Comparison between anterior and posterior decompression with instrumentation for cervical spondylotic myelopathy: sagittal alignment and clinical outcome

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>A variety of anterior, posterior, and combined approaches exist to decompress the spinal cord, restore sagittal alignment, and avoid kyphosis, but the optimal surgical strategy remains controversial. The authors compared the anterior and posterior approach used to treat multilevel cervical spondylotic myelopathy (CSM), focusing on sagittal alignment and clinical outcome.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>The authors studied 48 patients with CSM who underwent multilevel decompressive surgery using an anterior or posterior approach with instrumentation (24 patients in each group), depending on preoperative sagittal alignment and direction of spinal cord compression. In the anterior group, a 1–2-level corpectomy was followed by placement of an expandable titanium cage. In the posterior group, a multilevel laminectomy and posterior instrumentation using lateral mass screws was performed. Postoperative radiography and clinical examinations were performed after 1 week, 12 months, and at last follow-up (range 15–112 months, mean 33 months). The radiological outcome was evaluated using measurement of the cervical and segmental lordosis.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>Both the posterior multilevel laminectomy (with instrumentation) and the anterior cervical corpectomy (with instrumentation) improved clinical outcome. The anterior group had a significantly lower preoperative cervical and segmental lordosis than the posterior group. The cervical and segmental lordosis improved in the anterior group by 8.8 and 6.2°, respectively, and declined in the posterior group by 6.5 and 3.8°, respectively. The loss of correction was higher in the anterior than in the posterior group (−2.0 vs −0.7°, respectively) at last follow-up.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>. These results demonstrate that both anterior and posterior decompression (with instrumentation) are effective procedures to improve the neurological outcome of patients with CSM. However, sagittal alignment may be better restored using the anterior approach, but harbors a higher rate of loss of correction. In cases involving a preexisting cervical kyphosis, an anterior or combined approach might be necessary to restore the lordotic cervical alignment.</jats:p></jats:sec>

Correlation Between Cervical Sagittal Alignment and Functional Capacity in Cervical Spondylosis

“…[24][25][26] More recently, there has been an increase in the number of studies demonstrating that there is also an important correlation between the postoperative outcomes of spine interventions and sagittal parameters. 15,20,27 However, studies that correlate cervical sagittal parameters with quality of life indicators in patients who were not submitted to surgical treatment are extremely rare. This study analyzed the correlation of these radiographic parameters with indicators of quality of life and functional ability in a sample of patients with cervical spondylosis without an indication for surgical treatment or who opted not to undergo surgical treatment.…”

Four-level anterior cervical discectomies and cage-augmented fusion with and without fixation

“…Multilevel affection of the cervical spine represents a challenging problem [3,15]. A variety of anterior, posterior and combined approaches with and without instrumentation has been advocated [3].…”

“…Multilevel affection of the cervical spine represents a challenging problem [3,15]. A variety of anterior, posterior and combined approaches with and without instrumentation has been advocated [3]. As advanced cervical spondylosis most typically involves compression of the cord by anterior structures, the anterior approach allows for direct decompression of the spinal cord and excision of these pathologic elements [19].…”

“…As advanced cervical spondylosis most typically involves compression of the cord by anterior structures, the anterior approach allows for direct decompression of the spinal cord and excision of these pathologic elements [19]. The aim of surgery is to achieve an adequate decompression of the spinal cord, restore or maintain sagittal alignment, and avoid kyphosis [3]. Reconstruction of the defect after discectomy is still a matter of debate among spine surgeons.…”

“…However, the choices become limited in fourlevel disease. Furthermore, the necessity of adding anterior and/or posterior instrumentation in multilevel disease is still debatable [3]. Recently, stand-alone cages have been widely applied in mono-and bisegmental pathologies [8,16].…”