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Topic of the Issue: Review Article

Surgical management of cervical
spondylotic myelopathy
N. Muthukumar1,2

1
Departments of Neurosurgery, Madurai Medical College, 2Devadoss Multispeciality Hospitals, Madurai, India

Abstract
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
Address for correspondence: well as the complications and prognosis of surgery for cervical spondylotic
Dr. N. Muthukumar,
Muruganagam, 138, Anna Nagar, myelopathy. Choice of surgical approach for CSM should be based on the
Madurai – 625 020, India. clinical and radiological characteristics of the individual patient and not
E-mail: drnmuthukumar@yahoo.com on the preferences of the surgeon.
Received : 22-03-2012
Review completed : 22-03-2012 Key words: Anterior cervical discectomy, cervical spondylotic myelopathy,
Accepted : 26-03-2012 laminectomy, laminoplasty, lateral mass fusion, spinal fusion, surgery

Cervical spondylotic myelopathy (CSM) is emerging as
the most common cause of spinal cord dysfunction in
the elderly worldwide. With the average life expectancy
increasing worldwide, it is understandable that in future
the number of patients with CSM requiring medical
attention will increase significantly. In the past decade,
our understanding of the biomechanics of the spine has
improved along with advances in spinal instrumentation.
This has led to significant changes in the surgical
management of CSM. Hence, a review of the current status
of the various surgical options available for this disease
entity is necessary. This review will discuss the indications,
advantages and limitations of the various commonly
available surgical techniques for CSM. For brevity’s sake,
details of surgical techniques will not be discussed.
The goals of surgical treatment of CSM are the following:
1. Improvement or preservation of neurological function,
2. Prevention or correction of spinal deformity, and
3. Maintenance of spinal stability.[1] The aforementioned
goals should be accomplished with least morbidity to
the patient. Recent studies have shown that there are
wide variations in the choice of surgical approach to the
degenerative disorder of the cervical spine based on an
individual surgeon’s preferences.[2] Studies, including the
recent AOSpine International multicenter prospective
study, have also shown that the majority of the spine
surgeons prefer the anterior approach in 51–60% of
cases, posterior approach in about 35% and a combined
approach in the remaining.[3,4] This is mainly due to the
variations in the clinical and radiological parameters and
to some extent due to surgeons’ preferences.[3,5]

Access this article online Indications and Timing of Surgical

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At present, there is consensus that a modified Japanese
PMID:
*** Orthopedic Association score (mJOA) of ≤ 12 is a definite
indication for surgery in patients with CSM. [6] For
DOI: patients who have a mJOA score of >12 on presentation,
10.4103/0028-3886.96402
the decision to proceed with surgery should be based

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Muthukumar: Surgery for cervical spondylotic myelopathy
on an individualized basis. The timing of surgery
depends upon the patient’s clinical presentation. A
rapid neurological decline will require a more urgent
intervention whereas a stable deficit can be approached
in an elective manner.[7] When indicated, surgery should
be performed within six months to one year of symptom
onset to achieve good results.[8]
Choice of Operative Approach
The choice of operative procedure should take into
consideration the individual patient’s clinical and
radiological characteristics, age, co-morbidities,
lifestyle (smoking etc.), procedure-specific risks and
finally, the experience and comfort level of the surgeon
with various surgical procedures. Several important
questions should be carefully considered while choosing
the surgical approach as suggested by Komotar and
colleagues.[7] 1. Location of compression: anterior or
posterior: Logically, a ventral compressive pathology
should be treated by an anterior approach and vice
versa, although there might be exceptions to this rule.
2. Single or multilevel compression: Anterior interbody
grafting beyond two levels is associated with increased
rate of pseudoarthrosis. In such cases, supplemental
posterior stabilization might be required or a single-
stage posterior approach might be more appropriate. [7]
3. Presence or absence of congenital spinal stenosis,
4. Alignment of the cervical spine: Is the spine lordotic,
straight or kyphotic? For example, posterior procedures
are primarily indicated for lordotic or possibly, straight
spines. Standalone posterior decompressive procedures
are contraindicated for fixed kyphotic spines.5. Presence
or absence of instability: Severe subluxation visualized
on static images or any increase noted in dynamic images
necessitates stabilization and fusion. 6. Patient’s lifestyle-
related factors: Smoking is a well-known factor associated
with nonunion and pseudoarthrosis. This factor should
be factored into the equation while choosing the surgical
approach for a chronic, heavy smoker. 7.Other factors
such as the presence of developmental stenosis, pre-
existing neck pain and prior cervical spine surgery, if
any, should be considered.[5] For example, postoperative
axial pain is a well-known complication of laminoplasty
and hence, in patients with significant preoperative neck
pain this factor should be taken into consideration before
choosing the appropriate approach.
Failure of surgical treatment is often due two factors:
either poor patient selection or poor choice of surgical
procedure.
Anterior Approaches
The advantage of an anterior approach is that it addresses
the ventral pathology by direct decompression and if
202
grafting is added, immediate stability of the cervical
spine is achieved.[9] A variety of surgical approaches
are available for anterior decompression of the cervical
spinal cord in CSM. In this review, emphasis is placed
only on the more commonly used approaches: these
include 1. Anterior cervical discectomy alone without
fusion, 2. Anterior cervical discectomy with fusion
with or without supplemental instrumentation, 3.
Anterior cervical corpectomy and fusion with or without
instrumentation.
Anterior Cervical Discectomy without Fusion
The currently accepted indications for anterior
cervical discectomy without fusion are: 1. Single-level
compression anteriorly, 2. Normal cervical lordosis,
3. No instability seen on dynamic radiographs. Instability
is defined as: a) subluxation of more than 3.5 mm on
static radiographs, b) more than 11 degrees of angulation
between adjacent segments, and c) subluxation of
more than 4 mms on dynamic radiographs.[10] Special
attention should be paid to the sagittal alignment of
the cervical spine, i.e. both overall cervical lordosis as
well as segmental lordosis at the affected level. Recent
studies have shown that the current trend among spine
surgeons for single-level disease is moving towards
fusion than discectomy alone even though there is
no evidence to substantiate the superiority of fusion
in single-level disease.[2] For single level disease, The
Joint Guidelines Committee of american association
of neurological surgeons/congress of neurological
surgeons found that functional outcomes were the same
between anterior cervical discectomy alone and anterior
cervical discectomy with fusion.[11] The advantages
of standalone discectomy are: avoidance of implants
reduces the cost of surgery, shorter surgical time, shorter
hospital stay and sick leave, avoidance of the donor site
morbidity if autologous grafts are used.[12] However, a
recent study has shown that even though short-term
results of standalone discectomy are equal to discectomy
with fusion, in the long term approximately one-third of
patients complain of disabling neck pain.[12]
Anterior Cervical Discectomy with Fusion
The indications for anterior cervical discectomy
and fusion are as follows: 1. Two level compression
anteriorly, 2. Presence of segmental kyphosis i.e.
angulation of more than 11 degrees between adjacent
segments, 3. Instability seen in static or dynamic
radiographs. When Factors 2 and 3 are present, even
patients with single-level disease should undergo fusion.
The fusion can be an uninstrumented fusion [Figure 1]
or an instrumented one [Figure 2]. The material that is
used to replace the disc is most often autograft [Figure 3],
less commonly, allograft or spacers made of titanium
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Muthukumar: Surgery for cervical spondylotic myelopathy
a b
Figure 1: Uninstrumented fusion. (a) preoperative MRI showing
compression at C5-C6 and C6-C7 levels, (b) Postoperative sagittal
reconstructed CT showing unistrumented fusion with tricortical grafts at
the respective disc spaces (arrows)
a b
Figure 3: Instrumented fusion with autograft. (a) Immediate
postoperative radiograph, (b) Postoperative radiograph at 4 months
showing bony fusion
[Figure 4], polyetheretherketone (PEEK) or carbon. There
are specific advantages and disadvantages of using the
above mentioned struts or spacers and these would be
highlighted later in the discussion.
Anterior Cervical Corpectomy
Anterior cervical corpectomy is indicated for 1. patients
with pathology that extends beyond the interspace
level (for example, migrated disc fragment behind
the vertebral body or an associated ossified posterior
longitudinal ligament (OPLL) behind the vertebral
body), 2. patients with a narrow spinal canal who cannot
be treated by a posterior only procedure because of
associated kyphosis or instability, for example, a patient
with an irreducible kyphotic deformity for whom
an entire body must be resected to restore alignment
and lordosis.[11] The advantages of anterior cervical
corpectomy for multilevel disease include providing
fewer sites at which fusion must occur as well as
Neurology India | Mar-Apr 2012 | Vol 60 | Issue 2
a b c
Figure 2: Instrumented fusion. (a) preoperative MRI showing single-
level disc protrusion at C5-C6, (b) Postoperative radiograph showing
instrumented fusion, (c) Postoperative MRI of the same patient showing
adequate decompression and stabilization
a b c
Figure 4: Instrumented fusion with standalone cage. (a) Preoperative MRI
showing single-level disc causing cord compression, (b) Intraoperative
photograph with the standalone titanium spacer in situ, (c) Postoperative
radiograph with the spacer in situ
decreasing the operating time by preparation of one graft
and one recipient site rather than multiple grafts and
multiple recipient sites.[13] Anterior cervical corpectomy
can be followed by an uninstrumented fusion or more
commonly, an instrumented fusion. Instrumented
fusion for corpectomy is currently gaining popularity
in view of the decreased rates of pseudoarthrosis and
graft dislodgement.[11] The materials that can be used as
struts or spacers include: autologous iliac crest grafts,
fibular allografts, PEEK or carbon cages, and titanium
cages. There are several advantages and disadvantages
of using these different materials.
Autologous Iliac Crest Graft
Iliac crest graft is the traditional graft used in spine
surgery. The advantage is the well-known high rates
of fusion. However, the disadvantages include donor
site morbidity like pain, hernia, and lateral femoral
cutaneous nerve injury. The angulation of the iliac crest
might pose problems when more than two levels of
corpectomy is done.[14]
Fibular Allografts
The advantages of fibular allograft include: avoidance
of donor site morbidity, unlimited supply, ready
availability in different sizes and shapes, it can be
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Muthukumar: Surgery for cervical spondylotic myelopathy

used for more than two levels of corpectomy unlike
autologous iliac crest grafts. The disadvantages
include: fusion rates are inferior to autologous grafts,
especially, when used for more than two levels of
corpectomy.[14]
PEEK Cages
The advantages include avoiding donor site morbidity,
ready availability in different sizes, radiolucency which
enables assessment of fusion postoperatively, modulus
of elasticity of this material is almost similar to bone and
hence, they have lesser chance of telescoping or sinking
into the adjacent vertebral bodies unlike titanium cages.
Titanium Cages
These cages are available in different sizes; when
combined with ventral plate fixation [Figure 5] they
provide excellent stability by resisting flexion, extension
and lateral bending.[15] However, they also have several
disadvantages like: their high modulus of elasticity often
results in their migration (telescoping) into the end plates
of adjacent vertebral bodies, it is difficult to assess fusion,
and, when revision surgery is required, the titanium
cages are difficult to revise.[14]
Limitations of anterior approaches: Studies have shown
that for multilevel compression (≥3 levels), the anterior
approach is associated with more complications but with
better functional recovery in the short term but in the
long term, the results are no different when compared
to the posterior approach[9] This is attributed to the late
deterioration caused by adjacent segment degenerative
changes.[16,17] Failures after anterior approaches for CSM
are mainly due to: 1. Failure to fully appreciate the
extent of compression in the rostrocaudal and transverse
directions and, 2. Loss of midline orientation while
performing the decompression.[13]
Posterior Approaches for Cervical
Spondylotic Myelopathy
Advantages and disadvantages of the posterior
approach:
The major advantage of the posterior approach is
the familiarity of the surgeon with the procedure.
Anterior approaches may be difficult for obese
patients or for those with short, thick necks.[7] Certain
risks specific to the anterior procedure like recurrent
laryngeal nerve palsy, swallowing dysfunction, risk
of durotomy and resultant cerebrospinal fluid (CSF)
leak when there is associated OPLL are all eliminated.
Other advantages include: 1. As these procedures
are commonly performed for ³3-level disease, quick
decompression of multiple segments can be performed
which is important in debilitated patients who cannot
tolerate prolonged surgery, 2. Risks of dislodgement
of long strut grafts used in anterior approaches are
eliminated, 3. Motion-preserving operations like
laminoplasty allow decompression without necessitating
fusion and its attendant complications like adjacent
segment degeneration and, 4. Posterior approaches
allow decompression of segments at future risk in
one operation without substantially increasing patient
morbidity.[18]
The main disadvantage of the posterior approach is
that it cannot be done in patients with kyphotic spines
as the surgical procedure only indirectly decompresses
the cord and the decompression effect is dependent
on posterior migration of the cord from the ventral
pathology. This posterior migration cannot take place
in patients with fixed kyphotic spines and hence, the

a b c
Figure 5: Titanium expandable cage-plate combination construct for stabilization following cervical corpectomy. (a) and (b) Postoperative radiographs
showing the expandable cage (single arrow) and the attached plates (double arrowheads) that help secure the cage to the vertebral bodies above and
below, (c) Intraoperative photograph showing the expandable cage-plate construct in situ

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Muthukumar: Surgery for cervical spondylotic myelopathy
posterior approach is contraindicated in such patients.
Posterior approaches like laminoplasty are associated
with C5 root palsies which is a unique complication
of laminoplasty. Moreover, posterior approaches can
exacerbate pre-existing subclinical subluxations or
deformities, if they are not accompanied by fusion. They
are also associated with increased postoperative pain
than anterior approaches.
Currently, the posterior approaches in common clinical
practice are: 1. Laminectomy, 2. laminectomy with lateral
mass fusion and, 3. Laminoplasty.
Laminectomy
Laminectomy was the most commonly used surgical
procedure for CSM prior to the introduction of anterior
approaches. However, in recent times, the popularity
of standalone laminectomy has waned due to the well-
recognized complications of the laminectomy and the
availability of better alternatives. The complications of
standalone laminectomy include: 1. The development
of post-laminectomy kyphosis, the incidence of
which varies from 11–47%,[18] 2. Development of post-
laminectomy membranes, 3. Future posterior fusions are
compromised by the dura being exposed over multiple
levels and, 4. Even if the patient does not develop
neurological deterioration due to post-laminectomy
kyphosis, the stretching of the posterior musculo-
ligamentous structures due to altered alignment often
leads to disabling neck pain. However, laminectomy still
has a role in properly selected patients with the following
features: patients with preserved cervical lordosis and
without radiological instability visualized in dynamic
radiographs if they have 1. Cervical canal stenosis,
2. ≥3-level disease, 3. Associated posterior compression
due to thickened infolded ligamentum flavum, and
4, in patients with associated multilevel OPLL. While
performing standalone laminectomy specific care should
be taken not to violate the facet joints to avoid post-
laminectomy kyphosis.
Laminectomy with Lateral Mass Fusion
There are several advantages of combining lateral
mass fusion with laminectomy. These include: 1.
Fusion prevents the development of post-laminectomy
kyphosis, 2. Patients with multilevel disease with
associated subclinical instability brought out in
dynamic radiographs can be dealt with by this
procedure, 3. Fusion decreases the chance of dynamic
compression due to repetitive microtrauma that
is known to occur in CSM, [11,19] 4. As laminoplasty
is known to cause worsening of axial neck pain,
laminectomy with lateral mass fusion may be preferable
in patients with multilevel disease with significant
Neurology India | Mar-Apr 2012 | Vol 60 | Issue 2
neck pain preoperatively,[20] 5. Patients with multilevel
disease with neutral cervical alignment or in those with
reducible cervical kyphosis, lateral mass fusion is an
option as the cervical alignment can be restored prior
to securing the instrumentation.[18] In these patients,
performing standalone laminectomy or laminoplasty
may worsen the cervical alignment. Currently, the
commonly accepted indications for laminectomy with
lateral mass fusion include: 1. multilevel cervical stenotic
myelopathy (≥3-level disease) with preserved cervical
lordosis, 2. multilevel cervical stenotic myelopathy
(≥3-level disease) with subclinical instability requiring
posterior decompression with fusion. This procedure
can also be done in selected patients with multilevel
disease and neutral cervical alignment or a reducible
cervical kyphosis in whom a lordotic alignment can be
achieved by appropriate positioning before securing
the screw-rod system.[18]
Even though multiple techniques for posterior cervical
fusion were available historically including onlay
grafts, spinous process wiring, facet wiring, Halifax
interlaminar clamps, lateral mass plates and screws,[21]
they have been replaced by the currently popular lateral
mass fusion using polyaxial screw-rod constructs. The
currently available literature points to the good outcomes
associated with this procedure.[20,22] The other option
is cervical pedicle screw fixation.[23] However, cervical
pedicle screw fixation is not widely used at present, as
safe insertion of cervical pedicle screws often requires
navigation guidance.
There are four different techniques of placing lateral
mass screws: Roy Camille, Magerl, Anderson and An.[7]
This author prefers to use the An technique in which
the entry point is located 1 mm medial to the midpoint
of the lateral mass and the direction of the screw is
30* laterally and 15* rostrally [Figure 6]. The lateral
trajectory takes the screw away from the vertebral artery
which lies ventral to the lateral mass and the rostral
angulation is to avoid the nerve root traversing deep
to the superior facet of the caudal spinal segment.[7] In
addition, such a trajectory also increases the volume
of bony purchase in the lateral mass. Usually, to
achieve bicortical purchase 3.5-mm diameter screws
with a length of 14 mms are used. This author prefers
to insert the lateral mass screws prior to performing
laminectomy. After laminectomy, under fluoroscopic
guidance a lordotic alignment of the cervical spine is
achieved prior to securing the rods [Figure 7].
Laminoplasty
Laminoplasty was popularized in the late 1970s
by Japanese spine surgeons who recognized the
complications of standalone laminectomy. [24] The
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Muthukumar: Surgery for cervical spondylotic myelopathy

a b c e
Figure 6: Lateral mass fusion. (a) Preoperative MRI showing multilevel cervical stenosis with cord compression, (b) Postoperative lateral radiograph
showing the lateral mass screw-rod construct, (c) Six months’ postoperative MRI scan of the same patient showing good decompression, (d) and (e)
Postoperative axial CT scans showing the direction of lateral mass screws and bicortical purchase

lordosis if they have: 1. multilevel cervical stenotic

a b
myelopathy (≥3-level disease), 2. Cervical canal stenosis,
3. Posterior cord compression at multiple levels. The
contraindication for laminoplasty is the presence of
cervical kyphosis. As postoperative axial neck pain is
common in patients who undergo laminoplasty, the
decision to perform laminoplasty in a patient with
significant preoperative neck pain should be taken
cautiously.

Several modifications of cervical laminoplasty have been

c d e are created at the lamina-facet junction; the groove
Figure 7: Lateral mass fusion. (a), (b), (c) Sequential intraoperative
photographs showing the placement of lateral mass screws prior to
laminectomy (a), after laminectomy prior to placement of rods (b),
and securing the rods after restoring lordotic alignment (c); (d)and
(e) postoperative AP and lateral radiographs after lateral mass screw
placement
advantages of laminoplasty include: 1. It is a
motion-preserving procedure, 2. The disadvantage
of laminectomy, namely, the development of post-
laminectomy membrane is avoided, 3. Unlike in
laminectomy, because the posterior bony elements are
preserved, revision posterior surgery is not compromised
by the exposed dura, 4. If necessary, laminoplasty can
be combined with fusion,[25] 5. In patients who develop
adjacent segment degeneration after multilevel anterior
decompression and fusion, laminoplasty is a viable
option as the surgical procedure is carried out in virgin
surgical territory with the added advantage of not
requiring additional fusion and further predisoposition
to degeneration at adjacent segments.[26]
Currently the commonly accepted indications for
laminoplasty include: Patients with preserved cervical
described. However, they can be basically classified into
two groups: open-door laminoplasty and double-door
laminoplasty. In open-door laminoplasty, two grooves
retains the inner cortex of the lamina on the hinge side
and a through-and-through groove is made on the open
side. The lamina is kept open by one of the following
methods: autologous grafts, allografts, hydroxyapatite
spacers, titanium miniplates or simply by suturing the
spinous processes to the facets. This author prefers to
use autologous grafts to keep the laminar door open and
the grafts are kept at alternate levels. For example, for
a four-level laminoplasty of C3–C6, grafts are inserted
only at C3 and C5. As the supraspinous and interspinous
ligaments are kept intact, the closing force generated
by the intact ligaments keeps the laminar door open
even at the levels where grafts are not placed [Figures 8
and 9]. A ledge created in the graft helps secure the
opened lamina in position without the need for any
fixation using sutures or miniplates. In double-door
laminoplasty, two grooves are created, one on either side
at the lamina-facet junction. In both the grooves, the inner
cortex is kept intact. The laminae are then opened and a
graft is kept in between the opened laminae. The grafts
can be sutured in place using non-absorbable sutures
[Figures 10 and 11]. Both open-door and double-door

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Muthukumar: Surgery for cervical spondylotic myelopathy

a b

c a b
Figure 8: Open-door laminoplasty. (a) and (b) Postoperative axial CT Figure 9: Open-door laminoplasty. (a) Preoperative MRI showing
after open-door laminoplasty in Panel A, the arrow points to the laminar multilevel cord compression, (b) Postoperative MRI showing good
door remaining open even though there is no graft at that level (refer decompression
text for details); single arrowhead in B points to the graft in situ, double
arrowheads point to the tilted spinous process, single arrow points to
the ledge in the graft that secures the graft to the lamina; (c) Sagittal
reconstructed CT showing the opened laminae (arrowheads) with
increased sagittal diameter of the spinal canal at the operated levels

a b
Figure 10: Double-door laminoplasty. (a) and (b) Pre- and postoperative
axial CT scans showing the effect of double-door laminoplasty; arrows
point to the grooves in the lamina-facet junction, arrowhead points to the
graft in situ
laminoplasty give equally good functional outcomes.
However, there are certain technical factors that should
be taken into consideration for a successful outcome in
laminoplasty. These include: 1. The laminar door should
be opened for a minimum of 10-12 mms; openings less
than this dimension will not lead to adequate space for
the cord to shift posteriorly and openings more than
18 mms will lead to increased shift resulting in higher
incidence of segmental root palsy,2. An opening of 10-
12 mms will increase the anteroposterior diameter of the
spinal canal by 4-5 mms and the cross-sectional area by
90-120 mm2, 3. A posterior shift of the cord of ≥3 mms
is required for good outcomes.[27] A study conducted
by this author showed that a graft size of 10-12 mms
increased the AP diameter of the canal by 5-6 mms
and was associated with good outcome (unpublished
data). Moreover, the AP diameter of the canal increased
more in open-door laminoplasty than in double-door
laminoplasty even though this was not found to be
statistically significant (unpublished data). There are
certain unique complications of laminoplasty which
a b
Figure 11: Double-door laminoplasty. (a) Preoperative MRI showing
multilevel compression with intramedullary signal changes,
(b) Postoperative MRI showing good decompression with reduction of
intramedullary signal
include: 1. Postoperative axial neck pain,[28] 2. Segmental
root palsy with an incidence of approximately 5%,[29]
3. Closing of the laminar door[30] and, 4. Worsening of
the cervical alignment.
Combined Approaches
Studies have also shown that the majority of the spine
surgeons prefer the anterior approach in 51–60% of
cases, posterior approach in about 35% and a combined
approach in the remaining. [3,4] The indications for
combined approaches are: when there is both ventral
and dorsal compression of the thecal sac [Figure 12]
or if a patient with multilevel disease had developed
kyphosis.[14] For example, a patient with significant
ventral and dorsal osteophytic compression might not
have adequate decompression with a single ventral or
dorsal surgery.[14] In patients with severe osteoporosis

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Muthukumar: Surgery for cervical spondylotic myelopathy
Figure 12: Combined approach. Postoperative radiograph of a patient
with cervical canal stenosis from C3–C6 with focal ventral compression
at C4-C5; patient underwent anterior cervical discectomy with fusion at
C4-C5 followed by lateral mass screw fixation and laminectomy from
C3–C6 in the same sitting (one lower screw is in C5 and another at C6
because of fracture of one lateral mass while placement)
or those with poor bone quality due to renal disease or
heavy smokers in whom poor bone fusion is anticipated,
if a multilevel corpectomy is necessary, a combined
approach should be undertaken.[31] A detailed discussion
of whether the anterior or posterior procedure should
be done first or whether the patient requires a 540*
procedure and whether all the procedures should be
done in the same sitting or in separate sittings is beyond
the scope of this review.
Complications of Surgery for CSM
Knowledge of the rate and type of complications that occur
after surgery for CSM is necessary for patient counseling
and quality improvement.[32] A recent AOSpine North
America cervical spondylotic myelopathy study found
that the overall perioperative complication rate was
15.6%, the rate of major complications was 7% and the
delayed complication rate was 4%. The complication
rates of anterior, posterior and combined approaches
were 11%, 19% and 37% respectively.[32] Interestingly,
anterior fusions and posterior fusions had an almost
similar rate of complications irrespective of whether
the procedure involved corpectomy or laminoplasty.[32]
Older age, longer operative time and combined anterior-
posterior approaches were associated with higher
complication rates.
Prognosis of Surgery for Cervical Spondylotic
Myelopathy
A recent AOSpine study found that 75% of patients who
undergo surgery for CSM have a more than 2-point
increase in their mJOA score.[33] The Joint Guidelines
208
Committee of the American Association of Neurological
Surgeons/Congress of Neurological Surgeons found
that surgery for CSM leads to significant improvement
that is maintained for a minimum of 5 years to as long
as 15 years postoperatively.[34] Another recent study has
shown that surgery for CSM is associated with significant
functional recovery and such recovery reaches a plateau
at six months after surgery.[35] However, approximately,
4% of patients show neurological deterioration after
decompressive surgery. [35] The compression ratio
assessed by magnetic resonance imaging (MRI) can
provide a clue to the prognosis. This ratio is assessed by
dividing the smallest antero-posterior diameter of the
spinal cord by the broadest transverse diameter of the
spinal cord.[36] If the ratio is 0.4, especially, after surgery,
the chance of neurological recovery is poor. Conversely,
if there is an increase in the compression ratio to >0.4 or
the transverse area of the spinal cord increases to more
than 40 mm2 in the postoperative scan, the outcome is
likely to be good.[37] The presence and persistence of
focal high signal intensity in T2 images and the lack
of re-expansion of the cord in the postoperative MRI
obtained six months after surgery are associated with
poor outcomes.[38] If the postoperative MRI shows good
decompression and yet the patient has less than expected
outcome, then other causes that might contribute to
disability in these patients like lumbar canal stenosis,
normal pressure hydrocephalus and neurodegenerative
conditions should be sought.[38]
Conclusions
Significant advances have taken place in the surgical
management of CSM. Therefore, it behooves the
contemporary spine surgeon to be familiar with the
indications, advantages, limitations, complications and
prognosis of various operative approaches for CSM.
The choice of surgical approach should not be based
on the preferences of the surgeon but on the individual
patient characteristics. The “science” of spine surgery
consists of learning the needed surgical skills. The “art”
of spine surgery is choosing the right approach for the
right patient.
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How to cite this article: Muthukumar N. Surgical management of
cervical spondylotic myelopathy. Neurol India 2012;60:201-9.
Source of Support: Nil, Conflict of Interest: None declared.
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