Anterior Versus Posterior Approach for Treatment of Cervical Spondylotic Myelopathy: A Systematic Review

Lawrence, Brandon D. MD*; Jacobs, W. Bradley MD; Norvell, Daniel C. PhD; Hermsmeyer, Jeffrey T. BS; Chapman, Jens R. MD§; Brodke, Darrel S. MD*

doi: 10.1097/BRS.0b013e3182a7eaaf
Surgical Treatment of Cervical Spondylotic Myelopathy

Study Design. Systematic review.

Objective. We performed a systematic review to determine the comparative effectiveness and safety profiles of anterior versus posterior decompression procedures for multilevel cervical spondylotic myelopathy (CSM).

Summary of Background Data. CSM is a common cause of neurological dysfunction. It is well established that surgical decompression of the cervical spinal cord is an effective treatment option for CSM. Because of the lack of well-designed prospective studies, there remains a lack of consensus whether multilevel spondylotic compression is best treated via an anterior or posterior surgical route and whether one of these surgical approaches is superior in terms of patient outcomes and/or complication profiles.

Methods. We conducted a systematic search for literature published through September 2012. We sought to identify comparative studies (e.g., randomized controlled trials, cohort studies) comparing anterior with posterior procedures in patients with 2-level or greater cord compression resulting in CSM. Standardized mean differences were calculated to allow comparisons of the change (i.e., improvement or decline) in scores between anterior and posterior surgical procedures by study. Clinical recommendations were made through a modified Delphi approach by applying the GRADE (Grading of Recommendation Assessment, Development and Evaluation)/AHRQ (Agency for Healthcare Research and Quality) criteria.

Results. We identified 8 level III retrospective cohort studies that met the inclusion criteria from a total of 135 possible studies for review. With regard to effectiveness between the 2 approaches, improvements in JOA (Japanese Orthopaedic Association) scores were similar, whereas canal diameter change was larger after posterior surgery. With regard to safety, postoperative C5 palsy rates were similar, infection rates were lower with anterior surgery, and dysphagia rates were lower with posterior surgery.

Conclusion. This systematic review demonstrates that, for both effectiveness and safety, there is no clear advantage to either an anterior surgical approach or a posterior surgical approach when treating patients with multilevel CSM. With that, a surgical strategy developed on a patient-to-patient basis should be used to achieve optimal patient outcomes. In addition, development of a consensus for standardized reporting of outcome measures and complication profiles would facilitate improved comparisons across differing treatment centers and surgical techniques.

Evidence-Based Clinical Recommendations.

Recommendation. We recommend an individualized approach when treating patients with CSM accounting for pathoanatomical variations (ventral vs. dorsal, focal vs. diffuse, sagittal, dynamic instability) because there are similar outcomes between the anterior and posterior approaches with regard to effectiveness and safety.

Overall Strength of Evidence. Low

Strength of Recommendation. Strong

A systematic review was performed to evaluate the comparative effectiveness and safety of the anterior versus posterior approach in patients treated for multilevel cervical spondylotic myelopathy. There were similar effectiveness and safety profiles noted across the 8 articles meeting our inclusion criteria. Therefore, an individualized approach is recommended. Consensus on outcome measures and reported complication profiles need to be developed to facilitate improved future comparisons across different treatment centers and surgical techniques.

*Department of Orthopaedics, University of Utah, Salt Lake City, UT

Calgary Spine Program, Foothills Medical Center, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada

Spectrum Research, Inc., Tacoma, WA; and

§Department of Orthopaedic Surgery, Harborview Medical Center, University of Washington, Seattle, WA.

Address correspondence and reprint requests to Brandon D. Lawrence, MD, Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108; E-mail: Brandon.lawrence@hsc.utah.edu

Acknowledgment date: March 4, 2013. First revision date: May 31, 2013. Acceptance date: July 12, 2013.

The device(s)/drug(s) is/are FDA-approved or approved by corresponding national agency for this indication.

Supported by AOSpine North America, Inc. Analytic support for this work was provided by Spectrum Research, Inc., with funding from the AOSpine North America.

Relevant financial activities outside the submitted work: board membership, consultancy, payment for lectures, royalties, stock/stock options, Fees for participation in review activities such as data monitoring boards, statistical analysis, end point committees, and the like, payment for writing or reviewing the manuscript, grants/grants pending, support for travel to meetings for the study or other purposes.

© 2013 by Lippincott Williams & Wilkins