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Paul G. Matz, Langston T. Holly, Praveen V. Mummaneni, Paul A. Anderson, Michael W. Groff, Robert F. Heary, Michael G. Kaiser, Timothy C. Ryken, Tanvir F. Choudhri, Edward J. Vresilovic, and Daniel K. Resnick

Object

The objective of this systematic review was to use evidence-based medicine to examine the efficacy of anterior cervical surgery for the treatment of cervical spondylotic myelopathy (CSM).

Methods

The National Library of Medicine and Cochrane Database were queried using MeSH headings and key words relevant to anterior cervical surgery and CSM. Abstracts were reviewed, and studies meeting inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I–III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons.

Results

Mild CSM (modified Japanese Orthopaedic Association [mJOA] scale scores > 12) responds in the short term (3 years) to either surgical decompression or nonoperative therapy (prolonged immobilization in a stiff cervical collar, “low-risk” activity modification or bed rest, and antiinflammatory medications) (Class II). More severe CSM responds to surgical decompression with benefits being maintained a minimum of 5 years and as long as 15 years postoperatively (Class III).

Conclusions

Treatment of mild CSM may involve surgical decompression or nonoperative therapy for the first 3 years after diagnosis. More severe CSM (mJOA scale score ≤ 12) should be considered for surgery depending upon the individual case. The shortcomings of this systematic review are that the group was not able to determine whether an mJOA scale score of 12 was indicative of a more severe CSM disease course, and whether patients who received nonsurgical treatment for 3 years had a significant probability for clinical deterioration after that time point.

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Paul G. Matz, Paul A. Anderson, Michael W. Groff, Robert F. Heary, Langston T. Holly, Michael G. Kaiser, Praveen V. Mummaneni, Timothy C. Ryken, Tanvir F. Choudhri, Edward J. Vresilovic, and Daniel K. Resnick

Object

The objective of this systematic review was to use evidence-based medicine to examine the efficacy of cervical laminoplasty in the treatment of cervical spondylotic myelopathy (CSM).

Methods

The National Library of Medicine and Cochrane Database were queried using MeSH headings and keywords relevant to cervical laminoplasty and CSM. Abstracts were reviewed and studies meeting the inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I–III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons and Congress of Neurological Surgeons.

Results

Cervical laminoplasty has improved functional outcome in the setting of CSM or ossification of the posterior longitudinal ligament. Using the Japanese Orthopaedic Association scale score, ~ 55–60% average recovery rate has been observed (Class III). The functional improvement observed after laminoplasty may be limited by duration of symptoms, severity of stenosis, severity of myelopathy, and poorly controlled diabetes as negative risk factors (Class II). There is conflicting evidence regarding age, with 1 study citing it as a negative risk factor, and another not demonstrating this result.

Conclusions

Cervical laminoplasty is recommended for the treatment of CSM or ossification of the posterior longitudinal ligament (Class III).

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Timothy C. Ryken, Robert F. Heary, Paul G. Matz, Paul A. Anderson, Michael W. Groff, Langston T. Holly, Michael G. Kaiser, Praveen V. Mummaneni, Tanvir F. Choudhri, Edward J. Vresilovic, and Daniel K. Resnick

Object

The objective of this systematic review was to use evidence-based medicine to determine the efficacy of interbody graft techniques.

Methods

The National Library of Medicine and Cochrane Database were queried using MeSH headings and keywords relevant to cervical interbody grafting. Abstracts were reviewed and studies that met the inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I–III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgerons/Congress of Neurological Surgeons.

Results

Autograft bone harvested from the iliac crest, allograft bone from either cadaveric iliac crest or fibula, or titanium cages and rectangular fusion devices, with or without the use of autologous graft or substitute, have been successful in creating arthrodesis after 1- or 2-level anterior cervical discectomy with fusion (Class II). Alternatives to autograft, allograft, or titanium cages include polyetheretherketone cages and carbon fiber cages (Class III). Polyetheretherketone cages have been used successfully with or without hydroxyapatite for anterior cervical discectomy with fusion. Importantly, recombinant human bone morphogenic protein-2 carries a complication rate of up to 23–27% (especially local edema) compared with 3% for a standard approach.

Conclusions

Current evidence does not support the routine use of interbody grafting for cervical arthrodesis. Multiple strategies for interbody grafting have been successful with Class II evidence supporting the use of autograft, allograft, and titanium cages.

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Daniel K. Resnick, Paul A. Anderson, Michael G. Kaiser, Michael W. Groff, Robert F. Heary, Langston T. Holly, Praveen V. Mummaneni, Timothy C. Ryken, Tanvir F. Choudhri, Edward J. Vresilovic, and Paul G. Matz

Object

The objective of this systematic review was to use evidence-based medicine to examine the diagnostic and therapeutic utility of intraoperative electrophysiological (EP) monitoring in the surgical treatment of cervical degenerative disease.

Methods

The National Library of Medicine and Cochrane Database were queried using MeSH headings and key words relevant to cervical spine surgery and EP monitoring. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I–III). The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons.

Results

The reliance on changes in EP monitoring as an indication to alter a surgical plan or administer steroids has not been observed to reduce the incidence of neurological injury during routine surgery for cervical spondylotic myelopathy or cervical radiculopathy (Class III). However, there is an absence of study data examining the benefit of altering a surgical plan due to EP changes.

Conclusions

Although the use of EP monitoring may serve as a sensitive means to diagnose potential neurological injury during anterior spinal surgery for cervical spondylotic myelopathy, the practitioner must understand that intraoperative EP worsening is not specific—it may not represent clinical worsening and its recognition does not necessarily prevent neurological injury, nor does it result in improved outcome (Class II). Intraoperative improvement in EP parameters/indices does not appear to forecast outcome with reliability (conflicting Class I data).

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Langston T. Holly, Paul G. Matz, Paul A. Anderson, Michael W. Groff, Robert F. Heary, Michael G. Kaiser, Praveen V. Mummaneni, Timothy C. Ryken, Tanvir F. Choudhri, Edward J. Vresilovic, and Daniel K. Resnick

Object

The objective of this systematic review was to use evidence-based medicine to assess whether clinical factors predict surgical outcomes in patients undergoing cervical surgery.

Methods

The National Library of Medicine and Cochrane Database were queried using MeSH headings and keywords relevant to clinical preoperative factors. Abstracts were reviewed, and studies that met the inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I–III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons.

Results

Preoperative sensory-evoked potentials may aid in providing prognostic information in selected patients in whom clinical factors do not provide clear guidance (Class II). Age, duration of symptoms, and preoperative neurological function may commonly affect outcome (Class III).

Conclusions

Age, duration of symptoms, and preoperative neurological function should be discussed with patients when surgical intervention for cervical spondylotic myelopathy is considered. Preoperative sensory-evoked potentials may be considered for patients in whom clinical factors do not provide clear guidance if such information would potentially change therapeutic decisions.

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Robert F. Heary, Timothy C. Ryken, Paul G. Matz, Paul A. Anderson, Michael W. Groff, Langston T. Holly, Michael G. Kaiser, Praveen V. Mummaneni, Tanvir F. Choudhri, Edward J. Vresilovic, and Daniel K. Resnick

Object

The objective of this systematic review was to use evidence-based medicine to examine the efficacy of posterior laminoforaminotomy in the treatment of cervical radiculopathy.

Methods

The National Library of Medicine and Cochrane Database were queried using MeSH headings and key words relevant to posterior laminoforaminotomy and cervical radiculopathy. Abstracts were reviewed, and studies meeting inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I–III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations which contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons.

Results

Posterior laminoforaminotomy improves clinical outcome in the treatment of cervical radiculopathy resulting from soft lateral cervical disc displacement or cervical spondylosis with resulting narrowing of the lateral recess. All studies were Class III. The most frequent design flaw involved the lack of utilization of validated outcomes measures. In addition, few historical studies included a detailed preoperative analysis of the patients. As such, the vast majority of studies that included both pre- and postoperative assessments with legitimate outcomes measures have been performed since 1990.

Conclusions

Posterior laminoforaminotomy is an effective treatment for cervical radiculopathy.