Original ArticlePosterior Cervical Laminectomy Results in Better Radiographic Decompression of Spinal Cord Compared with Anterior Cervical Discectomy and Fusion
Introduction
Cervical spondylitic myelopathy (CSM) is a degenerative condition resulting from chronic spinal cord compression and is a leading cause of nontraumatic spinal cord dysfunction.1 Patient presentation can vary from mild hyperreflexia to progressive weakness and gait dysfunction, and minor trauma can lead to devastating neurologic injury. If left untreated, 20%–60% of patients experience neurologic decline.2 Pathophysiologically, chronic compression of the spinal cord leads to vascular endothelial dysfunction and disruption of the blood–spinal cord barrier, resulting in neuroinflammation, hypoxia, and cell death. Spinal canal diameter is a major risk factor for developing symptomatic CSM,3, 4 and spinal canal parameters, such as sagittal diameter and cerebrospinal fluid (CSF) space for cord, have been shown to be significant predictors of spinal cord injury after mild trauma.5, 6
Although nonoperative management for symptomatic patients is generally not recommended,7 there is significant clinical equipoise within the literature regarding optimal surgical management.8, 9, 10 The chief surgical goal in the management of CSM is adequate spinal cord decompression with or without fusion to slow or prevent further neurologic decline. The 2 primary surgical strategies consist of 1) anterior decompression, via discectomy and/or corpectomy, and fusion and 2) posterior cervical decompression, via laminectomy with or without fusion or laminoplasty. Few large, prospective studies have directly compared anterior and posterior approaches,8 and pooled analyses have demonstrated conflicting results.10, 11, 12, 13 Moreover, although a number of studies have compared postoperative alignment between these 2 approaches,14, 15 few studies have assessed the degree of spinal cord decompression achieved by anterior versus posterior strategies. Given the importance of the degree of spinal cord compression in not only the development of CSM but also the risk of associated spinal cord injury with mild trauma, we conducted a radiographic analysis of canal parameters preoperatively and postoperatively for patients undergoing either anterior or posterior cervical decompression.
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Materials and Methods
Patients undergoing surgical management of CSM from January 1, 2012, to March 1, 2017, in the University of Pennsylvania Health System were enrolled in this study. Patients <18 years of age, patients with isolated radiculopathy without cord compression, and patients who had combined approaches were excluded from the study. Patients who had both preoperative and postoperative magnetic resonance imaging (MRI) for any reason were investigated. Patient baseline and clinical variables were collected
Results
Over the study period, 37 patients were identified who underwent surgical treatment for CSM and who had both preoperative and postoperative MRI studies that were available for analysis. Of these patients, 22 underwent anterior cervical discectomy and fusion, and 16 underwent posterior cervical laminectomy with or without fusion. Baseline variables are listed in Table 1. Mean age for anterior and posterior groups was 55.3 years and 65.5 years, respectively (P = 0.008). Average time between
Discussion
In this quantitative radiographic study, we found that both posterior and anterior approaches to the treatment of CSM resulted in significant spinal cord decompression as assessed by AP diameter, anterior CSF space, and posterior CSF space. However, posterior laminectomy resulted in a significantly greater improvement in overall AP diameter and posterior CSF space. This result suggests that posterior laminectomy may be preferable to anterior cervical discectomy when spinal cord compression has
Conclusions
In this quantitative radiographic study, we found that although both posterior cervical laminectomy and anterior cervical discectomy yielded significant decompression, laminectomy yielded a greater degree of decompression of the posterior CSF space. This finding has important implications for choice of surgery in patients with a significant element of dorsal cord compression from ligamentous hypertrophy. Larger, prospective studies are needed to validate these findings and correlate with
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2021, Interdisciplinary Neurosurgery: Advanced Techniques and Case ManagementCitation Excerpt :Some people found that decompressive laminectomy for poor grade myelopathy demonstrated substantial improvement in outcome [30]. Although both posterior cervical laminectomy and anterior cervical discectomy yielded significant decompression, laminectomy yielded a higher degree of decompression of the posterior CSF space [31]. But few people use these methods for elderly patients as we present.
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Matthew Piazza and Brendan J. McShane contributed equally to this work and are considered co-first authors.