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Posterior surgery for Cervical Spondylotic Myelopathy Mehmet Zileli , M.D.

Posterior surgery for Cervical Spondylotic Myelopathy Mehmet Zileli , M.D. Izmir - Turkey. CSM Posterior Decompression. Indications Posterior compression >2 level anterior compression Hyperlordosis Contraindications Kyphosis 1-2 level anterior compression.

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Posterior surgery for Cervical Spondylotic Myelopathy Mehmet Zileli , M.D.

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  1. Posterior surgery for Cervical Spondylotic MyelopathyMehmet Zileli, M.D. Izmir - Turkey

  2. CSM Posterior Decompression • Indications • Posterior compression • >2 level anterior compression • Hyperlordosis • Contraindications • Kyphosis • 1-2 level anterior compression

  3. Anterior vs Posterior Surgery?Decision Making 1-Site of compression 2-Cervical curve 3-Number of compressions 4-Patient’s general condition, bone quality

  4. Anterior vs Posterior Surgery?Importance of Site of Compression Anterior compression • Anterior surgery Posterior compression • Posterior surgery Anterior & posterior compression • ??? • The number of levels ? • Instability ?

  5. Anterior vs Posterior Surgery?Importance of Curve • Kyphotic curve • Anterior surgery • Multiple levels ?? • Hyperlordotic curve • Posterior surgery • Lordosis preserved - lost • ???

  6. Anterior vs Posterior Surgery?Patient’s age, general condition, bone quality • Age is not a factor alone • Graft problems if osteoporotic • Poor general condition • Posterior surgery > Anterior surgery

  7. Complications of Anterior Surgeryappr. 20-25% 1-Neurological complications 2-Cervical site compl. Airway problems Hematom Esophageal injury Vascular Hoarseness Dysphagia Chylothorax 3-Graft related compl. Graft dislocation Pseudarthrosis Adjacent level degeneration Plate & screw problems 4-Graft site compl.

  8. CSM: Posterior Surgery Advantages 1-Very good technique for decompression of structures from posterior such as ligamentum flavum hypertrophy. Disadvantages 1-Increasing instability resulting in osteophyte formation 2-Hard discs and anterior osteophytes are not possible to remove, if attempted, it would cause root injury 3-Neurological complications are more in comparison to anterior surgery

  9. Posterior SurgeryAbsolute Indications 44 y.o. male, quadriparesis for 5-6 yrs, gait disturbance for 1 yr, sphincter disturbancePosterior compression only > posterior surgery

  10. Posterior SurgeryAbsolute Indications 79 y.o. Female, walking disturbance for years. Inability to walk for 1 month, wheel-chair dependent. MRI: severe anterior and posteriorcompression at C3-4. Coronary artery disease, high risk for cardiac reasons

  11. Posterior SurgeryRelative Indications 72 y.o. Male. Tetraparesisi prominent on right side for 1 year. MRI C4-5-6-7 severe narrowing T2 hyperintensity , lordoticcurve.

  12. C4-5-6 laminectomy, lateral mass plate

  13. 3 levels anterior-posterior compression, lordosis is preserved > posterior surgery Postop MRI

  14. CSM: Posterior Surgery Laminectomy & Fusion Lateral mass fixation Laminoplasty Hemilateral opening Bilateral opening

  15. Laminectomy & Fusion Lateral mass fixation

  16. Laminoplasty • Unilateral opening • Bilateral opening

  17. Laminoplasty

  18. Laminectomy or Laminoplasty? Laminectomy Causes instability Laminectomy membrane Laminoplasty Technically demanding Restricted neck movements Insufficient decompression?

  19. OutcomeAnterior vs Posterior • Success rates range between 70-85% in different series • Duration of symptoms are important

  20. ComplicationsAnterior vs Posterior • Functional outcomes similar • But complications greater with corpectomy Yonenobu, et. al. – Spine, 1992 Heller, et. al. – Spine, 2001 Wada, et. al. – Spine, 2001 Edwards, et.al. – Spine, 2002

  21. Conclusions For multi-level anteriorcompression < 2 Levels Multi-level ACDF 2 Levels Corpectomy >2 Levels Laminectomy or Laminoplasty For multi-level diffuse (e.g. congenital) compression • No Kyphosis Laminoplasty or corpectomy • Kyphosis Corpectomy

  22. Conclusions • With proper indications, results comparable with either corpectomy or laminectomy / laminaplasty • Higher complication rate with corpectomy

  23. CSM Posterior Decompression • Indications • Posterior compression • >2 level anterior compression • Hyperlordosis • Contraindications • Kyphosis • 1-2 level anterior compression

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