Review Question - QID 218858

A combined anterior-posterior cervical decompression and fusion is favored in the presence of cervical kyphosis > +12 degrees and >2 levels of spinal cord compression.

Cervical myelopathy develops from long-standing spinal cord compression and leads to a predictable step-wise decline in function. Common complaints include gait instability, loss of dexterity, urinary incontinence, and paresthesias. Treatment is almost always surgical to prevent further neurologic deterioration. Approach selection is dependent on the number of levels involved and cervical sagittal alignment. In cases with greater than two levels of spinal cord compression and the presence of > +12 degrees of cervical kyphosis a combined anterior-posterior approach is favored. The anterior approach functions to restore cervical lordosis and the posterior approach provides decompression and improved fusion rates with multilevel ACDFs.

Mayer et al. reviewed cervical laminectomy as a useful posterior decompression technique in certain cervical spine conditions. The authors acknowledge that anterior cervical decompression has shown better outcomes in certain situations, but highlight that laminectomy can still be beneficial when combined with instrumented lateral mass fusion for specific indications. They guide decision-making, technical aspects, and potential complications.

Farrokhi et al. reviewed the literature regarding the surgical treatment of cervical spondylotic myelopathy and provided an evidence-based approach. The authors recommended surgical techniques depending on factors such as the number of affected levels, cervical lordosis, spinal stability, and the presence of kyphosis. The authors recommended anterior cervical discectomy and fusion (ACDF) or arthroplasty for patients with cervical kyphosis and fewer than 3 levels of ventral disease, while laminoplasty is recommended for patients with more than 3 levels of compression and preserved lordotic curvature.

Aebli et al. aimed to investigate the use of the Torg-Pavlov ratio, a radiological parameter for assessing developmental spinal canal stenosis, in patients with acute cervical spinal cord injury (SCI) following minor trauma. They found that patients with SCI had significantly smaller Torg-Pavlov ratio values compared to those without neurologic symptoms. A Torg-Pavlov ratio cutoff value of 0.7 was identified as predictive of SCI occurrence. They concluded these findings suggest that the Torg-Pavlov ratio can help identify patients at risk of SCI after minor trauma, but other factors also influence symptom severity and outcome.

Incorrect answers:
Answer 1: This scenario would favor an all-posterior approach (laminoplasty) given the presence of four-level disease, preserved cervical lordosis, and absence of axial neck pain.
Answer 2: This scenario would favor a two-level anterior cervical discectomy and fusion given the presence of axial neck pain, cervical kyphosis, and two-level disease.
Answer 4: Single-level radiculopathy without significant spondylosis can be treated with a single-level ACDF, disc replacement, or posterior cervical foraminotomy.
Answer 5: Preserved cervical lordosis and the presence of spondylosis from axial neck pain would be ideally treated with a posterior instrumented fusion and decompression.