Cervical spondylotic myelopathy and radiculopathy are common disorders which can lead to significant clinical morbidity. Conservative management, such as physical therapy, cervical immobilisation, or anti-inflammatory medications, is the preferred and often only required intervention. Surgical intervention is reserved for those patients who have intractable pain or progressive neurological symptoms. The goals of surgical treatment are decompression of the spinal cord and nerve roots and deformity prevention by maintaining or supplementing spinal stability and alleviating pain. Numerous surgical techniques exist to alleviate symptoms, which are achieved through anterior, posterior, or circumferential approaches. Under most circumstances, one approach will produce optimal results. It is important that the surgical plan is tailored to address each individual's unique clinical circumstance. The objective of this paper is to analyse the major surgical treatment options for cervical myelopathy and radiculopathy focusing on outcomes and complications.
Spondylosis is the most common cause of neural dysfunction in the cervical spine and is becoming more prevalent as the average life-expectancy increases [
Many surgical techniques have been described to decompress the spinal cord and roots which can employ an anterior, posterior, or circumferential approach. Under most circumstances, one approach will produce optimal results [
A posterior approach is best utilised when pathology is present dorsally in the spinal canal. It avoids extensive dissection of vital neck structures and graft-related complications encountered with anterior approaches. Major approach-related complications include postoperative pain from injury to paraspinal muscles, epidural haematoma, and neurological injury. It is contraindicated in a kyphotic deformity, and there is limited potential for open deformity reduction with the more common posterior fixation techniques [
Laminectomy has been proven to be a safe and effective technique for multilevel decompression for cervical spondylotic myelopathy (CSM) [
Miyazaki and Kirita described 155 patients who underwent multilevel laminectomy [
Neurological injury is a rare but serious complication of this procedure. The incidence of spinal cord injury is from 0% to 3%, whereas injury to an individual nerve root can be as high as 15% [
Laminectomy can be augmented to include posterior instrumentation to address instability which leads to lower rates of kyphosis and segmental instability. Despite this increased stability, addition of instrumentation can lead to complications such as hardware failure with loss of alignment and neurological damage from misplaced lateral mass screws. Heller et al. from their series reported a 1% risk of nerve root injury per screw placed [
Laminoplasty was developed to allow cord decompression while preserving motion with less substantial alteration to the natural biomechanics of the cervical spine. Multiple studies have demonstrated its effectiveness using the JOA outcome scale, with approximately 55–65% achieving recovery [
In the short term, Kihara et al. reported on 151 patients with CSM who underwent laminoplasty [
Several variations of laminoplasty have been described in order to minimise complications [
Decreased range of movement and axial neck pain are frequently reported complications. Ratliff and Cooper performed a meta-analysis evaluating the outcomes after laminoplasty in 71 retrospective reports [
This approach allows direct decompression of ventral pathology but can also be used to restore lordosis to a kyphotic spine. The anterior approach comes in proximity with many vital structures in the neck. Complications resulting from this approach include, dysphagia, recurrent laryngeal nerve damage, dural tears, and rarely tracheal or oesophageal perforation (less than 0.25%) [
Postoperative dysphagia has been reported to have an overall average incidence of 12.3% [
Anterior Cervical Discectomy with or without fusion is effective for ventral pathology that is confined to the cervical interspaces such as osteophyte or disc complexes. Most of the recent literature has focused on outcomes for Anterior Cervical Discectomy with Fusion (ACDF). Short- and long-term clinical success in the range of 67% to 100% has been extensively reported in the literature [
Ebersold et al. reported Nurick scale outcomes in 33 patients with ACDF at 1 or 2 levels [
Autograft from either the iliac crest or fibula is traditionally gold standard for fusion [
ACDF of 1 to 3 levels has been reported to be effective and safe in decompressing ventral pathology. The rate of fusion following single-level ACDF generally ranges from 80% to 95% [
Nirala et al. reviewed 69 patients that underwent multilevel ACDF using autograft iliac crest without fixation. Fusion was assessed on dynamic radiographs. The overall fusion rate for multilevel ACDF was 69.6%, The fusion rate was 86.7% for 2 levels, 57.6% for 3 levels, and 50% for 4 levels. The outcome score using Odom's criteria was good or excellent in 81.1%. Graft dislodgements were noted in 1.4% [
The use of plating remains a controversial issue. In multilevel ACDFs, studies have demonstrated that rigid plate fixation dramatically increases fusion rates [
Anterior cervical corpectomy with fusion (ACCF) is effective in addressing ventral pathology that extends beyond the cervical spine interspaces [
ACCF compares favourably when compared to other decompression techniques in terms of stability and clinical outcomes [
Single-level corpectomy is generally considered safe and associated with successful outcomes for CSM [
Plating has been shown to reduce multilevel corpectomy but also in single level corpectomy [
Several articles have evaluated effectiveness of titanium mesh cage for reconstruction following anterior cervical corpectomy. Narotam et al. prospectively evaluated 37 patients over a 4-year period, and noted a stability rate of 100% at 1 year after ACCF with a TMC cage. Cage-related complication rate was low (2.7%). Excellent neurological outcome was documented in 95% of the patients. Similarly, Daubs and Kabir et al. reported similar good short-term results with spinal fusion observed in 100% of patients [
The objective of operative treatment in cervical radiculopathy is to alleviate pain, decrease sensorimotor deficits, and improve quality of life. This can be achieved by the permanent decompression of the compressed nerve root [
Posterior laminoforaminotomy is used for decompression of the nerve root in cases of foraminal stenosis or removal of posterolateral soft disc fragments. It maintains the motion in the affected segment and does not cause major instability [
Kumar et al. reviewed 89 patients treated with laminoforaminotomy for cervical spondylotic radiculopathy caused by osteophytes [
Shorter duration of the operation and fewer complications, compared to anterior surgery, have been reported as major advantages of posterior laminoforaminotomy [
Anterior cervical discectomy and fusion (ACDF) is suggested for the treatment of single-level degenerative cervical radiculopathy for compressive lesions medioventral to the nerve root [
Peolsson et al. reported 34 patients that underwent anterior decompression for cervical radiculopathy with 3-year followup [
As previously discussed, iliac crest autograft is the gold standard but other fusion techniques may be utilised, each with their own benefits and complications [
In recent times, much attention has been focused on the use of cervical disc arthroplasty in an attempt to preserve motion segments. Short-term outcomes suggested comparable efficacy to ACDF for the treatment of single-level degenerative cervical radiculopathy [
Cervical spondylotic myelopathy and radiculopathy are common disorders which can lead to significant clinical morbidity. Numerous surgical techniques exist to alleviate symptoms, which are achieved through anterior, posterior, or circumferential approaches. Under most circumstances, one approach will produce optimal results. The surgical plan should be tailored to address each individual’s unique clinical circumstance.
When considering surgical outcomes for CSM, it is important to remember that regardless of surgical technique employed, results of operative treatment generally are better in patients who undergo early decompression. In a prospective study of 146 patients with cervical spondylotic myelopathy, Suri et al. noted that patients with less than a one-year duration of symptoms showed significantly greater motor recovery following operation than did those with a longer duration of symptoms [
An extensive review of the current peer-reviewed literature does not provide an evidence base to indicate whether anterior or posterior surgery yields superior short- and long-term results for both CSM and cervical radiculopathy. Well-designed prospective randomised-control trials involving patients with these clinical scenarios could help to properly evaluate this.