Review Question - QID 213132

In the presence of myelomalacia, the goal of treatment for cervical spondylotic myelopathy is to prevent further neurologic deterioration, which would best be achieved with posterior decompression and fusion from C4-7 in this patient. Patients must be counseled that neurologic recovery is variable.

Cervical myelopathy is a progressive deterioration of neurologic function as a result of chronic cord compression. Patients typically present hand clumsiness, gait instability, urinary symptoms, and neck pain. Treat is almost always surgical due to the progressive decline in function. In the setting of myelomalacia on magnetic resonance imaging, especially with decreased signal intensity on T1 weighted images, there is less likely to be a good recovery and the goal of treatment is to prevent further decline in the patient's neurological status. Posterior decompression and fusion is the preferred treatment with more than 2 levels requiring decompression and preserved cervical lordosis.

Fehlings et al. performed a multicenter prospective study of patients with cervical spondylotic myelopathy undergoing either anterior or posterior surgery. The authors found that patients were more likely to undergo anterior surgery if they were younger, had a less severe neurological impairment, and more focal pathology. The authors concluded that when the treatment choice is left to the surgeon, outcomes of anterior and posterior surgery are equivalent.

Lawrence et al. reviewed key literature regarding indications of anterior versus posterior surgery for degenerative cervical myelopathy. The literature recommends selecting a surgical approach based on ventral versus dorsal cord compression, sagittal malalignment, focal versus diffuse involvement, presence of radiculopathy, presence of spondylotic axial neck pain, and surgeon familiarity with the procedure.

Shamji et al. performed a systematic review of the literature regarding anterior surgical technique and outcomes between multiple diskectomies, diskectomy-corpectomy hybrid, and multiple corpectomies. The authors recommended multiple diskectomies when there was minimal retrovertebral disease. For extensive retrovertebral disease, they recommended diskectomy-corpectomy hybrid over multiple corpectomies due to improved sagittal alignment and better patient-reported outcomes.

Figure A demonstrates a T2 sagittal MRI of the cervical spine with stenosis at C4-5, C5-6, and C6-7 with severe corresponding myelomalacia at C5-6. Figure B is the axial T2 MRI at C5-6 with severe cervical stenosis.

Incorrect answers:
Answer 1: Surgical decompression is likely to result in neurologic improvements in many patients with cervical myelopathy, but in the setting of severe myelomalacia full recovery is unlikely. Cervical laminectomy alone will likely result in instability and progressive kyphosis.
Answer 2: The presence of myelomalacia suggests a less favorable outcome as opposed to the absence of myelomalacia. Given that there is no retrovertebral disease and maintenance of cervical lordosis corpectomy of the affected levels in unnecessary and comes with extensive surgical risk.
Answer 4: C5 nerve palsy occurs equally between anterior and posterior surgery. In this patient performing a posterior cervical decompression and fusion would be a more preferred treatment than ACDF
Answer 5: Laminoplasty most effectively addresses diffuse disease in a spine with preserved lordosis.