Pathophysiology and treatment of cervical spondylotic myelopathy

Operative procedures on the cervical vertebral column and spinal cord must be designed selectively for the individual patient. The majority of present series suggest that the anterior approach, especially vertebrectomy, may be associated with the highest levels of clinical improvement, but posterior approaches present significant advantages in treating the patient with multilevel disease (three or more levels). Laminectomy, however, must be avoided in the presence of straightening or curvature reversal of the cervical vertebral column. In certain select cases, consideration of a combined anterior and posterior approach or total stabilization may be considered. Although no consensus exists regarding the exclusivity of a specific surgical procedure and all possible approaches should be considered, the final decision should be based on detailed biomechanical considerations. Complete radiographic and neurophysiologic studies, including evaluation in various dynamic positions of the cervical spine (flexion, extension, and rotation), are of assistance in defining the most efficacious treatment method.