title: Anterior versus posterior approach for treatment of cervical spondylotic myelopathy: a systematic review.
abstract: METHODS
  Systematic review.
  
  
  OBJECTIVE
  We performed a systematic review to determine the comparative effectiveness and safety profiles of anterior versus posterior decompression procedures for multilevel cervical spondylotic myelopathy (CSM).
  
  
  BACKGROUND
  CSM is a common cause of neurological dysfunction. It is well established that surgical decompression of the cervical spinal cord is an effective treatment option for CSM. Because of the lack of well-designed prospective studies, there remains a lack of consensus whether multilevel spondylotic compression is best treated via an anterior or posterior surgical route and whether one of these surgical approaches is superior in terms of patient outcomes and/or complication profiles.
  
  
  METHODS
  We conducted a systematic search for literature published through September 2012. We sought to identify comparative studies (e.g., randomized controlled trials, cohort studies) comparing anterior with posterior procedures in patients with 2-level or greater cord compression resulting in CSM. Standardized mean differences were calculated to allow comparisons of the change (i.e., improvement or decline) in scores between anterior and posterior surgical procedures by study. Clinical recommendations were made through a modified Delphi approach by applying the GRADE (Grading of Recommendation Assessment, Development and Evaluation)/AHRQ (Agency for Healthcare Research and Quality) criteria.
  
  
  RESULTS
  We identified 8 level III retrospective cohort studies that met the inclusion criteria from a total of 135 possible studies for review. With regard to effectiveness between the 2 approaches, improvements in JOA (Japanese Orthopaedic Association) scores were similar, whereas canal diameter change was larger after posterior surgery. With regard to safety, postoperative C5 palsy rates were similar, infection rates were lower with anterior surgery, and dysphagia rates were lower with posterior surgery.
  
  
  CONCLUSIONS
  This systematic review demonstrates that, for both effectiveness and safety, there is no clear advantage to either an anterior surgical approach or a posterior surgical approach when treating patients with multilevel CSM. With that, a surgical strategy developed on a patient-to-patient basis should be used to achieve optimal patient outcomes. In addition, development of a consensus for standardized reporting of outcome measures and complication profiles would facilitate improved comparisons across differing treatment centers and surgical techniques. EVIDENCE-BASED CLINICAL RECOMMENDATIONS:
  
  
  CONCLUSIONS
  We recommend an individualized approach when treating patients with CSM accounting for pathoanatomical variations (ventral vs. dorsal, focal vs. diffuse, sagittal, dynamic instability) because there are similar outcomes between the anterior and posterior approaches with regard to effectiveness and safety.
  
  
  METHODS
  Low.
  
  
  METHODS
  Strong.
authors: *Department of Orthopaedics, University of Utah, Salt Lake City, UT †Calgary Spine Program, Foothills Medical Center, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada ‡Spectrum Research, Inc., Tacoma, WA; and §Department of Orthopaedic Surgery, Harborview Medical Center, University of Washington, Seattle, WA.
authors: Brandon D
authors: BD
authors: Lawrence
authors: W Bradley
authors: WB
authors: Jacobs
authors: Daniel C
authors: DC
authors: Norvell
authors: Jeffrey T
authors: JT
authors: Hermsmeyer
authors: Jens R
authors: JR
authors: Chapman
authors: Darrel S
authors: DS
authors: Brodke
mesh_terms: D002574:Cervical Vertebrae / Q000601:surgery*; D019299:Decompression, Surgical / Q000379:methods*; D006801:Humans; D013118:Spinal Cord Diseases / Q000601:surgery*; D055009:Spondylosis / Q000601:surgery*; D016896:Treatment Outcome