Comparison of Anterior Surgical Options for the Treatment of Multilevel Cervical Spondylotic Myelopathy: A Systematic Review

Shamji, Mohammed F. MD, PhD, FRCSC*; Massicotte, Eric M. MD, MSc, FRCSC*; Traynelis, Vincent C. MD, PhD, FACS; Norvell, Daniel C. PhD; Hermsmeyer, Jeffrey T. BS; Fehlings, Michael G. MD, PhD, FRCSC*

doi: 10.1097/BRS.0b013e3182a7eb27
Surgical Treatment of Cervical Spondylotic Myelopathy

Study Design. Systematic review.

Objective. The primary objectives of this review were to compare the effectiveness and safety of various anterior cervical decompressive and reconstructive procedures for diffuse or multifocal cervical spondylotic myelopathy (CSM). An additional objective was to describe the most common ancillary stabilization techniques used with the different anterior decompressive procedures.

Summary of Background Data. Surgical management of CSM provides for neurological recovery and disease stabilization in a cost-effective way. Although both retrospective and prospective data support management of CSM by anterior cervical decompression and fusion, the choice decision between various anterior surgical options remains unclear.

Methods. We conducted a systematic search in MEDLINE and the Cochrane Collaboration Library for human studies in the English-language literature published through September 2012. We included studies comparing multiple discectomies with single or multiple corpectomy, multiple discectomies with discectomy-corpectomy hybrid, and multiple corpectomies with discectomy-corpectomy hybrid, comparing effectiveness and safety outcomes of each procedure, and defining the ancillary stabilization techniques used. Exclusion criteria included patients with degenerative disc disease or degenerative joint disease without CSM, single-level CSM, ossified posterior longitudinal ligament (OPLL), spinal tumor, concomitant infection, and ankylozing spondylitis. Case series, case reports, data not reported separately for each comparison group, or studies that consisted of an N less than 10 for either comparison group were excluded. The evidence strength was rated using the GRADE (Grades of Recommendation Assessment, Development, and Evaluation) criteria.

Results. Of the 49 citations identified from our search, 10 studies were initially found suitable for inclusion. Patients undergoing any of the 3 procedures generally experienced improvements in clinical outcomes (neck disability index, Japanese Orthopaedic Association score, and Visual Analogue Scale score for pain) as well as overall sagittal alignment, with minimal perioperative morbidity. There is moderate evidence supporting selection of multiple discectomies compared with corpectomy or discectomy-corpectomy hybrid procedures with regard to superior clinical outcomes and postoperative sagittal alignment. Furthermore, if more extensive operation is needed, there is evidence to support the selection of discectomy-corpectomy hybrid procedures compared with multiple corpectomies if it is technically feasible to accomplish the requisite decompression. The multiple discectomies approach also may have a lower incidence of C5 palsy than corpectomy or discectomy-corpectomy hybrid approaches.

Conclusion. All 3 operative approaches are effective strategies for the anterior surgical management of CSM. When the patient pathoanatomy permits, selection of multiple discectomies is favored compared with corpectomy or discectomy-corpectomy hybrid approaches.

Evidence-Based Clinical Recommendations.

Recommendation 1. When pathoanatomically appropriate with minimal retrovertebral disease, we recommend the selection of multiple discectomy over corpectomy or discectomy-corpectomy hybrid procedures.

Overall Strength of Evidence. Low

Strength of Recommendation. Strong

Recommendation 2. When retrovertebral disease is significant, we recommend, when possible, that discectomy-corpectomy hybrid procedures be performed instead of multiple corpectomies.

Overall Strength of Evidence. Moderate

Strength of Recommendation. Strong

Summary Statements. There is no evidence to guide choice of ancillary external immobilization techniques following multilevel anterior decompression and fusion procedures for CSM.

In a systematic review, there is moderate evidence to support the selection of multiple discectomies over corpectomy or discectomy-corpectomy hybrid procedures when the pathoanatomy supports both anterior approach and equipoise about surgical options. If more extensive operation is needed, the selection of discectomy-corpectomy hybrid procedures is favored over multiple corpectomies, if the decompression is technically feasible by such approach.

*Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada

Division of Neurosurgery, Rush University, Chicago, IL; and

Spectrum Research, Inc., Tacoma, WA.

Address correspondence and reprint requests to Mohammed F. Shamji MD, PhD, FRCSC, Division of Neurosurgery, Toronto Western Hospital, 399 Bathurst St, West Wing, 4th Flr, Room WW4-446, Toronto, Ontario, Canada M5T 2S8; E-mail: mohammed.shamji@uhn.ca

Acknowledgment date: March 7, 2013. First revision date: May 31, 2013. Second revision date: July 6, 2013. Third revision date: July 15, 2013. Acceptance date: August 2, 2013.

The manuscript submitted does not contain information about medical device(s)/drug(s).

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: fees for participation in review activities, payment for writing or reviewing the manuscript, support for travel, consultancy, grants/grants pending, patents, royalties, and travel/accommodations/meeting expenses.

© 2013 by Lippincott Williams & Wilkins