Surgical decision-making in degenerative cervical myelopathy - Anterior versus posterior approach

Surgery is the only effective treatment option for advanced degenerative cervical myelopathy. Decompression may be achieved via either an anterior or posterior approach. They are both well-established techniques that are used to achieve optimal clinical results with each approach having its own pros and cons. Generally, the approach is dictated by preoperative imaging features with the aim of directly addressing the sources of spinal cord compression. However, there are frequently multiple sources of compression and several other factors should be also considered. The posterior approach is optimal for multilevel stenosis using consecutive laminectomies. Conversely, in cases of rigid kyphosis, the anterior approach is preferable as it enables thorough decompression and lordotic realignment. The existence of radiculopathy, neck pain and dysphagia should be carefully considered, and patients' occupational and cosmetic demands must be also discussed given the risk of voice change and scar formation. Body habitus or previous history of skin incision or radiation may also influence the decision. Since the clinical benefit seems to be similar between the two approaches, the decision has to be made on a case-by-case basis depending on the surgeons' experiences and preferences.