What is the best treatment approach for a patient with multilevel degenerative changes in the cervical spine (c-spine)?

Treatment of Multilevel Degenerative Cervical Spine Changes

For multilevel degenerative cervical spine disease, the treatment approach depends critically on whether myelopathy is present: if myelopathy exists with moderate-to-severe stenosis at ≥2 levels, surgical decompression is indicated, with laminoplasty preferred over laminectomy alone for multilevel posterior compression when cervical lordosis is preserved. 1

Initial Assessment and Conservative Management

Determining Surgical Candidacy

• Document presence or absence of myelopathy by examining for progressive hand weakness, dexterity loss, gait instability, and bilateral Hoffman's signs, which confirm spinal cord compression requiring surgical intervention 1, 2
• Obtain MRI to confirm multilevel compression showing significant central canal stenosis at multiple levels, as this determines whether anterior versus posterior approaches are appropriate 1
• Complete minimum 6-week conservative trial including active in-person physical therapy with documented attendance, NSAIDs or acetaminophen, and neuropathic pain medications before considering surgery 2

When Conservative Treatment is Appropriate

• Mild symptoms without myelopathy may be managed conservatively with physical therapy, pharmacological treatment, and lifestyle modifications 3
• Patients unsuitable for surgery due to comorbidities should continue conservative management 3

Surgical Decision-Making Algorithm

For Myelopathy with Multilevel Disease (≥3 Levels)

Posterior approaches are preferred when disease involves ≥4 segments, as this exceeds the 3-level threshold where posterior decompression becomes more favorable than anterior corpectomy 1

Laminoplasty (Preferred Posterior Option)

• Laminoplasty is recommended for multilevel posterior compression in patients with preserved cervical lordosis, offering 55-60% recovery rate on JOA scale 1
• Laminoplasty demonstrates superior outcomes compared to laminectomy alone with fewer late complications and better preservation of range of motion 1
• Postoperative kyphosis risk is significantly lower with laminoplasty (7%) compared to laminectomy alone (34%) 4

Laminectomy Considerations

• Laminectomy alone is acceptable for near-term functional improvement but carries increased risk of postoperative kyphosis (14-47% incidence) and late deterioration (23% at mean 9.5 years) 4
• Laminectomy should only be used in selected patients where risk of postoperative kyphosis is minimal 4
• Development of kyphosis does not necessarily correlate with neurological deterioration, though late deterioration remains a concern 4

Laminectomy with Fusion

• Laminectomy with fusion should be considered when stability is an issue or when preoperative cervical kyphosis exists 4
• This approach provides comparable near-term improvement to anterior techniques without the late deterioration seen with laminectomy alone 4

For Focal Compression at Limited Levels (≤3 Levels)

Anterior Approaches

• ACDF or ACCF are preferred for focal anterior compression at the disc level in patients requiring multilevel anterior decompression 4
• ACDF and ACCF yield similar results when anterior plate fixation is used, providing equivalent fusion rates 4
• Without anterior fixation, ACCF provides higher fusion rates than multilevel ACDF but carries higher graft failure risk 4
• ACDF should be considered over laminectomy for short-segment decompression when technically feasible, given laminectomy's association with late deterioration 4

For Cervical Kyphosis or Significant Instability

• Laminectomy with fusion is required to achieve adequate decompression, restore spinal alignment, and enhance stability 3
• Combined anterior-posterior approach may be necessary in severe deformities or multilevel involvement with significant instability 3

Critical Pitfalls and Monitoring

Postoperative Complications to Monitor

• Assess for hematoma formation requiring emergent reoperation for acute spinal cord compression 1
• Monitor for respiratory depression with parenteral pain control, particularly in patients with preoperative pain medication use 1
• Ensure adequate pain control to prevent delayed mobilization that increases DVT and pneumonia risk in myelopathic patients 1

Long-Term Follow-Up Requirements

• Monitor for late neurological deterioration occurring in approximately 23% of laminectomy patients at mean 9.5 years 4, 5
• Assess for postoperative instability development requiring potential future intervention 5
• Arrange occupational therapy for bilateral upper extremity involvement to address activities of daily living 1

Avoiding Common Errors

• Do not perform isolated laminoplasty if dynamic instability exceeds 3mm translational motion on flexion-extension radiographs, as fusion would be required in addition to decompression 1
• Verify that anterolisthesis reduces with positional changes before proceeding with decompression alone 1
• Counsel patients about realistic expectations including potential for postoperative kyphosis with multilevel laminectomies 5