Surgical Treatment of Cervical Spondylotic Myelopathy

Abstract

Cervical spondylotic myelopathy (CSM) is the leading cause of spinal cord injury in adults. The typical symptoms of CSM are poor hand dexterity and unsteady gait pattern, which prevent patients from completing fine movements, seriously affecting their quality of life. Surgical treatment is generally recommended for patients who have moderate to severe CSM and who have received conservative treatment but whose symptoms are still progressing. However, the choice of surgical method has been controversial due to the diversity of surgical procedures of CSM. For spine surgeons, understanding the features of different procedures can greatly assist them in making clinical decisions. Based on the different approaches, operative treatments can be grouped into anterior surgery, posterior surgery, and combined anterior and posterior surgery. Anterior surgeries include anterior cervical discectomy and fusion (ACDF), anterior cervical corpectomy and fusion (ACCF), as well as cervical disc replacement (CDR). Posterior surgeries consist of laminectomy and laminoplasty. For patients with a complex pathophysiology and more severe CSM, combined anterior-posterior surgery, such as posterior laminoplasty or laminectomy and fusion combined with ACDF or ACCF, is often recommended. Additionally, ACDF has been applicated as the mainstay of treatment for CSM patients whose compression is confined to the disc level and has fewer than three compression segments, but the high incidence of complication should be expected, as well as the high readmission rate and additional costs. Meanwhile, as knowledge about CSM and its surgical treatment continues to expand, many trials have demonstrated the superiority of CDR in preserving the mobility of the index segments and reducing the incidence of complications. Therefore, CDR could be a better option than ACDF for patients with similar pathological changes but relatively stable cervical spine. This article summarized the pathophysiology of CSM as well as the characteristics, indications, clinical efficacy, and safety of various surgical treatments, and pays special attention to the clinical selection of CDR and ACDF, which can provide a more comprehensive reference for spine surgeons to make clinical decisions about CSM surgery.