What are the surgical approaches for treating cervical myelopathy?

Surgical Approaches for Cervical Myelopathy

Multiple surgical approaches exist for treating cervical spondylotic myelopathy (CSM), with the choice depending on specific factors including the location of compression, number of levels involved, and cervical alignment. Anterior cervical discectomy with fusion (ACDF) or anterior cervical corpectomy with fusion (ACCF) are recommended for multilevel anterior cervical spine decompression for lesions at the disc level. 1

Anterior Surgical Approaches

ACDF (Anterior Cervical Discectomy and Fusion)

• Recommended for compression at disc levels, especially for short segment decompression 1
• Involves removal of intervertebral discs and fusion of adjacent vertebrae 2
• Can be performed at multiple levels (multilevel ACDF) 2
• Anterior plating is recommended to provide stability and improve fusion rates 2
• Associated with less late deterioration compared to laminectomy alone 1

ACCF (Anterior Cervical Corpectomy with Fusion)

• Recommended alternative to ACDF for multilevel anterior decompression 1
• Involves removal of vertebral bodies in addition to discs 2
• When anterior fixation is not used, ACCF may provide higher fusion rates than multilevel ACDF 1
• However, ACCF is associated with higher graft failure rates compared to ACDF 1
• With anterior plating, fusion rates between ACDF and ACCF are equivalent 1

Circumferential Cervical Decompression and Fusion (CCDF)

• Combines anterior and posterior approaches 3
• May provide more extensive decompression and greater stability 3
• Shown to improve myelopathy with minimal operative morbidity 3
• Typically reserved for more complex cases with severe instability or deformity 3

Posterior Surgical Approaches

Laminoplasty

• Comparable to anterior approaches for multilevel compression 1
• Preserves posterior elements while expanding the spinal canal 4
• Preferred when multiple segments require decompression in patients with preserved cervical lordosis 5
• Less associated with late deformity compared to laminectomy alone 1

Laminectomy

• Provides comparable near-term improvement to other approaches 1
• However, associated with higher rates of late deterioration and deformity 1
• Not recommended as standalone procedure due to risk of late deterioration 1

Laminectomy with Arthrodesis (Fusion)

• Comparable to anterior approaches for improvement in CSM 1
• Addition of fusion helps prevent late deformity associated with laminectomy alone 1
• Should be considered when stability is an issue over time 1

Decision-Making Algorithm for Surgical Approach

Factors Favoring Anterior Approach (ACDF/ACCF):

• Compression primarily at disc levels 2, 5
• 1-3 level disease 1
• Presence of kyphotic deformity 5, 6
• Significant anterior compression from osteophytes or ossification of posterior longitudinal ligament 5
• Need for direct decompression of ventral pathology 5, 6

Factors Favoring Posterior Approach (Laminoplasty/Laminectomy with fusion):

• Multilevel disease (≥4 levels) 1
• Preserved or lordotic cervical alignment 5
• Compression primarily from posterior elements 5
• Congenital stenosis with multilevel compression 5, 6

Important Considerations and Pitfalls

• Standalone laminectomy should be avoided due to risk of late deterioration and kyphotic deformity 1
• Anterior approaches directly address ventral pathology but may be technically challenging for multilevel disease 5, 6
• Posterior approaches are better suited for multilevel compression but require preserved lordosis for indirect decompression 5
• Surgical treatment is recommended over conservative management for moderate to severe myelopathy 1
• For mild myelopathy, both surgical and nonsurgical approaches may be considered in the short term 1
• The presence of kyphotic deformity is a critical factor - posterior approaches may worsen kyphosis 5, 6

Outcomes and Prognosis

• All surgical approaches provide near-term functional improvement for CSM 1
• Benefits of surgical decompression can be maintained for at least 5 years and up to 15 years postoperatively 1
• Anterior approaches may provide better outcomes when addressing specific ventral pathology 5, 6
• Posterior approaches may be more suitable for diffuse multilevel compression 5
• Surgical intervention generally prevents progression of myelopathy and improves neurological status regardless of approach 5