Posterior surgery for Cervical Spondylotic Myelopathy Mehmet Zileli, M Posterior surgery for Cervical Spondylotic Myelopathy Mehmet Zileli, M.D. Izmir - Turkey

CSM Posterior Decompression Indications Posterior compression >2 level anterior compression Hyperlordosis Contraindications Kyphosis 1-2 level anterior compression

Anterior vs Posterior Surgery? Decision Making 1-Site of compression 2-Cervical curve 3-Number of compressions 4-Patient’s general condition, bone quality

Anterior vs Posterior Surgery? Importance of Site of Compression Anterior compression Anterior surgery Posterior compression Posterior surgery Anterior & posterior compression ??? The number of levels ? Instability ?

Anterior vs Posterior Surgery? Importance of Curve Kyphotic curve Anterior surgery Multiple levels ?? Hyperlordotic curve Posterior surgery Lordosis preserved - lost ???

Age is not a factor alone Graft problems if osteoporotic Anterior vs Posterior Surgery? Patient’s age, general condition, bone quality Age is not a factor alone Graft problems if osteoporotic Poor general condition Posterior surgery > Anterior surgery

Complications of Anterior Surgery appr. 20-25% 1-Neurological complications 2-Cervical site compl. Airway problems Hematom Esophageal injury Vascular Hoarseness Dysphagia Chylothorax 3-Graft related compl. Graft dislocation Pseudarthrosis Adjacent level degeneration Plate & screw problems 4-Graft site compl.

CSM: Posterior Surgery Advantages 1-Very good technique for decompression of structures from posterior such as ligamentum flavum hypertrophy. Disadvantages 1-Increasing instability resulting in osteophyte formation 2-Hard discs and anterior osteophytes are not possible to remove, if attempted, it would cause root injury 3-Neurological complications are more in comparison to anterior surgery

Posterior Surgery Absolute Indications 44 y.o. male, quadriparesis for 5-6 yrs, gait disturbance for 1 yr, sphincter disturbance Posterior compression only > posterior surgery

Posterior Surgery Absolute Indications 79 y.o. Female, walking disturbance for years. Inability to walk for 1 month, wheel-chair dependent. MRI: severe anterior and posterior compression at C3-4. Coronary artery disease, high risk for cardiac reasons

Posterior Surgery Relative Indications 72 y.o. Male. Tetraparesisi prominent on right side for 1 year. MRI C4-5-6-7 severe narrowing T2 hyperintensity , lordotic curve.

C4-5-6 laminectomy, lateral mass plate

3 levels anterior-posterior compression, lordosis is preserved > posterior surgery Postop MRI

CSM: Posterior Surgery Laminectomy & Fusion Lateral mass fixation Laminoplasty Hemilateral opening Bilateral opening

Laminectomy & Fusion Lateral mass fixation

Laminoplasty Unilateral opening Bilateral opening

Laminoplasty

Laminectomy or Laminoplasty? Causes instability Laminectomy membrane Laminoplasty Technically demanding Restricted neck movements Insufficient decompression?

Outcome Anterior vs Posterior Success rates range between 70-85% in different series Duration of symptoms are important

Complications Anterior vs Posterior Functional outcomes similar But complications greater with corpectomy Yonenobu, et. al. – Spine, 1992 Heller, et. al. – Spine, 2001 Wada, et. al. – Spine, 2001 Edwards, et.al. – Spine, 2002

Conclusions For multi-level anterior compression < 2 Levels Multi-level ACDF 2 Levels Corpectomy >2 Levels Laminectomy or Laminoplasty For multi-level diffuse (e.g. congenital) compression No Kyphosis Laminoplasty or corpectomy Kyphosis Corpectomy

Conclusions With proper indications, results comparable with either corpectomy or laminectomy / laminaplasty Higher complication rate with corpectomy

CSM Posterior Decompression Indications Posterior compression >2 level anterior compression Hyperlordosis Contraindications Kyphosis 1-2 level anterior compression