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You Must Go Front and Back – Everybody Knows That! Let Me Show You the Way Frank X Pedlow Jr MD Spine Service Massachusetts General Hospital Boston MA

23 yo former D1 Linebacker with Cervical myelopathy and three level disease

Cervical myelopathy • Indications for surgery

Cervi vical m myelopath thy • Goals for surgery: • Preserve / improve neurologic function • Relieve symptoms • Prevent or correct spinal malalignment • Maintain spinal stability • Minimize risk and potential morbidity

Surgi gical a approach o options • Anterior approach • decompression / fusion • ACDF, multilevel ACDF, Cervical corpectomy, hybid • arthroplasty • Posterior approach • Laminectomy, laminectomy / fusion, laminoplasty • Combined anterior / posterior surgery

Factors i influ luencin ing c choic ice of of s surgic ical a l approach ch • Location of neural compression Anterior / posterior / combined • • Severity of neurologic compromise • # of levels of compression • Presence or absence of congenital stenosis • Cervical alignment Lordotic, straight, kyphotic • • Spinal stability • Lifestyle factors Smoking • • Other factors Previous surgery • Degree of neck pain • Surgeon experience • Patient age and comorbidities • Komotar Spine J 2006 • Mummaneni NS 2001 •

Indications f for c combined a anterior / / posterior a approach i in ce cervic ical l myelopathy hy • Combined ventral and dorsal neural compression that cannot be addressed by anterior or posterior approach alone • Multilevel anterior disease in a kyphotic spine • Kyphosis > 10 degrees, three levels of more • Multilevel corpectomy ( 3 or more) • Sasso Spine 2003 • Post-laminectomy kyphosis • Revision cases • ASD, non-unions, persisting/recurrent stenosis • Instability • Metabolic factors: ex -smokers, renal disease, osteoporosis

Literature • Retrospective review 72 patients in Neurosurg Focus 2000 Post-laminectomy kyphosis – 15 • Trauma – 19 • Spondylosis w/ congenital stenosis – 32 • OPLL – 6 • • 100 % fusion, no sig. hardware related complications, no repeat operations • Benefits: • Single stage decompression, reconstruction, stabilization • No need for HALO • Prevention of anterior plate failure or strut graft extrusion • High fusion rate • Others papers on treating complex cervical spine conditions with AP surgery McAfee JBJS AM 1995 • Aryan Eur Spine J 2007 •

Literature • Retrospective review of 37 patients with degenerative kyphosis • Patients who underwent anterior –posterior surgery had: • Greater correction and maintenance of sagittal alignment • Higher fusion rate • Lower rate of graft subsidence • Lower complication rate

Literature • Bram Am J Ortho 2017 Retrospective review of 21 pts who underwent anterior-posterior dec/fusion of cervical spondylotic myelopathy • Few complications, no neurologic deficits, 19/21 improved neuro function • • Konya J Clin Neuroscience 2009 • Retrospective review of 40 patients 3 level or more cervical spondylotic myelopathy • At 1 year: • 85% patient satisfaction • All patient showed improved neurologic function • 97.5% fusion rate • Recommended treatment in multilevel cases: prevent graft and anterior instrumentation related complications

Literature Anterior procedures • Multiple papers have described the risks associated with multilevel anterior corpectomy with plate fixation • Zdeblick JBJS (Am) 1997 • DiAngelo Spine 2000 • Wang Spine 2003 • Sasso Spine 2009 • Addition of posterior fusion to minimize risk of plate failure and graft dislodgement

Literature Posterior procedures • May not address anterior pathology, disc herniation, cervical spondylosis and neuroforaminal narrowing leading to persisting radicular symptoms • Requires an alignment that allows for appropriate amount of posterior drift of spinal cord Patients not infrequently fused in less than optimal alignment, causing neck pain and stress on adjacent segments

45 yo male with myelo-radiculopathy

Calcified central disc protrusions associated with marginal posterior osteophytes and/or focal ossification of the posterior longitudinal ligament at multiple levels

Conclusion on • Combined anterior-posterior decompression and fusion is an excellent option in select cases of cervical spondylotic myelopathy • Immediate spinal stabilization • Restoration and maintenance of sagittal balance • Able to address well anterior pathology • Circumferential decompression when needed • Very high fusion rate • Help eliminate graft and plate/screw associated problems seen in multilevel anterior decompressions • Recommended in this case involving 3 levels of spondylotic compression if there is any kyphosis, OPLL, congenital stenosis, need for circumferential decompression or risks for non-union ( ex: smoking, diabetes)

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