Cervical spondylotic myelopathy with severe axial neck pain: is anterior or posterior approach better?

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  • 1 Department of Neurosurgery, Duke University, Durham, North Carolina;
  • | 2 Department of Neurological Surgery, University of Utah, Salt Lake City, Utah;
  • | 3 Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota;
  • | 4 Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina;
  • | 5 Goodman Campbell Brain and Spine, Indianapolis, Indiana;
  • | 6 Department of Neurosurgery, University of Tennessee, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee;
  • | 7 Department of Neurological Surgery, University of Miami, Florida;
  • | 8 Department of Neurosurgery, Weill Cornell Medical Center, New York, New York;
  • | 9 Atlantic Neurosurgical Specialists, Morristown, New Jersey;
  • | 10 Department of Neurological Surgery, University of Michigan, Ann Arbor, Michigan;
  • | 11 Marion Bloch Neuroscience Institute, Saint Luke’s Health System, Kansas City, Missouri;
  • | 12 Department of Neurosurgery, University of Virginia, Charlottesville, Virginia;
  • | 13 Barrow Neurological Institute, Phoenix, Arizona;
  • | 14 Department of Neurological Surgery, University of California, San Francisco, California; and
  • | 15 Atlanta Brain and Spine Care, Atlanta, Georgia
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OBJECTIVE

The aim of this study was to determine whether multilevel anterior cervical discectomy and fusion (ACDF) or posterior cervical laminectomy and fusion (PCLF) is superior for patients with cervical spondylotic myelopathy (CSM) and high preoperative neck pain.

METHODS

This was a retrospective study of prospectively collected data using the Quality Outcomes Database (QOD) CSM module. Patients who received a subaxial fusion of 3 or 4 segments and had a visual analog scale (VAS) neck pain score of 7 or greater at baseline were included. The 3-, 12-, and 24-month outcomes were compared for patients undergoing ACDF with those undergoing PCLF.

RESULTS

Overall, 1141 patients with CSM were included in the database. Of these, 495 (43.4%) presented with severe neck pain (VAS score > 6). After applying inclusion and exclusion criteria, we compared 65 patients (54.6%) undergoing 3- and 4-level ACDF and 54 patients (45.4%) undergoing 3- and 4-level PCLF. Patients undergoing ACDF had worse Neck Disability Index scores at baseline (52.5 ± 15.9 vs 45.9 ± 16.8, p = 0.03) but similar neck pain (p > 0.05). Otherwise, the groups were well matched for the remaining baseline patient-reported outcomes. The rates of 24-month follow-up for ACDF and PCLF were similar (86.2% and 83.3%, respectively). At the 24-month follow-up, both groups demonstrated mean improvements in all outcomes, including neck pain (p < 0.05). In multivariable analyses, there was no significant difference in the degree of neck pain change, rate of neck pain improvement, rate of pain-free achievement, and rate of reaching minimal clinically important difference (MCID) in neck pain between the two groups (adjusted p > 0.05). However, ACDF was associated with a higher 24-month modified Japanese Orthopaedic Association scale (mJOA) score (β = 1.5 [95% CI 0.5–2.6], adjusted p = 0.01), higher EQ-5D score (β = 0.1 [95% CI 0.01–0.2], adjusted p = 0.04), and higher likelihood for return to baseline activities (OR 1.2 [95% CI 1.1–1.4], adjusted p = 0.002).

CONCLUSIONS

Severe neck pain is prevalent among patients undergoing surgery for CSM, affecting more than 40% of patients. Both ACDF and PCLF achieved comparable postoperative neck pain improvement 3, 12, and 24 months following 3- or 4-segment surgery for patients with CSM and severe neck pain. However, multilevel ACDF was associated with superior functional status, quality of life, and return to baseline activities at 24 months in multivariable adjusted analyses.

ABBREVIATIONS

ACDF = anterior cervical discectomy and fusion; CSM = cervical spondylotic myelopathy; MCID = minimal clinically important difference; mJOA = modified Japanese Orthopaedic Association scale; NDI = Neck Disability Index; PCLF = posterior cervical laminectomy and fusion; QOD = Quality Outcomes Database; RCT = randomized controlled trial; SES = socioeconomic status; VAS = visual analog scale.

Supplementary Materials

    • Supplementary Data 1-3 (PDF 550 KB)

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JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

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