Introduction: Degenerative Cervical Myelopathy (DCM) encompasses a spectrum of age-related pathologies of the cervical spine that result in spinal cord impairment. We conducted a survey to understand how specific pathologic features on MRI influence surgeons toward an anterior or posterior surgical approach.
Methods: A questionnaire was sent out to 6,179 AOSpine International members via email with 2 subsequent reminders. This included 18 questions on a 7-point Likert scale regarding how MRI features influence the respondent’s decision to perform an anterior or posterior surgical approach. Influence was classified based on the mean and mode. Variations in responses were assessed by region and training.
Results: There were 513 respondents: 51.7% were orthopedic surgeons, 36.8% neurosurgeons and the remainder classified as fellows, residents or “other”. In ascending order, multilevel bulging discs, cervical kyphosis and a high degree of anterior cord compression had a moderate to strong influence toward an anterior approach. A high degree of posterior cord compression had a strong-moderate influence, while multilevel compression, OPLL, ligamentum flavum enlargement, and congenital stenosis had a moderate influence toward a posterior approach. Differences in the degree of influence were noted between regions and training for 15 and 6 out of 18 MRI factors (p<0.05), respectively. Neurosurgeons chose anterior approaches more and posterior approaches less, in comparison to orthopedic surgeons (p<0.01). Of note, 59.8% of respondents were equally comfortable performing multilevel (=3 levels) anterior and posterior procedures, while 61.5% did not feel comfortable in determining the surgical approach based MRI alone.
Conclusions: Specific DCM pathology influences the choice for an anterior or posterior surgical approach, and these factors vary based on training and region of practice. These findings will be helpful in defining future areas of investigation in an effort to provide individualized surgical strategies and optimize patient outcomes.
Patient Care: As both anterior and posterior approaches are treatment options for DCM, there has been considerable interest to determine which approach may be more effective when both can be used. Indeed, this topic is the subject of a current multicenter trial. This study was undertaken to provide further insight into the influences on surgical decision-making by surgeons to help address this ongoing area of controversy. Ultimately, these research results will help shape and tailor surgical decision-making towards more individualized strategies, with an effort to improve surgical outcomes and patient care.
Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the importance of MRI features in influencing surgeons toward anterior and/or posterior surgical approaches, 2) Discuss, in small groups how these findings are similar or different from their own experience, 3) Discuss some of the reasons why MRI influences differed between training and region.
References: GHOGAWALA, Z., BENZEL, E. C., HEARY, R. F., RIEW, K. D., ALBERT, T. J., BUTLER, W. E., BARKER, F. G., 2ND, HELLER, J. G., MCCORMICK, P. C., WHITMORE, R. G., FREUND, K. M. & SCHWARTZ, J. S. 2014. Cervical spondylotic myelopathy surgical trial: randomized, controlled trial design and rationale. Neurosurgery, 75, 334-46.
GHOGAWALA, Z., MARTIN, B., BENZEL, E. C., DZIURA, J., MAGGE, S. N., ABBED, K. M., BISSON, E. F., SHAHID, J., COUMANS, J. V., CHOUDHRI, T. F., STEINMETZ, M. P., KRISHNANEY, A. A., KING, J. T., JR., BUTLER, W. E., BARKER, F. G., 2ND & HEARY, R. F. 2011. Comparative effectiveness of ventral vs dorsal surgery for cervical spondylotic myelopathy. Neurosurgery, 68, 622-30; discussion 630-1.