Spine

SPINE Volume 38, Number 22S, pp S173-S182

2013, Lippincott Williams & Wilkins

SURGICAL TREATMENT OF CERVICAL SPONDYLOTIC MYELOPATHY

Anterior Versus Posterior Approach for Treatment

of Cervical Spondylotic Myelopathy
A Systematic Review
Brandon D. Lawrence, MD,* W. Bradley Jacobs, MD,t Daniel C. Norvell, PhD,+
Jeffrey T. Hermsmeyer, BS,+ Jens R. Chapman, MD, and Darrel S. Brodke, MD*

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).

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.

From the Department of Orthopaedics, University of Utah, Salt Lake City,

UT; tCalgary Spine Program, Foothills Medical Center, Department of
Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada;
tSpectrum Research, Inc., Tacoma, WA; and Department ot Orthopaedic
Surgery, Harborview Medical Center, University of Washington, Seattle, WA.

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 Gapanese 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 V5. dorsal, focal vs. diffuse, sagittal, dynamic
instability) because there are similar outcomes between the anterior
and posterior approaches with regard to effectiveness and safety.

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

Overall Strength of Evidence. Low

Strength of Recommendation. Strong

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

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.
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
DOI; 10.1097/BRS.ObOI 3e3182a7eaaf
Spine

Key words: cervical spine, cervical spondylotic myelopathy,

discectomy, corpectomy, laminectomy, laminoplasty.
Spine 2013;38:S173-S182

ervical spondylotic myelopathy (CSM) is a common

cause of neurological dysfunction. The onset of CSM
is typically marked by fine motor dysfunction and
decreased hand dexterity, as well as worsening gait and balance. Upper and lower extremity sensorimotor dysfunction
and sphincter disturbance most commonly occur in a slow,
stepwise pattern with disease progression, although rapid
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SURGICAL TREATMENT OF CERVICAL SPONDYLOTIC MYELOPATHY

neurological decline can occur in a minority of cases. In keeping with the degenerative etiology of CSM, it is intuitive that
the incidence increases with advancing age, and accordingly,
CSM represents the most common cause of spinal cord dysfunction in individuals older than 55 years.'
It is well established that surgical decompression of the
cervical spinal cord is an effective treatment option for CSM
that, at a minimum, not only halts the progression of symptoms, but can also promote meaningful functional recovery
in a significant portion of treated individuals.'-' Spondylotic
spinal cord compression can arise from pathologies located
either anterior or posterior to the spinal canal, and, accordingly, surgical decompression can be performed via either an
anterior surgical approach or a posterior surgical approach.
Anterior surgery typically takes the form of either an anterior cervical discectomy and fusion or corpectomy, and
posterior surgery typically involves a laminoplasty or laminectomy and fusion. Although laminectomy without fusion
was widely used for the treatment of CSM in the past, the
increasing recognition of the low but not insignificant incidence of postlaminectomy kyphotic deformities has resulted
in a dramatic reduction in stand-alone laminectomy in the
setting of CSM.''
Presently, it remains unclear 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 profile. Several reports using large administrative databases have attempted to elucidate the safety and effectiveness profiles of the anterior versus posterior approach when
treating multilevel CSM. Unfortunately, in the study by
Shamji et al,^ no conclusions could be drawn regarding the
effectiveness differences of anterior versus posterior surgery
because of the lack of pathoanatomical patient data in this
large administrative database. More recently, Fehlings et at
described the complications of surgical treatment in patients
with CSM and found that the posterior surgical group had a
higher incidence of postoperative wound infection but overall complication rates, C5 palsy, and incidence of dysphagia were similar. Given this ongoing uncertainty as to the
optimal surgical treatment paradigm for multilevel spondylotic cervical cord compression, there remains a substantive
need for a rational algorithm on how best to surgically treat
CSM.
Accordingly, the primary objective of this report was to
perform a systematic review comparing anterior multilevel
cervical discectomy or corpectomy with posterior cervical
laminoplasty or laminectomy and fusion with regard to the
following clinical outcomes: neurological outcome, postoperative neck pain, neck range of motion, and sagittal alignment,
as well as the postoperative complication profile. Ultimately,
we sought to answer the following key questions:
1. What is the comparative effectiveness of anterior versus
posterior decompression procedures for multilevel CSM?
2. What is the comparative safety of anterior versus posterior decompression procedures for multilevel CSM?
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Anterior vs. Posterior Approach for

Treatment of CSM Lawrence et al

MATERIALS AND METHODS

Electronic Literature Search
We conducted a systematic search in MFDLINE and the
Cochrane Collaboration Library for literature published
through September 2012. The search results were limited to
human studies published in the English language. Reference
lists of key articles were also systematically checked to identify additional eligible articles. We sought to identify comparative studies (e.g., randornized controlled trials, cohort
studies) comparing anterior surgical approaches (discectomy and/or corpectomy) with posterior surgical approaches
(laminectomy, laminectomy/fusion, and laminoplasty). We
were interested in the following effectiveness and complication profiles: neurological, functional, quality of life, sagittal
alignment, cervical range of motion, pain, and complications (Table 1). Reasons for exclusion included patients with
degenerative disc disease or degenerative joint disease without
CSM, patients with ossification of the posterior longitudinal
ligament (OPLL), and a majority of subjects in one or both
treatment arms with single-level CSM, spine tumor, trauma,
and infection. We excluded studies that did not report results
separately by treatment group because this prevented appropriate comparisons. Furthermore, studies that stated in the
"Methods" section that patients were differentially selected
for treatments based on important baseline characteristics
were excluded. These studies created comparisons with significant imbalances with respect to key factors that influence
outcome (e.g., age, disease levels) and put specific treatments
at a clear disadvantage that we could not control for. Case
series, case reports, data not reported separately for each comparison group, or studies that consisted of a sample size of less
than 10 for either comparison group were excluded. Animal,
cadaver, and biomechanical studies were also excluded.

Data Extraction
From the included articles, the following data were extracted:
study design, patient demographics, diagnosis and operated
levels, follow-up duration and the rate of follow-up for each
treatment group (if reported or calculable), and treatment
intervention descriptions. We reported change in JOA (Japanese Orthopaedic Association) scores, postoperative axial
pain, change in sagittal alignment, change in canal diameter,
and complication rates.

Study Quality and Overall Strength of Body of

Literature
Level of evidence ratings were assigned to each article independendy by 2 reviewers (J.T.H., D.C.N.) using criteria set by
The Journal of Bone & Joint Surgery, American Volume,'^ for
therapeutic studies and modified to delineate criteria associated with methodological quality described elsewhere.* (See
the Supplemental Digital Content, available at http://links.
lww.com/BRS/A826, for individual study ratings.)
The overall body of evidence with respect to each key
question was determined on the basis of precepts outlined
by the GRADE (Grading of Recommendation Assessment,
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SURGICAL TREATMENT OE CERVICAL SPONDYLOTIC MYELOPATHY

TABLE 1

Ratient

COSumrniiff i f Inclusion and

Inclusion

Exclusions

Age>18yr

Majority singlelevel cervical

myelopathy

Majority subjects in
both treatment arms
have multilevel
myeloradiculopathy
secondary to cervical
spondylosis

DDD/DjD w/o CSM,

pdiatrie, tumor,
trauma, infection,
OPLL

Anterior cervical surgery

Intervention

Discectomy (multilevel)
Corpectomy (single or
multilevel)
Posterior cervical surgery
Laminectomy

Comparison

Laminectomy with
fusion
Laminoplasty

Differential treatment
group selection
based on heterogeneous characteristics such as disease
levels and age*

Neurological outcome
mjOA score
Nurick score
Functional outcome and
quality of life
Axial neck pain
Outcomes

Complications
Pseudoarthrosis,
dysphagia, infection
Neurological
(including C5 palsy)
Sagittal alignment
Neck range of motion
Case reports
Case series

Study
design

Randomized controlled
trial
Cohort study

Biomechanical
studies
Cadaver studies
N < 10 in either
comparison group
Data not reported
separately by
treatment group

*Studies that stated upfront in the "Methods" section that surgeons selected
specific treatments for specific conditions that differed by important characteristics that might influence outcome were not included.
SM indicates cervical spondylotic myelopathy; DDD, degenerative disc
disease; DJD, degenerative joint disease; OM, apese Orthopaedic As'ociation; OPLL, ossification of the posterior longitudinal ligament.
Spine

Anterior vs. Posterior Approach for

Treatment of CSM Lawrence et al

Development and Evaluation) Working Group' and recommendations made by the AHRQ (Agency for Healthcare
Research and Quality).'" Risk of bias was evaluated during
the individual study evaluation described earlier in this section. This system, which derives a strength-of-evidence grade
of "high," "moderate," "low," or "insufficient" for each
outcome or key question, is described in further detail in the
Methodology article in this focus issue.** A detailed description of how we arrived at the strength of evidence for each key
question can he found in the Supplemental Digital Content
(available at http://links.lviw.coniyBRS/A826).
Data Analysis
We performed all analyses on an individual study level. For
continuous outcome measures, we reported, or if necessary
calculated, the mean change scores and standard deviations
(SDs). We imputed the change score SDs using a formula
recommended by the Cochrane Handbook for Systematic
Reviews of Interventions.'' Mean baseline, mean followup, mean change scores, and their respective SDs allowed
calculation of a standardized mean difference (SMD) that
permitted comparison of change in scores between anterior
and posterior surgical procedures within the different studies. SMDs and their 95% confidence intervals were displayed
using forest plots generated using Review Manger 5.2.1. A
random-effects model was assumed in an attempt to address
heterogeneity. Cohen'^ has reported an effect size of 0.2 to
0.3 as a "small" effect, around 0.5 as a "medium" effect, and
0.8 to infinity as a "large" effect. We used unpaired t tests to
determine whether the outcome score changes were variable
between different approaches. If the confidence interval did
not cross the neutral line in the forest plot, then the effect
can also be considered statistically significant. For dichotomous outcomes {e.g., axial pain rates or comphcations), we
reported the raw data and rates and calculated risk differences
and relative risks and their 95% confidence intervals. To test
whether the differences in rates were statistically significant,
we used the Fischer exact test. Risk differences are calculated
by subtracting the 2 rates and relative risks by dividing one
rate by another. Because of significant clinical (differences
in demographics, interventions, and outcome assessment)
and statistical (variability in intervention effects or followup rates) heterogeneity, we did not combine studies into a
meta-analysis; however, we presented studies side by side in
summary tables and figures to make a qualitative assessment
of treatment effectiveness and complications. We performed
statistical analyses using Stata 9.1.'^
Clinical Recommendations and Consensus Statements
Clinical recommendations were made through a modified
Delphi approach by applying the GRADF/AHRQ criteria
that impart a deliberate separation between the strength of
the evidence {i.e.., high, moderate, low, or insufficient) from
the strength of the recommendation. When appropriate, recommendations or statements "for" or "against" were given
"strong" or "weak" designations based on the quality of
the evidence, the balance of benefits/harms, and values and
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SURGICAL TREATMENT OE CERVICAL SPONDYLOTIC MYELOPATHY

patient preferences. In some instances, costs may have been

considered. A thorough description of this process can be
found in the Methodology article in this focus issue.*
RESULTS

Study Selection
The search strategy yielded 135 potentially relevant citations. Of these, 115 were excluded on the basis of title and/
or abstract. Twenty were selected for full-text review. An additional 12 were excluded on the basis of full-text review for the
following reasons: differential treatment group selection based
on heterogeneous characteristics such as disease levels and age,
data not reported separately hy treatment group, and majority
of anterior surgery group containing single-level CSM ( 6 1 % 770/^)14-17 (figure 1). A total of 8 studies"*^-' were selected for
inclusion and are summarized in this report. Among the 8
studies, 2 compared multilevel discectomy with laminoplasty,
1 study compared multilevel discectomy with laminectomy,
4 studies compared multilevel corpectomy with laminoplasty,
and 1 study compared multilevel corpectomy with laminectomy with fusion in patients with multilevel CSM. No study
was identified comparing multilevel corpectomy with laminectomy alone or multilevel discectomy with laminectomy with
fusion.
The mean age of subjects was similar across studies, with
age ranges of 48 to 59 years. All studies had a greater percentage of male patients (range, 58%-86%) than of female
patients. The most common number of operated levels was
3 and relatively consistent across studies. Follow-up times differed between studies. Five studies had follow-up times hetween
2 and 4 years, and 2 studies had follow-up times between 7 and
11 years postoperatively. The main limitation of these studies
was that the authors did not report follow-up rates or give
the raw data to calculate follow-up rates. These differences
in follow-up times and unknown follow-up rates should caution the final conclusions. Details regarding the demographics, operative characteristics, and results can he found in the
detailed tables in the Supplemental Digital Content material
(available at http://links.lww.com/BRS/A826).
1. Total Citations

(n = 135)

Anterior vs. Posterior Approach for

Treatment of CSM Lawrence et al

"We summarized the comparative effectiveness and safety

of anterior versus posterior surgery in the following sections.
Effectiveness outcomes consistent across studies and reported
in a similar manner included change in JOA scores, postoperative axial pain scores, and change in canal diameter scores.
The results by study on these outcomes are reported in summary tables and figures. Sagittal alignment was reported by
several studies, but the methods were so heterogeneous that
we were unahle to summarize them in a comparable way.
Neck range of motion was rarely reported and therefore
not useful for summary. Unfortunately, none of the studies
reported the NDI (Neck Disability Index) or a quality-of-life
outcome such as the SF-36 (36-Item Short Form Health Survey). Consistent complications reported across all the studies
included pseudoarthrosis, C5 palsy, infection, and dysphagia.
Comparative Effectiveness of Anterior Versus Posterior
Decompression Procedures for Multilevel CSM
JOA Scores
When evaluating the change in JOA scores among studies
that reported hoth pre- and postoperative scores, 2 of the 4
studies'**-'* reported greater improvement after anterior surgery than after posterior surgery. Among these studies, the
difference in change scores was statistically significant in
only one of them," with an SMD of 1.44, which represents a
"large effect" (Figure 2). Among the 2 studies favoring posterior surgery,'-'-' neither demonstrated a statistically significant difference between change scores with SMDs of 0.31 and
0.03, respectively. Both are considered small effects.
Axial Pain Scores

When evaluating the risk differences among studies that

reported postoperative axial pain, 3 of the 4 favored anterior surgery-"---^' with less postoperative axial pain and
1 reported no difference." Among the studies favoring anterior surgery, the risk differences were 3.7% (P = 0.34), 40.5%
(F = 0.0004), and 28% {P = 0.03) (Tahle 2).
Canal Diameter

When evaluating the change in canal diameter measurements

among studies that reported both pre- and postoperative
measurements, all 3 studies--'-"*"^' reported a greater increase
in canal diameter after posterior surgery than after anterior

2. Title/Abstract

3. Retrieved for full-text

(n = 20)

Uu et al
Yoshidaea/
Yonenobu et al
Benzel ef al

4. Excluded at full-text
(n = 12)

5. Publications
(n = 8)

Figure 1. Study selection flowchart for search for articles pertaining

to the anterior versus posterior surgical approach for the treatment of
cervical spondylotic myelopathy.
SI 76

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Study or subgroup

standardized mean
difference

Standardized mean
difference

iV, Random, 95% Cl

IV, Random, 95% Cl

0.03 [-0.52.0.59]
0.301-0.15.0.761
-1.441-1.89,-1.00]
-0.231-0.90.0.431
-2
-i
O
1 2
Favors anterior Favors posterior

Figure 2. Standardized mean differences comparing the effect of anterior and posterior surgery on JOA scores by study. JOA indicates Japanese Orthopaedic Association.
October 2013

Spine

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SURGICAL TREATMENT OF CERVICAL SPONDYLOTIC MYELOPATHY

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Evidence Summary
The overall strength of evidence that one approach (anterior
vs. posterior) is more effective than the other when treating
patients with CSM is "insufficient" (the evidence does not
permit a conclusion) with regard to improvements of JOA/
modified JOA (mJOA) scores; "low" with regard to postoperative pain favoring anterior surgery; and "moderate" (moderate confidence that the evidence reflects the true effect) with
regard to increasing canal diameter favoring posterior surgery.
The overall strength that one approach (anterior vs. posterior)
is more safe than the other when treating patients with CSM
is "insufficient" with regard to pseudoarthrosis, the development of postoperative C5 palsy, and infection. There is "low"
evidence that posterior surgery has fewer occurrences of dysphagia than anterior surgery (Table 3).

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Comparative Safety of Anterior Versus Posterior

Decompression Procedures for Multilevel CSM
The following complications among studies comparing anterior with posterior surgery for multilevel CSM were extracted
from the 8 included studies: pseudoarthrosis, C5 palsy, infection, and dysphagia (Table 2). Three studies reported pseudoarthrosis rates ""-''; however, unfortunately, the only studies
comparing pseudoarthrosis rates used laminoplasty as the
posterior comparator. Among these, pseudoarthrosis was
observed only after anterior surgery with postoperative rates
of 4%, 7.7%, and 17.6%, respectively, compared with 0% in
the posterior group. Only one of these was statistically significant (P = 0.48, P = 0.31, and P = 0.004, respectively). Three
studies reported dysphagia,"^'^- with rates of 8%, 30.8%,
and 7.1%, respectively, in the anterior groups compared with
no events in the posterior groups. Two of the 3 studies were
statistically significant (P = 0.13, P = 0.03, and P = 0.03,
respectively). Three studies reported C5 palsy with anterior
versus posterior rate comparisons of 0% versus 7.4% (P =
0.49)," 8.8% versus 10.2% (P = 0.83),^^ and 9.8% versus
7.1% (P = 0.67),^'' respectively. Infection rates were reported
in both groups in only one study,^' with 2.3% in the anterior
group and 6.5% in the posterior group (P = 0.33).

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surgery. Among these studies, the difference in canal diameter

increase was statistically significant in 2 of the 3 studies"-"
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SDMs of 1.35 and 1.57. These both represent a "large effect"
(Figure 3).

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Anterior vs. Posterior Approach for

Treatment of CSM Lawrence et al

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Liu etal
Yonenobu et al
Yoshida et al

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Standardized mean
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IV, Random, 95% Cl

IV, Random, 95% Cl

1.3510.74.1.96]
0.36 [-0.04.0.75]
1.57 [1.11,2.03]
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Figure 3. Standardized mean differences comparing the effect of anterior and posterior surgery on canal diameter by study.
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October 2013

Spine

SURGICAL TREATMENT OF CERVICAL SPONDYLOTIC MYELOPATHY

Anterior vs. Posterior Approach for

Treatment of CSM Lawrence et al

Figure 4. A, Sagittal T2-weghted magnetic resonance image of a 53-year-olcl male with progressive left-hand dysfunction, gait instability, and left
leg numbness. Note, focal pathology at C5-C6 and C6-C7. B, Axial T2-weighted magnetic resonance image of the C5-C6 (left) and C6-C7 (right)
disc spaces depicting ventrally based compression at each respective level. C, Postoperative anteroposterior (right) and lateral (left) radiographs
after patient underwent C5-C6 and C6-C7 anterior cervical discectomy and fusion.

DISCUSSION
When developing a surgical strategy to address CSM, there
are many variables that one must consider. In this systematic
review, an attempt was made to evaluate both the comparative effectiveness and safety of the anterior versus posterior
surgical approach for the treatment of multilevel cervical
degenerative spinal cord compression, with the goal of defining superiority of one surgical approach. Unfortunately, given
the paucity of well-designed studies and the heterogeneity of
outcome and complications reporting, defining a superior
approach is not possible. With that said, our analysis suggests that there is clinical equipoise with regard to efficacy
and safety between the anterior and posterior approaches for
the treatment of multilevel CSM. Thus, given the multitude of
variables that one must consider when deciding on an anterior or posterior surgical approach, including ventral versus
dorsal compression, the number of levels of spinal cord compression, the presence or absence of radiculopathy, and sagittal alignment of the cervical spine, our review supports using
a customized approach to each individual patient, given the
similarity with regard to outcome and safety.
When evaluating effectiveness across these studies, several variables were consistently available for comparison;
specifically neurological outcome, as measured by JOA/mJOA
scores, axial neck pain, and radiographical measurement of
postoperative spinal canal diameter. Unfortunately, none of
Spine

the studies used health-related quality-of-life scores, such as

the SF-36, or functional measures, such as the NDI, when
reporting their outcomes. Of the 5 studies for which pre- and
postoperative JOA scores were available for comparison, only
one study determined a statistically significant improvement
after anterior surgery.-'' Interestingly, in this study, the preoperative JOA scores were not equivalent between groups,
with the anterior group having significantly lower scores than
the posterior group (8.1 vs. 9.3). Postoperatively, patients
in both groups had similar JOA scores (13.3 vs. 12.8). Of
the 3 remaining studies that compared JOA/mJOA scores,
2 favored posterior surgery and 1 favored anterior surgery,
but none of these were statistically significant. As such, the
current literature is insufficient for making a statement with
regard to the superiority of the anterior versus posterior surgical approach for neurological outcome.
Similar confounding factors exist regarding postoperative
axial neck pain comparisons. A total of 4 studies, all comparing anterior procedures with laminoplasty, reported on
comparisons of postoperative neck pain, with 2 of the studies
favoring anterior surgery.^"-' It is important to point out that
none of the studies reported pre- to postoperative differences
because no preoperative pain assessments were reported in
any of these studies. Although this is consistent with clinical experience and is likely secondary to musculotendinous
disruption inherent in the posterior approach, it is difficult to
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Anterior vs. Posterior Approach for

Treatment of CSM Lawrence et al

Figure 5. A, Sagittal T2-weighted magnetic resonance image of a 46-year-old male with progressive
left-hand dysfunction and gait instability. No reported neck pain. Note, multilevel stenosis atC3-C7. B,
Given dorsal compression, multilevel compression,
maintained lordotic alignment, and lack of neck
pain, C3-C7 laminoplasty was performed: Lateral
radiograph (left); postoperative sagittal magnetic resonance image (right).

make conclusions based solely on postoperative data due to

potential confounding by baseline pain.
Because of tbe lack of concrete outcome measure differences between anterior and posterior surgical procedures, it
is difficult to ascertain the effects of tbe radiograpbical measurement^canal diameterthat was published. Although
it seems a larger canal diameter can be created more effectively with posterior surgery, it does not seem to correlate
with improvements in JOA/mJOA scores. Therefore, determining the clinical relevancy of this particular radiographical assessment is not possible. Perhaps, a measurement such
as pre- to postoperative cord compression would be more
clinically relevant; however, unfortunately this measurement was not included in any of the studies meeting our
criteria.
When evaluating safety across these studies, similar complication profiles were reported. Unfortunately, significant
heterogeneity with regard to reported complications exists,
making conclusions about the safety of the anterior versus
posterior surgical approach difficult. In addition, the number of events was so low that statistical significance was difficult to achieve due to low study power and comparators
were not clinically relevant in all circumstances. For instance,
pseudoarthrosis was compared with laminoplasty as the posterior comparator. Arthrodesis is not a goal in laminoplasty
and therefore not comparable with anterior cervical discectomy and fusion or corpectomy. It does seem that posterior
surgery may be associated with lower rates of postoperative
dysphagia, although not statistically significant. Anterior surgery may be associated with lower infection rates, but the
reported infection rates in this review are much higher than

those reported in the literature overall.*' This may be due to

the small numbers reported, but it may also influence the outcomes of this particular group of patients, given the morbidity
associated with postoperative wound infections. The rates for
C5 palsy were similar.
Because of the lack of well-designed randomized controlled trials, it remains unclear whether there is an optimal approach for surgical treatment of patients with CSM.
In light of this, individualizing the approach decision to the
details of each patient (location of compression, the number
of levels involved, overall cervical alignment, the presence or
absence of neck pain, etc. ) seems most appropriate. What is
known is that patients with moderate and severe myelopathy
report improved outcomes and improved neurological recovery after surgical decompression irrespective of approach.
Given the differing approaches to differing pathoanatomy,
several illustrative cases are presented: 1 case depicts that an
anterior approach is preferred (Figure 4); 1 case for which
a posterior approach is preferred (Figure 5); and for 2 cases
that are equivocal, either an anterior approach or a posterior
approach could be performed (Figures 6 and 7).
OPLL was excluded in this systematic review; however,
well-established treatment algorithms have been described for
the surgical treatment of this disease. Most surgeons prefer to
treat OPLL with a posterior approach, given the risk of cerebrospinal leakage, but if more than 60% of the canal is compromised by OPLL, then neurological outcomes have been
shown to improve with anterior surgery.^** A recent systematic review was attempted by Xu et aF comparing anterior
with posterior approaches in patients with multilevel OPLL.
Given the lack of comparable outcomes reported between the

Figure 6. A, Sagittal T2-weighted MRI of a 47-yearold female with rapidly progressive hand and gait
dysfunction. Note, cord signal change and stenosis
at C4-C5, C5-C6, and C6-C7. B, Postoperative anteroposterior (left) and lateral (right) radiographs after C4-C5, C5-C6, and C6-C7 anterior cervical discectomy and fusion. A posteriorly based approach
could also be advocated for easily.
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SURGICAL TREATMENT OF CERVICAL SPONDYLOTIC MYELOPATHY

Anterior vs. Posterior Approach for

Treatment of CSM Lawrence et al

Figure 7. A, Lateral radiograph (left) and sagittal T2-weighted magnetic resonance image (right) of a 77-year-old male with severe gait instability
and moderate hand dysfunction. B, Axial T2-weighted magnetic resonance image of the C3-C4 (left) and C4-C5 (right) disc spaces. C, Postoperative lateral radiograph after the patient underwent C2-C6 iaminectomy and fusion. An anterior approach could also be advocated for easily.

anterior and posterior approaches, as well as the inconsistency across the studies, no conclusions could be drawn.
This systematic review strengthens the strategy that most
surgeons use when treating patients with CSM, one that
requires understanding of the disease process and the complications associated with surgical treatment and one that is
individualized on the basis of the pathoanatomy. Clearly, consensus on outcome measures and reported complication profiles would facilitate comparisons across differing treatment
centers and surgical techniques. Such studies should use more
rigorous methods to include a prospective design to diminish heterogeneity in patient populations, follow-up times, and
patient-reported measures that take into account both neck
disability and extremity disability.

Evidence-Based Clinical Recommendations.

Recommendation. We recommend a individualized approach
when treating patients with CSM accounting for pathoanatomical variations (ventral vs. dorsal, focal vs. diffuse, sagittal,
dynamic instability), as there appears to be similar outcomes
between the anterior and posterior approaches in regards to
effectiveness and safety.
Overall Strength of Evidence. Low
Strength of Recommendation. Strong

>- Key Points

The comparative effectiveness is similar between

the anterior and posterior surgical approach when
treating patients with multilevel CSM.

The comparative safety is similar between the

anterior and posterior surgical approach when
treating patients with multilevel CSM.

Using an individualized approach when treating

multilevel CSM is recommended because differing
pathologies require differing surgical approaches ,,
in the cervical spine.

Supplemental digital content is available for this article. Direct

URL citation appears in the printed text and is provided in the
HTML and PDF versions of this article on the journal's Web
site (virww.spinejournal.com).
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