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Effect of Ventral vs Dorsal Spinal Surgery on Patient-Reported Physical Functioning in Patients With Cervical Spondylotic MyelopathyA Randomized Clinical Trial

Educational Objective
To learn about surgical treatments for cervical spondylotic myelopathy.
1 Credit CME
Key Points

Question  In patients with cervical spondylotic myelopathy, does a ventral surgical approach, compared with a dorsal surgical approach, improve patient-reported physical functioning at 1 year?

Findings  In this randomized clinical trial that included 163 patients, mean improvement in the Short Form 36 physical component summary score (range, 0-100) was 5.9 points in the ventral surgery group and 6.2 points in the dorsal surgery group at 1 year, a difference that was not statistically significant.

Meaning  Among patients with cervical spondylotic myelopathy undergoing cervical spinal surgery, a ventral approach did not significantly improve patient-reported physical functioning at 1 year compared with outcomes after a dorsal approach.

Abstract

Importance  Cervical spondylotic myelopathy is the most common cause of spinal cord dysfunction worldwide. It remains unknown whether a ventral or dorsal surgical approach provides the best results.

Objective  To determine whether a ventral surgical approach compared with a dorsal surgical approach for treatment of cervical spondylotic myelopathy improves patient-reported physical functioning at 1 year.

Design, Setting, and Participants  Randomized clinical trial of patients aged 45 to 80 years with multilevel cervical spondylotic myelopathy enrolled at 15 large North American hospitals from April 1, 2014, to March 30, 2018; final follow-up was April 15, 2020.

Interventions  Patients were randomized to undergo ventral surgery (n = 63) or dorsal surgery (n = 100). Ventral surgery involved anterior cervical disk removal and instrumented fusion. Dorsal surgery involved laminectomy with instrumented fusion or open-door laminoplasty. Type of dorsal surgery (fusion or laminoplasty) was at surgeon’s discretion.

Main Outcomes and Measures  The primary outcome was 1-year change in the Short Form 36 physical component summary (SF-36 PCS) score (range, 0 [worst] to 100 [best]; minimum clinically important difference = 5). Secondary outcomes included 1-year change in modified Japanese Orthopaedic Association scale score, complications, work status, sagittal vertical axis, health resource utilization, and 1- and 2-year changes in the Neck Disability Index and the EuroQol 5 Dimensions score.

Results  Among 163 patients who were randomized (mean age, 62 years; 80 [49%] women), 155 (95%) completed the trial at 1 year (80% at 2 years). All patients had surgery, but 5 patients did not receive their allocated surgery (ventral: n = 1; dorsal: n = 4). One-year SF-36 PCS mean improvement was not significantly different between ventral surgery (5.9 points) and dorsal surgery (6.2 points) (estimated mean difference, 0.3; 95% CI, −2.6 to 3.1; P = .86). Of 7 prespecified secondary outcomes, 6 showed no significant difference. Rates of complications in the ventral and dorsal surgery groups, respectively, were 48% vs 24% (difference, 24%; 95% CI, 8.7%-38.5%; P = .002) and included dysphagia (41% vs 0%), new neurological deficit (2% vs 9%), reoperations (6% vs 4%), and readmissions within 30 days (0% vs 7%).

Conclusions and Relevance  Among patients with cervical spondylotic myelopathy undergoing cervical spinal surgery, a ventral surgical approach did not significantly improve patient-reported physical functioning at 1 year compared with outcomes after a dorsal surgical approach.

Trial Registration  ClinicalTrials.gov Identifier: NCT02076113

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Article Information

Corresponding Author: Zoher Ghogawala, MD, Department of Neurosurgery, Lahey Hospital and Medical Center, 41 Mall Rd, Burlington, MA 01805 (zoher.ghogawala@lahey.org).

Accepted for Publication: January 29, 2021.

Author Contributions: Dr Ghogawala and Ms Breeze had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Ghogawala, Terrin, Freund, Barker, Schwartz, Harrop, Heary, Albert, Riew, Heller, Benzel.

Acquisition, analysis, or interpretation of data: Ghogawala, Terrin, Dunbar, Breeze, Freund, Kanter, Mummaneni, Bisson, Barker, Schwartz, Harrop, Magge, Heary, Fehlings, Albert, Arnold, Riew, Steinmetz, Wang, Whitmore, Benzel.

Drafting of the manuscript: Ghogawala, Terrin, Dunbar, Barker, Schwartz, Harrop, Heary, Albert, Benzel.

Critical revision of the manuscript for important intellectual content: Ghogawala, Terrin, Breeze, Freund, Kanter, Mummaneni, Bisson, Barker, Schwartz, Harrop, Magge, Heary, Fehlings, Albert, Arnold, Riew, Steinmetz, Wang, Whitmore, Heller, Benzel.

Statistical analysis: Ghogawala, Terrin, Breeze, Freund, Barker, Schwartz.

Obtained funding: Ghogawala, Freund, Schwartz, Arnold.

Administrative, technical, or material support: Ghogawala, Dunbar, Kanter, Harrop, Magge, Heary, Fehlings, Albert, Riew, Whitmore, Benzel.

Supervision: Ghogawala, Kanter, Mummaneni, Barker, Schwartz, Harrop, Magge, Heary, Albert, Riew, Steinmetz, Benzel.

Conflict of Interest Disclosures: Dr Kanter reported receipt of personal fees and royalties from Zimmer Biomet and NuVasive. Dr Mummaneni reported receipt of personal fees from DePuy Synthes, Globus, and Stryker; holding stock in Spinicity/ISD; receipt of grants from the Neurosurgery Research and Education Foundation, the International Spine Study Group, AO Spine, and the National Institutes of Health; and receipt of book royalties from Thieme and Springer. Dr Bisson reported receipt of personal fees from Stryker and MiRus and grants from the Neurosurgery Research and Education Foundation. Dr Schwartz reported receipt of personal fees from Allergan, Bayer, Blue Cross and Blue Shield Associations, and Pfizer. Dr Harrop reported receipt of personal consulting fees from DePuy Synthes and Ethicon. Dr Albert reported consultancy for NuVasive; board of directorship for Back Story, the American Orthopaedic Association (past relationship), and the Scoliosis Research Society; ownership interest in Augmedics, Bonovo Orthopedics, CytoDyn, HS2, Innovative Surgical Designs, InVivo Therapeutics, Morphogenesis, Paradigm Spine, Physician Recommended Nutriceuticals, Parvizi Surgical Innovations, Precision Orthopedics, Pulse Equity, Spinicity, Strathspey Crown, and Surg.io; and receipt of royalties from DePuy Synthes Spine, Zimmer Biomet, Elsevier, JP Medical Publishers, Springer, and Thieme. Dr Riew reported receipt of personal fees from Biomet and Medtronic and stock ownership in Amedica, Axiomed, Benvenue, Expanding Orthopedics, Osprey, Paradigm Spine, Spinal Kinetics, Spineology, and Vertiflex. Dr Steinmetz reported receipt of royalties from Zimmer Biomet and Elsevier and consultancy and receipt of an honorarium from Globus. Dr Wang reported consultancy for Zimmer Biomet, Medtronic, and Titan Biologics. Dr Whitmore reported receipt of personal fees from Intrinsic Therapeutics and DePuy Synthes and stock ownership in Theseus. Dr Heller reported receipt of personal fees and royalties from Medtronic and holding a patent for laminoplasty plates issued by Medtronic. No other disclosures were reported.

Funding/Support: This study was supported by the National Institutes of Health (grant R13AR065834-01), the Patient-Centered Outcomes Research Institute (grant CE 1304-6173), and the Tufts Clinical and Translational Science Institute (grant UL 1TR002544). Additional financial support was provided by the Alan L. and Jacqueline B. Stuart Spine Outcomes Research Center at Lahey Hospital and Medical Center.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

Group Information: A list of the CSM-S trial investigators appears in Supplement 3.

Data Sharing Statement: See Supplement 4.

Additional Contributions: We acknowledge the following contributions: from Lahey Hospital and Medical Center, Jill Curran, MS, was the national data manager; Susan Christopher, RN, BSN, was the patient-reported outcomes manager; and Juan Small, MD, and Aaron Paul, MD, served as independent radiology reviewers. Spinal expert panel reviewers included the 15 site investigators plus 9 auxiliary expert members: Paul C. McCormick, MD (Columbia-Presbyterian Hospital, New York, New York), Sigurd Berven, MD (University of California, San Francisco), Tanvir Choudhri, MD (Mt Sinai Medical Center, New York, NY), Asdrubal Falavigna, MD (University of Caxias do Sul, Caxias do Sul, Brazil), Alan Hilibrand, MD (Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania), Vedantam Rajshekhar, MD (Christian Medical College, Vellore, India), Daniel K. Resnick, MD (University of Wisconsin, Madison), Jeffrey Wang, MD (Keck School of Medicine, University of Southern California, Los Angeles), and Jean-Valery Coumans, MD (Massachusetts General Hospital, Boston). The data and safety monitoring board was chaired by Tamsin A. Knox, MD, MPH (Tufts University School of Medicine, Boston, Massachusetts), with Paul C. McCormick, MD, Jeffrey Wang, MD, Langston Holly, MD (University of California, Los Angeles), and Farzad Noubary, PhD (Tufts University School of Medicine) as members. Surgeons who randomized patients into the CSM-S trial included the 15 site investigators listed as authors along with the following surgeons: Rachid Assina, MD (Hackensack Meridian School of Medicine, Nutley, New Jersey), Sanjay Dhall, MD (University of California, San Francisco), Joshua Heller, MD (Thomas Jefferson University), Jeremy Amps, MD (Cleveland Clinic Foundation, Cleveland, Ohio), Shekar Kurpad, MD, PhD (Medical College of Wisconsin, Milwaukee), Jack Jallo, MD, PhD (Thomas Jefferson University), Keith Michael, MD (Emory University School of Medicine, Atlanta, Georgia), Srinivas Prasad, MD (Thomas Jefferson University), and Ajit Krishnaney, MD (Cleveland Clinic Foundation). None of these individuals received any personal compensation for their role in the study.

References
1.
Badhiwala  JH , Ahuja  CS , Akbar  MA ,  et al.  Degenerative cervical myelopathy: update and future directions.   Nat Rev Neurol. 2020;16(2):108-124. doi:10.1038/s41582-019-0303-0PubMedGoogle ScholarCrossref
2.
Henderson  FC , Geddes  JF , Vaccaro  AR ,  et al.  Stretch-associated injury in cervical spondylotic myelopathy: new concept and review.   Neurosurgery. 2005;56(5):1101-1113.PubMedGoogle Scholar
3.
Akter  F , Yu  X , Qin  X ,  et al.  The pathophysiology of degenerative cervical myelopathy and the physiology of recovery following decompression.   Front Neurosci. 2020;14:138. doi:10.3389/fnins.2020.00138PubMedGoogle ScholarCrossref
4.
Patil  PG , Turner  DA , Pietrobon  R .  National trends in surgical procedures for degenerative cervical spine disease: 1990-2000.   Neurosurgery. 2005;57(4):753-758. doi:10.1227/01.NEU.0000175729.79119.1dPubMedGoogle ScholarCrossref
5.
Lad  SP , Patil  CG , Berta  S ,  et al.  National trends in spinal fusion for cervical spondylotic myelopathy.   Surg Neurol. 2009;71(1):66-69. doi:10.1016/j.surneu.2008.02.045PubMedGoogle ScholarCrossref
6.
Witiw  CD , Tetreault  LA , Smieliauskas  F ,  et al.  Surgery for degenerative cervical myelopathy: a patient-centered quality of life and health economic evaluation.   Spine J. 2017;17(1):15-25. doi:10.1016/j.spinee.2016.10.015PubMedGoogle ScholarCrossref
7.
Ghogawala  Z , Coumans  JV , Benzel  EC ,  et al.  Ventral versus dorsal decompression for cervical spondylotic myelopathy: surgeons’ assessment of eligibility for randomization in a proposed randomized controlled trial: results of a survey of the Cervical Spine Research Society.   Spine (Phila Pa 1976). 2007;32(4):429-436. doi:10.1097/01.brs.0000255068.94058.8aPubMedGoogle ScholarCrossref
8.
Centers for Medicare & Medicaid Services. Research, statistics, data, and systems physician supplier procedure summary. Accessed December 2, 2020. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Physician-Supplier-Procedure-Summary/index
9.
Institute of Medicine. Appendix C, Table 5-13: musculoskeletal disorders priority topics. In: Learning What Works: Infrastructure Required for Comparative Effectiveness Research. Accessed April 30, 2019. https://www.ncbi.nlm.nih.gov/books/NBK64788/table/appendixes.app3.t13/?report=objectonly
10.
Zaveri  GR , Jaiswal  NP .  A comparison of clinical and functional outcomes following anterior, posterior, and combined approaches for the management of cervical spondylotic myelopathy.   Indian J Orthop. 2019;53(4):493-501. doi:10.4103/ortho.IJOrtho_8_16PubMedGoogle ScholarCrossref
11.
Fehlings  MG , Barry  S , Kopjar  B ,  et al.  Anterior versus posterior surgical approaches to treat cervical spondylotic myelopathy: outcomes of the Prospective Multicenter AOSpine North America CSM Study in 264 patients.   Spine (Phila Pa 1976). 2013;38(26):2247-2252. doi:10.1097/BRS.0000000000000047PubMedGoogle ScholarCrossref
12.
Wang  MC , Chan  L , Maiman  DJ ,  et al.  Complications and mortality associated with cervical spine surgery for degenerative disease in the United States.   Spine (Phila Pa 1976). 2007;32(3):342-347. doi:10.1097/01.brs.0000254120.25411.aePubMedGoogle ScholarCrossref
13.
Ghogawala  Z , Martin  B , Benzel  EC ,  et al.  Comparative effectiveness of ventral vs dorsal surgery for cervical spondylotic myelopathy.   Neurosurgery. 2011;68(3):622-630. doi:10.1227/NEU.0b013e31820777cfPubMedGoogle ScholarCrossref
14.
King  JT  Jr , Abbed  KM , Gould  GC ,  et al.  Cervical spine reoperation rates and hospital resource utilization after initial surgery for degenerative cervical spine disease in 12,338 patients in Washington State.   Neurosurgery. 2009;65(6):1011-1022. doi:10.1227/01.NEU.0000360347.10596.BDPubMedGoogle ScholarCrossref
15.
Hurwitz  EE , Simon  M , Vinta  SR ,  et al.  Adding examples to the ASA-Physical Status Classification improves correct assignment to patients.   Anesthesiology. 2017;126(4):614-622. doi:10.1097/ALN.0000000000001541PubMedGoogle ScholarCrossref
16.
Ghogawala  Z , Schwartz  JS , Benzel  EC ,  et al.  Increased patient enrollment to a randomized surgical trial through equipoise polling of an expert surgeon panel.   Ann Surg. 2016;264(1):81-86. doi:10.1097/SLA.0000000000001483PubMedGoogle ScholarCrossref
17.
Ghogawala  Z , Dziura  J , Butler  WE ,  et al.  Laminectomy plus fusion versus laminectomy alone for lumbar spondylolisthesis.   N Engl J Med. 2016;374(15):1424-1434. doi:10.1056/NEJMoa1508788PubMedGoogle ScholarCrossref
18.
Smith  GW , Robinson  RA .  The treatment of certain cervical-spine disorders by anterior removal of the intervertebral disc and interbody fusion.   J Bone Joint Surg Am. 1958;40-A(3):607-624. doi:10.2106/00004623-195840030-00009PubMedGoogle ScholarCrossref
19.
Hillard  VH , Apfelbaum  RI .  Surgical management of cervical myelopathy: indications and techniques for multilevel cervical discectomy.   Spine J. 2006;6(6)(suppl):242S-251S. doi:10.1016/j.spinee.2006.05.005PubMedGoogle ScholarCrossref
20.
Stewart  TJ , Schlenk  RP , Benzel  EC .  Multiple level discectomy and fusion.   Neurosurgery. 2007;60(1)(suppl 1):S143-S148. doi:10.1227/01.NEU.0000217015.96212.1BPubMedGoogle Scholar
21.
Kwon  BK , Vaccaro  AR , Grauer  JN , Beiner  JM .  The use of rigid internal fixation in the surgical management of cervical spondylosis.   Neurosurgery. 2007;60(1)(suppl 1):S118-S129. doi:10.1227/01.NEU.0000249222.57709.59PubMedGoogle Scholar
22.
Huang  RC , Girardi  FP , Poynton  AR , Cammisa  FP  Jr .  Treatment of multilevel cervical spondylotic myeloradiculopathy with posterior decompression and fusion with lateral mass plate fixation and local bone graft.   J Spinal Disord Tech. 2003;16(2):123-129. doi:10.1097/00024720-200304000-00002PubMedGoogle ScholarCrossref
23.
Heller  JG , Edwards  CC  II , Murakami  H , Rodts  GE .  Laminoplasty versus laminectomy and fusion for multilevel cervical myelopathy: an independent matched cohort analysis.   Spine (Phila Pa 1976). 2001;26(12):1330-1336. doi:10.1097/00007632-200106150-00013PubMedGoogle ScholarCrossref
24.
Ware  JEJ , Kosinski  M , Keller  SD .  SF-36 Physical and Mental Health Summary Scales: A Manual for Users of Version 1. 2nd ed. QualityMetric Inc; 2001.
25.
Copay  AG , Glassman  SD , Subach  BR ,  et al.  Minimum clinically important difference in lumbar spine surgery patients: a choice of methods using the Oswestry Disability Index, Medical Outcomes Study questionnaire Short Form 36, and pain scales.   Spine J. 2008;8(6):968-974. doi:10.1016/j.spinee.2007.11.006PubMedGoogle ScholarCrossref
26.
Glassman  S , Gornet  MF , Branch  C ,  et al.  MOS Short Form 36 and Oswestry Disability Index outcomes in lumbar fusion: a multicenter experience.   Spine J. 2006;6(1):21-26. doi:10.1016/j.spinee.2005.09.004PubMedGoogle ScholarCrossref
27.
Birkmeyer  NJ , Weinstein  JN , Tosteson  AN ,  et al.  Design of the Spine Patient Outcomes Research Trial (SPORT).   Spine (Phila Pa 1976). 2002;27(12):1361-1372. doi:10.1097/00007632-200206150-00020PubMedGoogle ScholarCrossref
28.
Suda  K , Abumi  K , Ito  M ,  et al.  Local kyphosis reduces surgical outcomes of expansive open-door laminoplasty for cervical spondylotic myelopathy.   Spine (Phila Pa 1976). 2003;28(12):1258-1262. doi:10.1097/01.BRS.0000065487.82469.D9PubMedGoogle Scholar
29.
Tetreault  L , Nouri  A , Kopjar  B ,  et al.  The minimum clinically important difference of the modified Japanese Orthopaedic Association scale in patients with degenerative cervical myelopathy.   Spine (Phila Pa 1976). 2015;40(21):1653-1659. doi:10.1097/BRS.0000000000001127PubMedGoogle ScholarCrossref
30.
Coric  D , Finger  F , Boltes  P .  Prospective randomized controlled study of the Bryan cervical disc: early clinical results from a single investigational site.   J Neurosurg Spine. 2006;4(1):31-35. doi:10.3171/spi.2006.4.1.31PubMedGoogle ScholarCrossref
31.
Badhiwala  JH , Witiw  CD , Nassiri  F ,  et al.  Patient phenotypes associated with outcome following surgery for mild degenerative cervical myelopathy: a principal component regression analysis.   Spine J. 2018;18(12):2220-2231. doi:10.1016/j.spinee.2018.05.009PubMedGoogle ScholarCrossref
32.
Suhonen  R , Virtanen  H , Heikkinen  K ,  et al.  Health-related quality of life of day-case surgery patients: a pre/posttest survey using the EuroQoL-5D.   Qual Life Res. 2008;17(1):169-177. doi:10.1007/s11136-007-9292-3PubMedGoogle ScholarCrossref
33.
Kato  S , Oshima  Y , Matsubayashi  Y ,  et al.  Minimum clinically important difference in outcome scores among patients undergoing cervical laminoplasty.   Eur Spine J. 2019;28(5):1234-1241. doi:10.1007/s00586-019-05945-yPubMedGoogle ScholarCrossref
34.
Tang  JA , Scheer  JK , Smith  JS ,  et al.  The impact of standing regional cervical sagittal alignment on outcomes in posterior cervical fusion surgery.   Neurosurgery. 2012;71(3):662-669. doi:10.1227/NEU.0b013e31826100c9PubMedGoogle ScholarCrossref
35.
Schriger  DL .  Graphic portrayal of studies with paired data: a tutorial.   Ann Emerg Med. 2018;71(2):239-246. doi:10.1016/j.annemergmed.2017.05.033PubMedGoogle ScholarCrossref
36.
Kurokawa  R , Kim  P .  Cervical laminoplasty: the history and the future.   Neurol Med Chir (Tokyo). 2015;55(7):529-539. doi:10.2176/nmc.ra.2014-0387PubMedGoogle ScholarCrossref
37.
Bakhsheshian  J , Mehta  VA , Liu  JC .  Current diagnosis and management of cervical spondylotic myelopathy.   Global Spine J. 2017;7(6):572-586. doi:10.1177/2192568217699208PubMedGoogle ScholarCrossref
38.
Highsmith  JM , Dhall  SS , Haid  RW  Jr ,  et al.  Treatment of cervical stenotic myelopathy: a cost and outcome comparison of laminoplasty versus laminectomy and lateral mass fusion.   J Neurosurg Spine. 2011;14(5):619-625. doi:10.3171/2011.1.SPINE10206PubMedGoogle ScholarCrossref
39.
Lau  D , Winkler  EA , Than  KD ,  et al.  Laminoplasty versus laminectomy with posterior spinal fusion for multilevel cervical spondylotic myelopathy: influence of cervical alignment on outcomes.   J Neurosurg Spine. 2017;27(5):508-517. doi:10.3171/2017.4.SPINE16831PubMedGoogle ScholarCrossref
40.
Warren  DT , Ricart-Hoffiz  PA , Andres  TM ,  et al.  Retrospective cost analysis of cervical laminectomy and fusion versus cervical laminoplasty in the treatment of cervical spondylotic myelopathy.   Int J Spine Surg. 2013;7:e72-e80. doi:10.1016/j.ijsp.2013.04.001PubMedGoogle ScholarCrossref
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