Surgical Approach Decision-Making

  • Mena G. Kerolus
  • Vincent C. TraynelisEmail author


Surgical approach decision-making in patients with cervical spondylotic myelopathy should be performed in a stepwise, systematic manner. Due to the heterogeneity of clinical presentations and radiographic findings, the correct surgical approach must be addressed on an individual basis. Based on the current systematic literature and a better understanding of cervical biomechanics and alignment parameters, surgical outcomes have improved. There is evidence that provides direction in choosing a particular surgical approach, but in some instances, there is equipoise between anterior and posterior surgical strategies. Case examples are provided to highlight particular surgical decisions.


Cervical spondylosis Myelopathy Radiculopathy Cervical lordosis Ossified posterior longitudinal ligament Anterior cervical discectomy and fusion Cervical laminectomy Cervical arthroplasty 


  1. 1.
    Klineberg E. Cervical spondylotic myelopathy: a review of the evidence. Orthop Clin North Am. 2010;41:193–202. Scholar
  2. 2.
    Fehlings MG, Jha NK, Hewson SM, Massicotte EM, Kopjar B, Kalsi-Ryan S. Is surgery for cervical spondylotic myelopathy cost-effective? A cost-utility analysis based on data from the AOSpine North America prospective CSM study. J Neurosurg Spine. 2012;17:89–93. Scholar
  3. 3.
    Witiw CD, Tetreault LA, Smieliauskas F, Kopjar B, Massicotte EM, Fehlings MG. Surgery for degenerative cervical myelopathy: a patient-centered quality of life and health economic evaluation. Spine J. 2017;17:15–25. Scholar
  4. 4.
    Hukuda S, Mochizuki T, Ogata M, Shichikawa K, Shimomura Y. Operations for cervical spondylotic myelopathy. A comparison of the results of anterior and posterior procedures. J Bone Joint Surg Br. 1985;67:609–15.CrossRefGoogle Scholar
  5. 5.
    Boden SD, McCowin PR, Davis DO, Dina TS, Mark AS, Wiesel S. Abnormal magnetic-resonance scans of the cervical spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. 1990;72:1178–84.CrossRefGoogle Scholar
  6. 6.
    Kalsi-Ryan S, Karadimas SK, Fehlings MG. Cervical spondylotic myelopathy the clinical phenomenon and the current pathobiology of an increasingly prevalent and devastating disorder. Neuroscientist. 2013;19:409–21. Scholar
  7. 7.
    Gillis CC, Kaszuba MC, Traynelis VC. Cervical radiographic parameters in 1- and 2-level anterior cervical discectomy and fusion. J Neurosurg Spine. 2016;25:421–9. Scholar
  8. 8.
    Carette S, Fehlings MG. Clinical practice. Cervical radiculopathy. N Engl J Med. 2005;353:392–9. Scholar
  9. 9.
    Puttlitz CM, DiAngelo DJ. Cervical spine arthroplasty biomechanics. Neurosurg Clin N Am. 2005;16:589–594, v. Scholar
  10. 10.
    Ames CP, Blondel B, Scheer JK, Schwab FJ, Le Huec J-C, Massicotte EM, et al. Cervical radiographical alignment: comprehensive assessment techniques and potential importance in cervical myelopathy. Spine. 2013;38:S149–60. Scholar
  11. 11.
    Smith JS, Klineberg E, Shaffrey CI, Lafage V, Schwab FJ, Protopsaltis T, et al. Assessment of surgical treatment strategies for moderate to severe cervical spinal deformity reveals marked variation in approaches, osteotomies, and fusion levels. World Neurosurg. 2016;91:228–37. Scholar
  12. 12.
    Karadimas SK, Erwin WM, Ely CG, Dettori JR, Fehlings MG. Pathophysiology and natural history of cervical spondylotic myelopathy. Spine. 2013;38:S21–36. Scholar
  13. 13.
    Rhee JM, Shamji MF, Erwin WM, Bransford RJ, Yoon ST, Smith JS, et al. Nonoperative management of cervical myelopathy: a systematic review. Spine. 2013;38:S55–67. Scholar
  14. 14.
    Fehlings MG, Wilson JR, Kopjar B, Yoon ST, Arnold PM, Massicotte EM, et al. Efficacy and safety of surgical decompression in patients with cervical spondylotic myelopathy: results of the AOSpine North America prospective multi-center study. J Bone Joint Surg Am. 2013;95:1651–8. Scholar
  15. 15.
    Choi G, Arbatti NJ, Modi HN, Prada N, Kim JS, Kim HJ, et al. Transcorporeal tunnel approach for unilateral cervical radiculopathy: a 2-year follow-up review and results. Minim Invasive Neurosurg MIN. 2010;53:127–31. Scholar
  16. 16.
    Hacker RJ, Miller CG. Failed anterior cervical foraminotomy. J Neurosurg. 2003;98:126–30.PubMedGoogle Scholar
  17. 17.
    Lawrence BD, Jacobs WB, Norvell DC, Hermsmeyer JT, Chapman JR, Brodke DS. Anterior versus posterior approach for treatment of cervical spondylotic myelopathy: a systematic review. Spine. 2013;38:S173–82. Scholar
  18. 18.
    Liu W-J, Hu L, Chou P-H, Wang J-W, Kan W-S. Comparison of anterior cervical discectomy and fusion versus posterior cervical foraminotomy in the treatment of cervical radiculopathy: a systematic review. Orthop Surg. 2016;8:425–31. Scholar
  19. 19.
    Bono CM, Ghiselli G, Gilbert TJ, Kreiner DS, Reitman C, Summers JT, et al. An evidence-based clinical guideline for the diagnosis and treatment of cervical radiculopathy from degenerative disorders. Spine J. 2011;11:64–72. Scholar
  20. 20.
    Fraser JF, Härtl R. Anterior approaches to fusion of the cervical spine: a metaanalysis of fusion rates. J Neurosurg Spine. 2007;6:298–303. Scholar
  21. 21.
    Jiang L, Tan M, Dong L, Yang F, Yi P, Tang X, et al. Comparison of anterior decompression and fusion with posterior laminoplasty for multilevel cervical compressive myelopathy: a systematic review and meta-analysis. J Spinal Disord Tech. 2015;28:282–90. Scholar
  22. 22.
    Fehlings MG, Smith JS, Kopjar B, Arnold PM, Yoon ST, Vaccaro AR, et al. Perioperative and delayed complications associated with the surgical treatment of cervical spondylotic myelopathy based on 302 patients from the AOSpine North America Cervical Spondylotic Myelopathy Study. J Neurosurg Spine. 2012;16:425–32. Scholar
  23. 23.
    Liu B, Ma W, Zhu F, Guo C, Yang W. Comparison between anterior and posterior decompression for cervical spondylotic myelopathy: subjective evaluation and cost analysis. Orthop Surg. 2012;4:47–54. Scholar
  24. 24.
    Ghogawala Z, Martin B, Benzel EC, Dziura J, Magge SN, Abbed KM, et al. Comparative effectiveness of ventral vs dorsal surgery for cervical spondylotic myelopathy. Neurosurgery. 2011;68:622–630–631. Scholar
  25. 25.
    Whitmore RG, Schwartz JS, Simmons S, Stein SC, Ghogawala Z. Performing a cost analysis in spine outcomes research: comparing ventral and dorsal approaches for cervical spondylotic myelopathy. Neurosurgery. 2012;70:860–7; discussion 867. Scholar
  26. 26.
    Sasso RC, Ruggiero RA, Reilly TM, Hall PV. Early reconstruction failures after multilevel cervical corpectomy. Spine. 2003;28:140–2. Scholar
  27. 27.
    Vaccaro AR, Falatyn SP, Scuderi GJ, Eismont FJ, McGuire RA, Singh K, et al. Early failure of long segment anterior cervical plate fixation. J Spinal Disord. 1998;11:410–5.PubMedPubMedCentralGoogle Scholar
  28. 28.
    Shamji MF, Massicotte EM, Traynelis VC, Norvell DC, Hermsmeyer JT, Fehlings MG. Comparison of anterior surgical options for the treatment of multilevel cervical spondylotic myelopathy: a systematic review. Spine. 2013;38:S195–209. Scholar
  29. 29.
    Kasliwal MK, Traynelis VC. Motion preservation in cervical spine: review. J Neurosurg Sci. 2012;56:13–25.PubMedGoogle Scholar
  30. 30.
    Turel MK, Kerolus MG, Adogwa O, Traynelis VC. Cervical arthroplasty: what does the labeling say? Neurosurg Focus. 2017;42:E2. Scholar
  31. 31.
    Sasso WR, Smucker JD, Sasso MP, Sasso RC. Long-term clinical outcomes of cervical disc arthroplasty: a prospective, randomized, controlled trial. Spine. 2016. Scholar
  32. 32.
    Shamji MF, Cook C, Pietrobon R, Tackett S, Brown C, Isaacs RE. Impact of surgical approach on complications and resource utilization of cervical spine fusion: a nationwide perspective to the surgical treatment of diffuse cervical spondylosis. Spine J. 2009;9:31–8. Scholar
  33. 33.
    Kaptain GJ, Simmons NE, Replogle RE, Pobereskin L. Incidence and outcome of kyphotic deformity following laminectomy for cervical spondylotic myelopathy. J Neurosurg. 2000;93:199–204.PubMedGoogle Scholar
  34. 34.
    Edwards CC, Riew KD, Anderson PA, Hilibrand AS, Vaccaro AF. Cervical myelopathy. Current diagnostic and treatment strategies. Spine J. 2003;3:68–81.CrossRefGoogle Scholar
  35. 35.
    Suda K, Abumi K, Ito M, Shono Y, Kaneda K, Fujiya M. Local kyphosis reduces surgical outcomes of expansive open-door laminoplasty for cervical spondylotic myelopathy. Spine. 2003;28:1258–62. Scholar
  36. 36.
    Iwasaki M, Okuda SY, Miyauchi A, Sakaura H, Mukai Y, Yonenobu K, et al. Surgical strategy for cervical myelopathy due to ossification of the posterior longitudinal ligament: Part 2: advantages of anterior decompression and fusion over laminoplasty. Spine. 2007;32:654–60. Scholar
  37. 37.
    Highsmith JM, Dhall SS, Haid RW, Rodts GE, Mummaneni PV. Treatment of cervical stenotic myelopathy: a cost and outcome comparison of laminoplasty versus laminectomy and lateral mass fusion. J Neurosurg Spine. 2011;14:619–25. Scholar
  38. 38.
    Leckie S, Yoon ST, Isaacs R, Radcliff K, Fessler R, Haid R, et al. Perioperative complications of cervical spine surgery: analysis of a prospectively gathered database through the association for collaborative spinal research. Global Spine J. 2016;6:640–9. Scholar
  39. 39.
    Goel A, Shah A. Facetal distraction as treatment for single- and multilevel cervical spondylotic radiculopathy and myelopathy: a preliminary report. J Neurosurg Spine. 2011;14:689–96. Scholar
  40. 40.
    Tan LA, Straus DC, Traynelis VC. Cervical interfacet spacers and maintenance of cervical lordosis. J Neurosurg Spine. 2015;22:466–9. Scholar
  41. 41.
    Heller JG, Edwards CC, Murakami H, Rodts GE. Laminoplasty versus laminectomy and fusion for multilevel cervical myelopathy: an independent matched cohort analysis. Spine. 2001;26:1330–6.CrossRefGoogle Scholar
  42. 42.
    Manzano GR, Casella G, Wang MY, Vanni S, Levi AD. A prospective, randomized trial comparing expansile cervical laminoplasty and cervical laminectomy and fusion for multilevel cervical myelopathy. Neurosurgery. 2012;70:264–77. Scholar
  43. 43.
    Woods BI, Hohl J, Lee J, Donaldson W, Kang J. Laminoplasty versus laminectomy and fusion for multilevel cervical spondylotic myelopathy. Clin Orthop. 2011;469:688–95. Scholar
  44. 44.
    Mummaneni PV, Haid RW, Rodts GE. Combined ventral and dorsal surgery for myelopathy and myeloradiculopathy. Neurosurgery. 2007;60:S82–9. Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of NeurosurgeryRush University Medical CenterChicagoUSA

Personalised recommendations