title: An Evidence-Based Stepwise Surgical Approach to Cervical Spondylotic Myelopathy: A Narrative Review of the Current Literature.
abstract: OBJECTIVE
  Cervical spondylotic myelopathy (CSM) is the most common progressive degenerative disease of the spine in the geriatric population. The aim of the current review is to provide an evidence-based stepwise surgical approach to CSM according to the recent literature.
  
  
  METHODS
  We searched for evidence regarding the surgical approach to CSM in medical databases with articles dated from 1985 to 2016.
  
  
  RESULTS
  In patients with effective cervical lordosis (fewer than 3 levels of ventral disease), anterior cervical discectomy and fusion (ACDF) or arthroplasty is preferred. Patients with more than 3 levels of compression are generally treated by laminoplasty, especially with preserved lordotic curvature. In patients with straightened spine who have less than 3 involved levels, ACDF with a plate is recommended, whereas patients with more than 3 involved levels with instability should undergo posterior decompression and fusion. In young patients who have a stable cervical spine, laminoplasty is recommended and in old patients with ankylosed spine, only laminectomy should be performed. Patients with mild cervical kyphosis (kyphotic angle ≤10°) should be managed in the same way as patients with straightened spine. However, in severe kyphosis, cervical traction is recommended. If the kyphosis is reducible, further posterior decompression and fusion is adequate. In patients with irreducible kyphosis, if the number of involved levels is less than 2, ACDF is adequate, but if it is more than 2 levels, anterior cervical corpectomy and fusion should be performed using cervical magnetic resonance imaging for evaluation of the patency of the subarachnoid space (SAS). With patent SAS, only posterior fusion is adequate, whereas in closed SAS, posterior decompression with posterior fusion is required. These approaches are based on the most recent evidence.
  
  
  CONCLUSIONS
  This article provides a stepwise evidence-based surgical approach for the management and treatment of patients with CSM.
authors.affiliation: Shiraz Neuroscience Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; Department of Neurosurgery, Shiraz Neuroscience Research Center, Shiraz, Iran. Electronic address: farrokhimr@yahoo.com.
authors.forename: Majid Reza
authors.initials: MR
authors.lastname: Farrokhi
authors.affiliation: Shiraz Neuroscience Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; Department of Neurosurgery, Shiraz Neuroscience Research Center, Shiraz, Iran.
authors.forename: Fariborz
authors.initials: F
authors.lastname: Ghaffarpasand
authors.affiliation: Shiraz Neuroscience Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
authors.forename: Mehdi
authors.initials: M
authors.lastname: Khani
authors.affiliation: Shiraz Neuroscience Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
authors.forename: Mehrnaz
authors.initials: M
authors.lastname: Gholami
mesh_terms: D001178:Arthroplasty / Q000379:methods; D002574:Cervical Vertebrae / Q000601:surgery*; D019299:Decompression, Surgical / Q000379:methods*; D017586:Diskectomy / Q000379:methods; D006801:Humans; D065406:Laminoplasty / Q000379:methods; D019635:Neurosurgical Procedures / Q000379:methods*; D013117:Spinal Cord Compression / Q000209:etiology / Q000601:surgery*; D013123:Spinal Fusion / Q000379:methods; D013130:Spinal Stenosis / Q000150:complications / Q000601:surgery*; D055009:Spondylosis / Q000150:complications / Q000601:surgery*
keywords: Anterior cervical discectomy; Cervical kyphosis; Cervical spondylotic myelopathy; Conservative care; Posterior cervical fusion; Stenosis; Stepwise approach; Straightened spine; Surgery