What are the surgical approaches for cervical myelopathy?

Surgical Approaches for Cervical Myelopathy

Surgical decompression is strongly recommended for moderate to severe cervical myelopathy (mJOA score ≤12), with benefits maintained for at least 5 years and up to 15 years postoperatively. 1

Classification and Treatment Decision Algorithm

• Cervical myelopathy is classified as mild (mJOA score >12), moderate, or severe (mJOA score ≤12) based on the degree of impairment in arm and leg function 2
• Mild cervical myelopathy can be treated with either surgical decompression or nonoperative therapy for the first 3 years after diagnosis 2, 1
• Moderate to severe cervical myelopathy should be treated with surgical decompression to prevent further neurological deterioration 1
• Delaying surgical intervention in patients with moderate to severe myelopathy can lead to irreversible spinal cord damage 1

Anterior Surgical Approaches

• Anterior Cervical Discectomy and Fusion (ACDF)

  • Optimal for 1-2 level disease 1, 3
  • Provides direct decompression of anterior pathology 3
  • Allows for correction of kyphotic deformity 3

• Anterior Corpectomy and Fusion

  • Recommended for 3-segment disease 1, 3
  • Provides improved decompression for patients with retrovertebral disease 3
  • Ideal for patients with kyphosis or significant neck pain 3
  • Subtotal corpectomy with reconstruction can improve neurological scores from an average of 7.9 preoperatively to 13.4 at 15-year follow-up 1
  • Risk of pseudarthrosis in approximately 10.9% of cases 1, 4
  • Inadequate stabilization can lead to cage movement and hardware failure 4

Posterior Surgical Approaches

• Laminoplasty

  • Preserves motion and reduces axial neck pain 1, 3
  • Appropriate for multilevel compression (≥3 levels) 3
  • Requires lordotic cervical alignment to be effective 5
  • Risk of post-surgical kyphosis in approximately 10% of patients 1, 6
  • Risk of C5 nerve palsy, especially when laminae are elevated to an angle >60° 1, 6

• Laminectomy with Fusion

  • Prevents post-laminectomy kyphosis 1, 6
  • Complications may include neurological deterioration, deep infection, and pseudarthrosis 1
  • Historically yielded poor results from late deformity and neurologic deterioration, but shows improved results with good surgical technique 3

Approach Selection Factors

• Number of involved levels (1-2 levels: anterior approach; ≥3 levels: posterior approach) 1, 3
• Location of compression (anterior vs. posterior) 5
• Cervical alignment (kyphosis favors anterior approach; lordosis favors posterior approach) 5
• Developmental narrowing of the canal (favors posterior approach if lordotic) 5
• Presence of instability (requires fusion) 5

Complications and Considerations

• Inadequate surgical decompression has been reported in 10% of cases, with a higher rate (23%) associated with anterior approaches 7
• Posterior or combined approaches showed no cases of inadequate decompression in one study 7
• Post-surgical kyphosis occurs in approximately 10% of patients after laminoplasty 1, 6
• Pseudarthrosis can occur in approximately 10.9% of cases after corpectomy 1, 4
• C5 nerve palsy can develop after surgery, especially with posterior approaches 1, 6

Revision Surgery Options

• Anterior revision with plate stabilization can be effective for pseudarthrosis, with 83.3% good/excellent outcomes 4
• Posterior approach revision can be a viable option for hardware failure, with a 94% fusion rate compared to 45% with anterior revision 4
• Combined anterior-posterior approaches may be necessary for complex cases with kyphosis and developmental narrowing 5

Outcomes

• Surgical intervention is superior to conservative management for moderate to severe CSM 8
• Benefits of surgery for moderate to severe cervical myelopathy are maintained for at least 5 years and up to 15 years postoperatively 2, 1
• Patients with severe myelopathy show significant improvement after surgical intervention 1
• Early recognition and treatment before the onset of significant spinal cord damage is essential for optimal outcomes 8