Posterior approach for cervical spondylotic myelopathy

Posterior approach may be chosen when pathology is present dorsally and/or in the presence of neutral to lordotic alignment. Anterior approach is the golden standard in patients with kyphosis and/or stenosis due to ventral lesions, even with three or more affected levels.

In patients with effective cervical lordosis (fewer than 3 levels of ventral disease), anterior cervical discectomy and fusion (ACDF) or cervical arthroplasty is preferred. Patients with more than 3 levels of compression are generally treated by cervical laminoplasty, especially with preserved lordotic curvature. In patients with straightened spine who have less than 3 involved levels, ACDF with a cervical plate is recommended, whereas patients with more than 3 involved levels with instability should undergo posterior decompression and fusion. In young patients who have a stable cervical spine, laminoplasty is recommended and in old patients with ankylosed spine, only cervical laminectomy should be performed. Patients with mild cervical kyphosis (kyphotic angle ≤10°) should be managed in the same way as patients with straightened spine. However, in severe kyphosis, cervical traction is recommended. If the kyphosis is reducible, further posterior decompression and fusion is adequate. In patients with irreducible kyphosis, if the number of involved levels is less than 2, ACDF is adequate, but if it is more than 2 levels, anterior cervical corpectomy and fusion should be performed using cervical magnetic resonance imaging for evaluation of the patency of the subarachnoid space (SAS). With patent SAS, only posterior fusion is adequate, whereas in closed SAS, posterior decompression with posterior fusion is required. These approaches are based on the most recent evidence ¹⁾.

Posterior foraminal cervical surgery with three-dimensional access and localization with anterior/posterior fluoroscopic imaging allows safe, reproducible docking on the cervical spine with subsequent exploration of the foramen and routine outpatient discharge. Complications related to difficulty with lateral localization in the lower cervical spine, and with inadvertent entry into the cervical spinal canal with possible catastrophic result are thus avoided ²⁾.

This approach allowed to reduce about 30% of the number of patients treated by the anterior approach, thus consistently reducing the need for intersomatic fixation ³⁾.

see Posterior cervical fixation technique.

see Posterior cervical foraminotomy.

Double-door staples

A retrospective review of patients with cervical myelopathy from cervical stenosis treated with minimally invasive posterior cervical decompression was performed. The operation was performed through a nonexpandable tubular retractor and operating microscope.

In twelve patients there were no early or late complications. Average age was 74.5 years. Three patients were > 80 years of age and tolerated the operation extremely well. Three cases were two-level decompressions; nine were single level. Eight patients were operated on as elective cases, with average postoperative length of stay of 0.9 days. Average surgical time was 77.5 minutes per level. Postoperative neck pain was minimal (1.5/10). All patients improved postoperatively, particularly those who started with severe deficits. In fact, five patients were unable to walk preoperatively and were wheelchair- or bed-bound, and they returned to walking within weeks. The Modified Japanese Orthopaedic Association scale improved from 8.4 (range: 4-14) to 13.5 (range: 10-15); the Nurick scale changed from 3.8 (range: 2-5) to 2.3 (range: 1-4).   Minimally invasive microscopic posterior cervical decompression is a safe and effective treatment for CSM in selected cases. The initial experience highlights the potential benefits of this relatively new technique ⁴⁾.

356 patients were treated for different spinal disorders using this approach. The approach was applied in 299 surgeries for lumbar disc herniation and we called the procedure: microscopic assisted percutaneous nucleotomy (MAPN). The approach was applied in another 34 patients with lumbar canal stenosis to perform what we called microscopic assisted percutaneous decompression (MAPD). The latter was applied for three cases with thoracic canal stenosis and six with cervical canal stenosis. The approach was also applied for other purposes and included myeloscopy in four cases, transpedicular biopsy in six, and transpedicular vertebroplasty in the remaining four. The 43 MAPN done in the early period were re-examined one year after the operation. We achieved 75% good and very good results regarding the relief of the sciatic pain and recovery of the neurological deficits. Re-surgery was necessary in only two cases (4.5%). The results with the use of this technique seem very promising. The minimal trauma induced by this approach allows rapid mobilisation of the patients and short hospital stay. A postoperative back orthoses is not necessary. The technique can also be done under local anaesthesia particularly when needed as in old people with severe co-morbidity ⁵⁾.