Advertisement

Current surgical practice for multi-level degenerative cervical myelopathy: Findings from an international survey of spinal surgeons

      Highlights

      • Degenerative cervical myelopathy is a major cause of disability.
      • Surgery is the mainstay of treatment, but there is significant variation in approach.
      • This was an international survey of spine surgeons.
      • We found that approach is decided on a case by case basis.
      • However, posterior approaches are favoured.
      • Further study required to assess need for fusion in addition to laminectomy.

      Abstract

      Degenerative cervical myelopathy (DCM) results from compression of the cervical spine cord as a result of age related changes in the cervical spine, and affects up to 2% of adults, leading to progressive disability. Surgical decompression is the mainstay of treatment, but there remains significant variation in surgical approaches used. This survey was conducted in order to define current practice amongst spine surgeons worldwide, as a possible prelude to further studies comparing surgical approaches. Methods: An electronic survey was developed and piloted by the investigators using SurveyMonkey. Collected data was categorical and is presented using summary statistics. Where applicable, statistical comparisons were made using a Chi-Squared test. The level of significance for all statistical analyses was defined as p < 0.05. All analysis, including graphs was performed using R (R Studio). Results: 127 surgeons, from 30 countries completed the survey; principally UK (66, 52%) and North America (15, 12%). Respondents were predominantly Neurosurgeons by training (108, 85%) of whom 84 (75%) reported Spinal Surgery as the principal part of their practice.
      The majority indicated they selected their surgical procedure for multi-level DCM on a case by case basis (62, 49%). Overall, a posterior approach was more popular for multi-level DCM (74, 58%). Region, speciality or annual multi-level case load did not influence this significantly. However, there was a trend for North American surgeons to be more likely to favour a posterior approach. Conclusions: A posterior approach was favoured and more commonly used to treat multi-level DCM, in an international cohort of surgeons. Posterior techniques including laminectomy, laminectomy and fusion or laminoplasty appeared to be equally popular.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Clinical Neuroscience
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Davies B.M.
        • Mowforth O.D.
        • Smith E.K.
        • Kotter M.R.
        Degenerative cervical myelopathy.
        BMJ. 2018; 360k186https://doi.org/10.1136/bmj.k186
        • Nouri A.
        • Cheng J.S.
        • Davies B.
        • Kotter M.
        • Schaller K.
        • Tessitore E.
        Degenerative cervical myelopathy: a brief review of past perspectives, present developments, and future directions.
        J Clin Med. 2020; 9: 535https://doi.org/10.3390/jcm9020535
        • Witiw C.D.
        • Mathieu F.
        • Nouri A.
        • Fehlings M.G.
        Clinico-radiographic discordance: an evidence-based commentary on the management of degenerative cervical spinal cord compression in the absence of symptoms or with only mild symptoms of myelopathy.
        Global Spine J. 2018; 8: 527-534https://doi.org/10.1177/2192568217745519
        • Fehlings M.G.
        • Tetreault L.A.
        • Riew K.D.
        • Middleton J.W.
        • Aarabi B.
        • Arnold P.M.
        • et al.
        A clinical practice guideline for the management of patients with degenerative cervical myelopathy: recommendations for patients with mild, moderate, and severe disease and nonmyelopathic patients with evidence of cord compression.
        Global Spine J. 2017; 7: 70S-83Shttps://doi.org/10.1177/2192568217701914
        • Fehlings M.G.
        • Ibrahim A.
        • Tetreault L.
        • Albanese V.
        • Alvarado M.
        • Arnold P.
        • et al.
        A global perspective on the outcomes of surgical decompression in patients with cervical spondylotic myelopathy: results from the prospective multicenter AOSpine international study on 479 patients.
        Spine. 2015; 40: 1322-1328https://doi.org/10.1097/BRS.0000000000000988
        • Kato S.o.
        • Fehlings M.
        Degenerative cervical myelopathy.
        Curr Rev Musculoskelet Med. 2016; 9: 263-271https://doi.org/10.1007/s12178-016-9348-5
        • Mowforth O.D.
        • Davies B.M.
        • Goh S.
        • O’Neill C.P.
        • Kotter M.R.N.
        Research inefficiency in degenerative cervical myelopathy: findings of a systematic review on research activity over the past 20 years.
        Global Spine J. 2020; 10: 476-485https://doi.org/10.1177/2192568219847439
        • Davies B.M.
        • Khan D.Z.
        • Mowforth O.D.
        • McNair A.G.K.
        • Gronlund T.
        • Kolias A.G.
        • et al.
        RE-CODE DCM (REsearch objectives and common data elements for degenerative cervical myelopathy): a consensus process to improve research efficiency in DCM, through establishment of a standardized dataset for clinical research and the definition of the research priorities.
        Global Spine J. 2019; 9: 65S-76Shttps://doi.org/10.1177/2192568219832855
      1. Nouri A, Martin A, Tetreault L, Nater A, Kato S, Nakashima H, et al. MRI analysis of the combined prospectively collected AOSpine North America and International Data: the prevalence and spectrum of pathologies in a global cohort of patients with degenerative cervical myelopathy. Spine 2016. doi:10.1097/BRS.0000000000001981.

        • Gharooni A.-A.
        • Grodzinski B.
        • Davies B.M.
        • Kotter M.R.N.
        How common is repeat surgery and multi-level treatment in Degenerative Cervical Myelopathy? Findings from a patient perspective survey.
        J Clin Neurosci. 2020; 77: 181-184https://doi.org/10.1016/j.jocn.2020.04.109
        • Kaptain G.J.
        • Simmons N.E.
        • Replogle R.E.
        • Pobereskin L.
        Incidence and outcome of kyphotic deformity following laminectomy for cervical spondylotic myelopathy.
        J Neurosurg. 2000; 93: 199-204https://doi.org/10.3171/spi.2000.93.2.0199
        • Rhee J.M.
        • Basra S.
        Posterior surgery for cervical myelopathy: laminectomy, laminectomy with fusion, and laminoplasty.
        Asian Spine J. 2008; 2: 114-126https://doi.org/10.4184/asj.2008.2.2.114
        • McAllister B.D.
        • Rebholz B.J.
        • Wang J.C.
        Is posterior fusion necessary with laminectomy in the cervical spine?.
        Surg Neurol Int. 2012; 3: S225-S231https://doi.org/10.4103/2152-7806.98581
        • Kim B.S.
        • Dhillon R.S.
        Cervical laminectomy with or without lateral mass instrumentation: a comparison of outcomes.
        Clin Spine Surg. 2019; 32: 226-232https://doi.org/10.1097/BSD.0000000000000852
        • Guigui P.
        • Benoist M.
        • Deburge A.
        Spinal deformity and instability after multilevel cervical laminectomy for spondylotic myelopathy.
        Spine. 1998; 23: 440-447https://doi.org/10.1097/00007632-199802150-00006
        • Hamanishi C.
        • Tanaka S.
        Bilateral multilevel laminectomy with or without posterolateral fusion for cervical spondylotic myelopathy: relationship to type of onset and time until operation.
        J Neurosurg. 1996; 85: 447-451https://doi.org/10.3171/jns.1996.85.3.0447
        • Anderson P.A.
        • Matz P.G.
        • Groff M.W.
        • Heary R.F.
        • Holly L.T.
        • Kaiser M.G.
        • et al.
        Laminectomy and fusion for the treatment of cervical degenerative myelopathy.
        J Neurosurg Spine. 2009; 11: 150-156https://doi.org/10.3171/2009.2.SPINE08727
        • Ryken T.C.
        • Heary R.F.
        • Matz P.G.
        • Anderson P.A.
        • Groff M.W.
        • Holly L.T.
        • et al.
        Cervical laminectomy for the treatment of cervical degenerative myelopathy.
        J Neurosurg Spine. 2009; 11: 142-149https://doi.org/10.3171/2009.1.SPINE08725
        • Abduljabbar F.H.
        • Teles A.R.
        • Bokhari R.
        • Weber M.
        • Santaguida C.
        Laminectomy with or without fusion to manage degenerative cervical myelopathy.
        Neurosurg Clin N Am. 2018; 29: 91-105https://doi.org/10.1016/j.nec.2017.09.017
        • Komotar R.J.
        • Mocco J.
        • Kaiser M.G.
        Surgical management of cervical myelopathy: indications and techniques for laminectomy and fusion.
        Spine J. 2006; 6: S252-S267https://doi.org/10.1016/j.spinee.2006.04.029
        • Nouri A.
        • Martin A.R.
        • Nater A.
        • Witiw C.D.
        • Kato S.o.
        • Tetreault L.
        • et al.
        Influence of magnetic resonance imaging features on surgical decision-making in degenerative cervical myelopathy: results from a global survey of AOSpine international members.
        World Neurosurg. 2017; 105: 864-874https://doi.org/10.1016/j.wneu.2017.06.025
      2. Davies BM, McHugh M, Elgheriani A, Kolias AG, Tetreault L, Hutchinson PJA, et al. The reporting of study and population characteristics in degenerative cervical myelopathy: a systematic review. 2017;12:e0172564. doi:10.1371/journal.pone.0172564.

        • Davies B.
        • Mowforth O.
        • Sadler I.
        • Aarabi B.
        • Kwon B.
        • Kurpad S.
        • et al.
        Recovery priorities in degenerative cervical myelopathy: a cross-sectional survey of an international, online community of patients.
        BMJ Open. 2019; 9: e031486https://doi.org/10.1136/bmjopen-2019-031486
        • Bajamal A.H.
        • Kim S.-H.
        • Arifianto M.R.
        • Faris M.
        • Subagio E.A.
        • Roitberg B.
        • et al.
        Posterior surgical techniques for cervical spondylotic myelopathy: WFNS Spine committee recommendations.
        Neurospine. 2019; 16: 421-434https://doi.org/10.14245/ns.1938274.137
      3. Hutton MJ. Spinal services. Getting it right first time n.d.

        • Veeravagu A.
        • Connolly I.D.
        • Lamsam L.
        • Li A.
        • Swinney C.
        • Azad T.D.
        • et al.
        Surgical outcomes of cervical spondylotic myelopathy: an analysis of a national, administrative, longitudinal database.
        Neurosurg Focus. 2016; 40: E11https://doi.org/10.3171/2016.3.FOCUS1669
      4. Puvanesarajah V, Jain A, Cancienne JM, Shimer AL, Singla A, Shen F, et al. Complication and reoperation rates following surgical management of cervical spondylotic myelopathy in medicare beneficiaries. Spine 2017;42:1–7. doi:10.1097/BRS.0000000000001639.

        • Tetreault L.
        • Nouri A.
        • Singh A.
        • Fawcett M.
        • Nater A.
        • Fehlings M.G.
        An assessment of the key predictors of perioperative complications in patients with cervical spondylotic myelopathy undergoing surgical treatment: results from a survey of 916 AOSpine International Members.
        World Neurosurgery. 2015; 83: 679-690https://doi.org/10.1016/j.wneu.2015.01.021
        • Lawrence B.D.
        • Jacobs W.B.
        • Norvell D.C.
        • Hermsmeyer J.T.
        • Chapman J.R.
        • Brodke D.S.
        Anterior versus posterior approach for treatment of cervical spondylotic myelopathy: a systematic review.
        Spine. 2013; 38: S173-S182https://doi.org/10.1097/BRS.0b013e3182a7eaaf
        • Laratta J.L.
        • Reddy H.P.
        • Bratcher K.R.
        • McGraw K.E.
        • Carreon L.Y.
        • Owens II R.K.
        Outcomes and revision rates following multilevel anterior cervical discectomy and fusion.
        J Spine Surg. 2018; 4: 496-500https://doi.org/10.21037/jss10.21037/jss.2018.06.16
        • McClelland S.
        • Marascalchi B.J.
        • Passias P.G.
        • Protopsaltis T.S.
        • Frempong-Boadu A.K.
        • Errico T.J.
        Impact of race and insurance status on surgical approach for cervical spondylotic myelopathy in the United States: a population-based analysis.
        Spine. 2017; 42: 186-194https://doi.org/10.1097/BRS.0000000000001693
        • Du W.
        • Wang L.
        • Shen Y.
        • Zhang Y.
        • Ding W.
        • Ren L.
        Long-term impacts of different posterior operations on curvature, neurological recovery and axial symptoms for multilevel cervical degenerative myelopathy.
        Eur Spine J. 2013; 22: 1594-1602https://doi.org/10.1007/s00586-013-2741-5
        • Singrakhia M.D.
        • Malewar N.R.
        • Singrakhia S.M.
        • Deshmukh S.S.
        Cervical laminectomy with lateral mass screw fixation in cervical spondylotic myelopathy: neurological and sagittal alignment outcome: do we need lateral mass screws at each segment?.
        Indian J Orthop. 2017; 51: 658-665https://doi.org/10.4103/ortho.IJOrtho_266_16
        • Gok B.
        • McLoughlin G.S.
        • Sciubba D.M.
        • McGirt M.J.
        • Chaichana K.L.
        • Wolinsky J.-P.
        • et al.
        Surgical management of cervical spondylotic myelopathy with laminectomy and instrumented fusion.
        Neurol Res. 2009; 31: 1097-1101https://doi.org/10.1179/174313209X383277
        • Mehdi S.K.
        • Alentado V.J.
        • Lee B.S.
        • Mroz T.E.
        • Benzel E.C.
        • Steinmetz M.P.
        Comparison of clinical outcomes in decompression and fusion versus decompression only in patients with ossification of the posterior longitudinal ligament: a meta-analysis.
        Neurosurg Focus. 2016; 40: E9https://doi.org/10.3171/2016.3.FOCUS1630
        • Kire N.
        • Jain S.
        • Merchant Z.A.
        • Kundnani V.
        The efficacy of posterior cervical laminectomy for multilevel degenerative cervical spondylotic myelopathy in long term period.
        Asian J Neurosurg. 2019; 14: 848-852https://doi.org/10.4103/ajns.AJNS_49_19
        • Kato Y.
        • Iwasaki M.
        • Fuji T.
        • Yonenobu K.
        • Ochi T.
        Long-term follow-up results of laminectomy for cervical myelopathy caused by ossification of the posterior longitudinal ligament.
        J Neurosurg. 1998; 89: 217-223https://doi.org/10.3171/jns.1998.89.2.0217
        • Bartels R.H.
        • Groenewoud H.
        • Peul W.C.
        • Arts M.P.
        Lamifuse: results of a randomized controlled trial comparing laminectomy with and without fusion for cervical spondylotic myelopathy.
        J Neurosurg Sci. 2017; 61: 134-139https://doi.org/10.23736/S0390-5616.16.03315-4
      5. Nurboja B, Kachramanoglou C, Choi D. Cervical laminectomy vs laminoplasty: is there a difference in outcome and postoperative pain? Neurosurgery 2012;70:965–70–discussion970. doi:10.1227/NEU.0b013e31823cf16b.

        • Lao L.
        • Zhong G.
        • Li X.
        • Qian L.
        • Liu Z.
        Laminoplasty versus laminectomy for multi-level cervical spondylotic myelopathy: a systematic review of the literature.
        J Orthop Surg Res. 2013; 8: 45-49https://doi.org/10.1186/1749-799X-8-45
        • Patil P.G.
        • Turner D.A.
        • Pietrobon R.
        National trends in surgical procedures for degenerative cervical spine disease: 1990–2000.
        Neurosurgery. 2005; 57: 753-758https://doi.org/10.1227/01.NEU.0000175729.79119.1d
        • O'Lynnger T.M.
        • Zuckerman S.L.
        • Morone P.J.
        • Dewan M.C.
        • Vasquez-Castellanos R.A.
        • Cheng J.S.
        Trends for spine surgery for the elderly: implications for access to healthcare in North America.
        Neurosurgery. 2015; 77: S136-S141https://doi.org/10.1227/NEU.0000000000000945
        • Manchikanti L.
        • Pampati V.
        • Falco F.J.E.
        • Hirsch J.A.
        Growth of spinal interventional pain management techniques: analysis of utilization trends and Medicare expenditures 2000 to 2008.
        Spine. 2013; 38: 157-168https://doi.org/10.1097/BRS.0b013e318267f463
        • Tarnaris A.
        • Arvin B.
        • Ashkan K.
        Evolution in practice: how has British neurosurgery changed in the last 10 years?.
        Ann R Coll Surg Engl. 2008; 90: 508-512https://doi.org/10.1308/003588408X321530
        • Passias P.G.
        • Marascalchi B.J.
        • Boniello A.J.
        • Yang S.
        • Bianco K.
        • Jalai C.M.
        • et al.
        Cervical spondylotic myelopathy: National trends in the treatment and peri-operative outcomes over 10years.
        J Clin Neurosci. 2017; 42: 75-80https://doi.org/10.1016/j.jocn.2017.04.017
        • Ergina P.L.
        • Cook J.A.
        • Blazeby J.M.
        • Boutron I.
        • Clavien P.-A.
        • Reeves B.C.
        • et al.
        Challenges in evaluating surgical innovation.
        Lancet. 2009; 374: 1097-1104https://doi.org/10.1016/S0140-6736(09)61086-2