Surgical treatment of severe multilevel circumferential compressive myelopathy of the cervical spine: is circumferential procedure necessary?

Objective: To determine the necessity of circumferential decompression and fusion in patients with severe multilevel cervical spondylotic myelopathy with circumferential cord compression. Methods: This prospective study involved 51 patients with severe multilevel circumferential cervical myelopathy underwent two-stage circumferential procedure between July 2008 and June 2010. VAS scores, satisfaction surveys and JOA scores and imaging studies were obtained. Twenty-three patients (45.1%) underwent two-stage surgery (group A); the other 28 patients (54.9%) were satisfied with the outcomes after first-stage surgery, and the second-stage surgery was avoided (group B). Age, sex and symptom duration did not differ between the groups. Results: Patients were followed up for 3-5 years (mean, 42.5 months). In group A, VAS and JOA scores significantly improved from 63.3 and 7.9 to 38.3 and 10.4, respectively, at 3 months after the first-stage operation and 10.2 and 12.7, respectively, at 3 months after the second-stage operation. In group B, the VAS and JOA scores significantly improved from 62.7 and 7.9 to 31.1 and 11.2 respectively, at 3 months and 18.2 and 12.4, respectively at 6 months. Patient satisfaction rate significantly increased from 43.5% after the first-stage operation to 82.6% after the second-stage operation in group A. In group B, this rate was 89.3%. In group A, cervical spine lordosis increased from 12.8 degrees preoperatively to 18.5 degrees (p<.0001) and 19.1 degrees (p>.05) at 3 months after the first-stage and second-stage operations, respectively. In group B, lordosis significantly increased from 12.5 degrees preoperatively to 18.8 degrees at 3 months. The total complication rate did not significantly differ from the rates after a single surgery (either anterior or posterior). Conclusion: Only 45.1% patients required surgery via both approaches. Therefore, a two-stage procedure is a rational choice and safe procedure. If outcomes are unsatisfactory after the first-stage operation, a second-stage operation can be performed.