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Anterior Versus Posterior Surgical Approaches to Treat Cervical Spondylotic Myelopathy: Outcomes of the Prospective Multicenter AOSpine North America CSM Study in 264 Patients

Fehlings, Michael G. MD, PhD*; Barry, Sean MD*; Kopjar, Branko MD; Yoon, Sangwook Tim MD; Arnold, Paul MD§; Massicotte, Eric M. MD*; Vaccaro, Alexander MD, PhD; Brodke, Darrel S. MD; Shaffrey, Christopher MD**; Smith, Justin S. MD**; Woodard, Eric MD††; Banco, Robert J. MD‡‡; Chapman, Jens MD; Janssen, Michael DO§§; Bono, Christopher MD¶¶; Sasso, Rick MD‖‖; Dekutoski, Mark MD***; Gokaslan, Ziya L. MD†††

doi: 10.1097/BRS.0000000000000047
Cervical Spine

Study Design. A prospective observational multicenter study.

Objective. To help solve the debate regarding whether the anterior or posterior surgical approach is optimal for patients with cervical spondylotic myelopathy (CSM).

Summary of Background Data. The optimal surgical approach to treat CSM remains debated with varying opinions favoring anterior versus posterior surgical approaches. We present an analysis of a prospective observational multicenter study examining outcomes of surgical treatment for CSM.

Methods. A total of 278 subjects from 12 sites in North America received anterior/posterior or combined surgery at the discretion of the surgeon. This study focused on subjects who had either anterior or posterior surgery (n = 264, follow-up rate, 87%). Outcome measures included the modified Japanese Orthopedic Assessment scale, the Nurick scale, the Neck Disability Index, and the Short-Form 36 (SF-36) Health Survey version 2 Physical and Mental Component Scores.

Results. One hundred and sixty-nine patients were treated anteriorly and 95 underwent posterior surgery. Anterior surgical cases were younger and had less severe myelopathy as assessed by mJOA and Nurick scores. There were no baseline differences in Neck Disability Index or SF-36 between the anterior and posterior cases. Improvement in the mJOA was significantly lower in the anterior group than posterior group (2.47 vs. 3.62, respectively, P < 0.01), although the groups started at different levels of baseline impairment. The extent of improvement in the Nurick Scale, Neck Disability Index, SF-36 version 2 Physical Component Score, and SF-36 version 2 Mental Component Score did not differ between the groups.

Conclusion. Patients with CSM show significant improvements in several health-related outcome measures with either anterior or posterior surgery. Importantly, patients treated with anterior techniques were younger, with less severe impairment and more focal pathology. We demonstrate for the first time that, when patient and disease factors are controlled for, anterior and posterior surgical techniques have equivalent efficacy in the treatment of CSM.

Level of Evidence: 3

The optimal surgical approach to treat cervical spondylotic myelopathy (CSM) remains debated with varying opinions favoring anterior versus posterior surgical approaches. This prospective observational multicenter study examining outcomes of treatment for CSM demonstrates that, when patient and disease factors are controlled for, anterior and posterior surgical techniques have equivalent efficacy for treating CSM.

*University of Toronto, Toronto, Ontario, Canada

University of Washington, Seattle, WA

Emory University, Atlanta, GA

§University of Kansas, Kansas City, KS

Thomas Jefferson University, Philadelphia, PA

University of Utah, Salt Lake City, UT

**University of Virginia, Charlottesville, VA

††New England Baptist Hospital, Boston, MA

‡‡Boston Spine Group, Newton, MA

§§Spine Education and Research Institute, Denver, CO

¶¶Brigham and Woman's Hospital, Boston, MA

‖ ‖Indiana Spine Group, Indianapolis, IN

***The CORE Institute, Phoenix, AZ; and

†††John Hopkins University, Baltimore, MD.

Address correspondence and reprint requests to Michael G. Fehlings, MD, PhD, Division of Neurosurgery, Toronto Western Hospital, 399 Bathurst St. Ste 4WW-449, Toronto, Ontario M5T2S8, Canada; E-mail: michael.fehlings@uhn.ca

Acknowledgment date: April 26, 2013. First revision date: June 27, 2013. Second revision date: September 3, 2013. Acceptance date: September 9, 2013.

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

No funds were received in support of this work.

Relevant financial activities outside the submitted work: consulting fee or honorarium, board membership, consultancy, grants/grants pending, expert testimony, stock/stock options, royalties, payment for lectures, travel/accommodations/meeting expenses, patents, payment for development of educational presentations, and support for travel.

© 2013 by Lippincott Williams & Wilkins