What is the treatment for a patient with a multilevel posterior disc osteophyte complex from C3 to C4?

Treatment of Multilevel Posterior Disc Osteophyte Complex from C3 to C4

For patients with a multilevel posterior disc osteophyte complex from C3 to C4, the primary treatment approach should be posterior cervical decompression with instrumented fusion, particularly when there is evidence of spinal cord compression causing myelopathy.

Diagnostic Evaluation

Before determining treatment, proper imaging is essential:

• MRI of the cervical spine: Gold standard for evaluating spinal cord compression, disc pathology, and osteophyte complexes 1
• CT of the cervical spine: Better visualization of bony structures, including osteophyte complexes 1
• Flexion/extension radiographs: To assess for dynamic instability 1

Treatment Algorithm Based on Clinical Presentation

1. Asymptomatic or Mild Symptoms (No Myelopathy)

• Conservative management including:
  • Physical therapy
  • Anti-inflammatory medications
  • Activity modification
  • Cervical collar for short-term immobilization if needed

2. Moderate to Severe Symptoms or Myelopathy

• Surgical intervention is indicated when there is:
  • Progressive neurological deficit
  • Spinal cord compression on imaging
  • Persistent radiculopathy despite conservative treatment
  • Evidence of myelopathy

Surgical Options

Posterior Approach (Preferred for Multilevel Disease)

• Posterior cervical decompression with instrumented fusion is the primary treatment for multilevel posterior disc-osteophyte complex 2
  • Laminectomy with fusion (LF) provides better regression of disc-osteophyte complexes (35.4% reduction) compared to laminoplasty (9.59% reduction) 3
  • Fusion prevents post-decompression instability and kyphosis

Anterior Approach (Alternative in Select Cases)

• Anterior cervical discectomy and fusion (ACDF) may be considered for:
  • Primarily anterior compression
  • Limited to 1-2 levels
  • No significant posterior compression
• Caution: Inadequate posterior osteophyte resection during ACDF is a concern as remnant osteophytes do not decrease in size over time and may enlarge in some patients 4

Special Considerations

Ossification of Posterior Longitudinal Ligament (OPLL)

• If OPLL coexists with disc-osteophyte complex:
  • Increased risk of spinal cord injury with anterior approach alone 5
  • Combined anterior and posterior approach may be necessary
  • Posterior decompression and fusion should be performed first if both approaches are needed 5

Post-Surgical Monitoring

• Regular follow-up with clinical examination
• Post-operative MRI at 6-12 months to assess decompression and regression of osteophytes
• Dynamic radiographs to evaluate fusion and stability

Complications to Monitor

• Pseudoarthrosis (associated with osteophyte enlargement) 4
• Post-operative instability (4.9% risk) 6
• Loss of cervical lordosis (higher risk in patients >60 years, those with preoperative lordosis <10°) 6
• Adjacent segment disease

Conclusion

Posterior cervical decompression with instrumented fusion is the most effective treatment for multilevel posterior disc-osteophyte complex at C3-C4, particularly when there is evidence of spinal cord compression. This approach provides better regression of osteophytes compared to laminoplasty alone and prevents post-decompression instability.