well as the complications and prognosis of surgery for cervical spondylotic myelopathy. Choice of surgical approach for CSM should be based on the clinical and radiological characteristics of the individual patient and not on the preferences of the surgeon.