Friday, August 3, 2012
From the Desk of Shifeng Wen, MD
The present study was only a preliminary attempt to demostrate that one-stage posterior-anterior surgical decompression resulted in the best primary outcome (the highest JOA recovery rate) among the three strategies and a significant improvement of sagittal alignment. Although one-stage posterior-anterior decompression incurred the highest direct care costs, the largest operative blood loss, and the longest operating time, it was not different from the other two strategies in postoperative hospital stay or complications. Importantly, it resulted in much fewer revisions than the other two. What is more, this procedure with two separate incisions is not a simple addition of posterior plus anterior decompressions, because patients undergoing this operation had significantly fewer anterior disc levels operated in anterior corpectomy or discectomy than those undergoing anterior decompression only (P<0.001). It is believed that one-stage posterior-anterior surgical decompression strategy could be the preferred treatment for MCM in a subgroup of patients whose cervical spinal cord is compressed with hypertrophic changes circumferentially according to MRI findings. The limitations of this study result from its retrospective nature. For example, it is difficult to establish cause and effect, and bias and confounders are also difficult to be controlled. So we are doing a prospective study to compare the clinical outcomes as well as surgical-related adverse events of MCM patients undergoing anterior, posterior, or one-stage posterior-anterior surgical decompression strategies.
According to the data in this study, we prefer to perform posterior-anterior surgery in one stage whenever possible, which in carefully selected MCM patients can effectively reduce perioperative complications and optimize the environment for maximum neurological recovery. Nevertheless, in selecting patients with comorbidities that would put them at significant risk with the increased operative time, it is safer to stage the procedure. And it has been our experience that with regard to the safety of the operation, we advocate operating from the back first, so we use” posterior-anterior surgery” in this study instead of “anterior- posterior surgery”. In our practice, after posterior cervical laminoplasty is performed, the decompression is still inadequate. Consequently, a viable option is to perform single-level or two-level ventral cervical discectomy or a single-level cervical corpectomy to provide for further anterior decompression of the spinal canal. This is what we call the one stage posterior-anterior approach.