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

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

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

4. 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 ?

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

6. 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

7. 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.

8. 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

9. 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

10. 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

11. Posterior Surgery Relative Indications
72 y.o. Male. Tetraparesisi prominent on right side for 1 year. MRI C severe narrowing T2 hyperintensity , lordotic curve.

12. C4-5-6 laminectomy, lateral mass plate

13. 3 levels anterior-posterior compression, lordosis is preserved > posterior surgery
Postop MRI

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

15. Laminectomy & Fusion
Lateral mass fixation

16. Laminoplasty
Unilateral opening
Bilateral opening

17. Laminoplasty

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

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

20. 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

21. 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

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

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