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Objectives: A common question posed by patients undergoing cervical fusion pertains to the likelihood of perceiving a postoperative limitation in neck mobility. The aim of this study was to assess the change in neck mobility after subaxial cervical fusion using an objective range of motion (ROM) measure and patient reported assessment., Patients and Methods: Patients older than 18 years of age, undergoing first-time anterior or posterior subaxial cervical arthrodesis for a symptomatic spondylotic process (radiculopathy, cervical spondylotic myelopathy or primary neck pain) at a single center were eligible. Assessment included: 1) neck pain on a numeric rating scale; 2) four-directional objective neck mobility using the validated cervical ROM goniometer; and 3) a novel Mobility Assessment Scale (MAS) for patient perceived neck mobility. Subjects were dichotomized by number of levels fused (1-2 levels and ≥3 levels)., Results: There were 25 patients with a mean of 2.7±1.5 levels fused. Neck pain was improved in both groups with mean change of -3.4 [95% CI -4.7,-2.1], p=0.004 for 1-2 levels and -3.5 [95% CI -5.4,-1.5], p=0.009 for ≥3 levels. MAS score improved significantly in group undergoing 1-2 level fusion (-1.8 [95% CI: -3.1,-0.4], p=0.016) but not in those with ≥3 levels fused. There was a significant positive correlation between MAS and neck pain in the 1-2 level fusion group (r s =0.667, p=0.012) but not in the ≥3 level group. Objective neck mobility did not changed significantly in either group., Conclusions: Patient reported neck mobility was significantly improved following 1-2 level cervical fusion. This change correlated significantly with patient reported improvement in neck pain. No significant difference in reported neck mobility was found in those undergoing fusion of ≥3 levels., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Study Design: Systematic review., Objective: The primary objectives of this review were to compare the effectiveness and safety of various anterior cervical decompressive and reconstructive procedures for diffuse or multifocal cervical spondylotic myelopathy (CSM). An additional objective was to describe the most common ancillary stabilization techniques used with the different anterior decompressive procedures., Summary of Background Data: Surgical management of CSM provides for neurological recovery and disease stabilization in a cost-effective way. Although both retrospective and prospective data support management of CSM by anterior cervical decompression and fusion, the choice decision between various anterior surgical options remains unclear., Methods: We conducted a systematic search in MEDLINE and the Cochrane Collaboration Library for human studies in the English-language literature published through September 2012. We included studies comparing multiple discectomies with single or multiple corpectomy, multiple discectomies with discectomy-corpectomy hybrid, and multiple corpectomies with discectomy-corpectomy hybrid, comparing effectiveness and safety outcomes of each procedure, and defining the ancillary stabilization techniques used. Exclusion criteria included patients with degenerative disc disease or degenerative joint disease without CSM, single-level CSM, ossified posterior longitudinal ligament (OPLL), spinal tumor, concomitant infection, and ankylozing spondylitis. Case series, case reports, data not reported separately for each comparison group, or studies that consisted of an N less than 10 for either comparison group were excluded. The evidence strength was rated using the GRADE (Grades of Recommendation Assessment, Development, and Evaluation) criteria., Results: Of the 49 citations identified from our search, 10 studies were initially found suitable for inclusion. Patients undergoing any of the 3 procedures generally experienced improvements in clinical outcomes (neck disability index, Japanese Orthopaedic Association score, and Visual Analogue Scale score for pain) as well as overall sagittal alignment, with minimal perioperative morbidity. There is moderate evidence supporting selection of multiple discectomies compared with corpectomy or discectomy-corpectomy hybrid procedures with regard to superior clinical outcomes and postoperative sagittal alignment. Furthermore, if more extensive operation is needed, there is evidence to support the selection of discectomy-corpectomy hybrid procedures compared with multiple corpectomies if it is technically feasible to accomplish the requisite decompression. The multiple discectomies approach also may have a lower incidence of C5 palsy than corpectomy or discectomy-corpectomy hybrid approaches., Conclusion: All 3 operative approaches are effective strategies for the anterior surgical management of CSM. When the patient pathoanatomy permits, selection of multiple discectomies is favored compared with corpectomy or discectomy-corpectomy hybrid approaches. EVIDENCE-BASED CLINICAL RECOMMENDATIONS:, Recommendation 1: When pathoanatomically appropriate with minimal retrovertebral disease, we recommend the selection of multiple discectomy over corpectomy or discectomy-corpectomy hybrid procedures., Overall Strength of Evidence: Low., Strength of Recommendation: Strong., Recommendation 2: When retrovertebral disease is significant, we recommend, when possible, that discectomy-corpectomy hybrid procedures be performed instead of multiple corpectomies., Overall Strength of Evidence: Moderate., Strength of Recommendation: Strong. SUMMARY STATEMENTS: There is no evidence to guide choice of ancillary external immobilization techniques following multilevel anterior decompression and fusion procedures for CSM.

Study Design: Narrative review., Objective: To provide a comprehensive narrative review of cervical alignment parameters, the methods for quantifying cervical alignment, normal cervical alignment values, and how alignment is associated with cervical deformity and myelopathy with discussions of health-related quality of life., Summary of Background Data: Indications for surgery to correct cervical alignment are not well-defined and there is no set standard to address the amount of correction to be achieved. In addition, classifications of cervical deformity have yet to be fully established and treatment options defined and clarified., Methods: A survey of the cervical spine literature was conducted., Results: New normative cervical alignment values from an asymptomatic volunteer population are introduced, updated methods for quantifying cervical alignment are discussed, and describing the relationship between cervical alignment, disability, and myelopathy are outlined. Specifically, methods used to quantify cervical alignment include cervical lordosis, cervical sagittal vertical axis, and horizontal gaze with the chin-brow vertical angle. Updated methods include T1 slope. Evidence from a few recent studies suggests correlations between radiographical parameters in the cervical spine and health-related quality of life. Analysis of the cervical regional alignment with respect to overall spinal pelvic alignment is emerging and critical. Cervical myelopathy and sagittal alignment of the cervical spine are closely related as cervical deformity can lead to spinal cord compression and tension., Conclusion: Cervical deformity correction should take on a comprehensive approach in assessing global cervical-pelvic relationships and the radiographical parameters that effect health-related quality of life scores are not well-defined. Cervical alignment may be important in assessment and treatment of cervical myelopathy. Future work should concentrate on correlation of cervical alignment parameters to disability scores and myelopathy outcomes. SUMMARY STATEMENTS: STATEMENT 1: Cervical sagittal alignment (cervical SVA and kyphosis) is related to thoracolumbar spinal pelvic alignment and to T1 slope. STATEMENT 2: When significant deformity is clinically or radiographically suspected, regional cervical and relative global spinal alignment should be evaluated preoperatively via standing 3-foot scoliosis X-rays for appropriate operative planning. STATEMENT 3: Cervical sagittal alignment (C2-C7 SVA) is correlated to regional disability, general health scores and to myelopathy severity. STATEMENT 4: When performing decompressive surgery for CSM, consideration should be given to correction of cervical kyphosis and cervical sagittal imbalance (C2-C7 SVA) when present.

Degenerative cervical myelopathy (DCM), including cervical spondylotic myelopathy and ossification of the posterior longitudinal ligament, presents a heterogeneous set of variables reflecting its complex nature. Multiple studies in the past have attempted to elucidate an ideal surgical algorithm that surgeons may use when treating these patients, unfortunately all studies to date, including the rigorous systematic review used in this focus issue, have fallen short in identifying a superior approach when addressing DCM. Likely because of a superior approach being nonexistent because there are multiple pathoanatomical considerations. In addition to the multitude of variables that spine surgeons face when deciding the treatment options for patients with DCM, the previous studies that have been published, unfortunately, lack in consistent outcome and complication reporting. Therefore, synthesizing a treatment algorithm remains difficult, however, the articles in this focus issue use the GRADE system to assess the overall quality (strength) of available evidence and, where appropriate, formulate evidence-based recommendations. Factors that should be included in surgical decision making are the sagittal alignment, anatomical location of the compressive pathology, number of levels of compression, presence of absence or instability or subluxation, the type compressive pathology (e.g., spondylosis vs. ossification of the posterior longitudinal ligament), neck anatomy, bone quality, and surgeon experience or preference. Fortunately, as reviewed in the accompanying articles, a number of excellent surgical options exist that can be selected on the basis of the aforementioned pathoanatomical considerations.

Study Design: Systematic review., Objective: To perform an evidence synthesis of the literature assessing the efficacy of arthroplasty, oblique corpectomy without fusion, and skip laminectomy to treat symptomatic cervical spondylotic myelopathy (CSM)., Summary of Background Data: Traditionally, patients with symptomatic cervical spinal cord compression due to degenerative disease have been treated with anterior or posterior approaches or both. Recent reports suggest that there are several nontraditional management strategies that merit attention. The anterior procedures include decompression and anterior reconstruction with an artificial disc and oblique corpectomy without fusion. A posterior option is decompression, using the skip laminectomy technique., Methods: We conducted a systematic search in MEDLINE and the Cochrane Collaboration Library for literature published through October 15, 2012, on human studies published in the English language containing abstracts to answer the following key questions: (1) Is there evidence that artificial disc replacement after neural decompression results in equal or improved outcomes compared with anterior cervical decompression and fusion for CSM? (2) Describe the outcomes of oblique corpectomy without fusion for CSM? (3) Is there evidence that skip laminectomy results in equal or improved outcomes compared with laminoplasty for CSM?, Results: The initial literature search yielded 141 unique, potentially relevant citations, which were evaluated against the inclusion/exclusion criteria set a priori. A total of 10 studies were selected for inclusion. For question 1, 2 studies suggested that neurological outcomes favored artificial disc replacement compared with anterior cervical decompression and fusion, whereas functional and pain outcomes were inconsistently reported. For question 2, 5 reported case series suggested favorable neurological, functional, and pain outcomes associated with oblique corpectomy in subjects with CSM, compared with the pretreatment condition. For question 3, 3 studies comparing laminoplasty with skip laminectomy suggested similar neurological outcomes between treatment groups, although functional and pain outcomes were inconsistently reported., Conclusion: A paucity of high-quality literature exists regarding treatment outcomes associated with arthroplasty, oblique corpectomy without fusion, and skip laminectomy for symptomatic CSM. Comparative prospective studies with long-term follow-up and standardized outcome measures are needed to assess treatment outcomes associated with these alternative techniques appropriately. EVIDENCE-BASED CLINICAL RECOMMENDATIONS:, Recommendation 1: No recommendation can be made from comparative literature regarding treatment outcomes comparing ADR with ACDF for CSM., Overall Strength of Evidence: Insufficient., Strength of Recommendation: Strong., Recommendation 2: No recommendation can be made from comparative literature regarding treatment outcomes comparing laminoplasty with skip laminectomy for CSM., Overall Strength of Evidence: Low., Strength of Recommendation: Strong. SUMMARY STATEMENTS: Oblique corpectomy is an option in selected cases of CSM. It should not be considered a first-line treatment strategy because of the relatively high morbidity associated with this procedure.

Study Design: Post hoc analysis of prospectively collected data., Objective: Development of methods to determine in vivo spinal cord dimensions and application to correlate preoperative alignment, myelopathy, and health-related quality-of-life scores in patients with cervical spondylotic myelopathy (CSM)., Summary of Background Data: CSM is the leading cause of spinal cord dysfunction. The association between cervical alignment, sagittal balance, and myelopathy has not been well characterized., Methods: This was a post hoc analysis of the prospective, multicenter AOSpine North America CSM study. Inclusion criteria for this study required preoperative cervical magnetic resonance imaging (MRI) and neutral sagittal cervical radiography. Techniques for MRI assessment of spinal cord dimensions were developed. Correlations between imaging and health-related quality-of-life scores were assessed., Results: Fifty-six patients met inclusion criteria (mean age = 55.4 yr). The modified Japanese Orthopedic Association (mJOA) scores correlated with C2-C7 sagittal vertical axis (SVA) (r = -0.282, P = 0.035). Spinal cord volume correlated with cord length (r = 0.472, P < 0.001) and cord average cross-sectional area (r = 0.957, P < 0.001). For all patients, no correlations were found between MRI measurements of spinal cord length, volume, mean cross-sectional area or surface area, and outcomes. For patients with cervical lordosis, mJOA scores correlated positively with cord volume (r = 0.366, P = 0.022), external cord area (r = 0.399, P = 0.012), and mean cross-sectional cord area (r = 0.345, P = 0.031). In contrast, for patients with cervical kyphosis, mJOA scores correlated negatively with cord volume (r = -0.496, P = 0.043) and mean cross-sectional cord area (r = -0.535, P = 0.027)., Conclusion: This study is the first to correlate cervical sagittal balance (C2-C7 SVA) to myelopathy severity. We found a moderate negative correlation in kyphotic patients of cord volume and cross-sectional area to mJOA scores. The opposite (positive correlation) was found for lordotic patients, suggesting a relationship of cord volume to myelopathy that differs on the basis of sagittal alignment. It is interesting to note that sagittal balance but not kyphosis is tied to myelopathy score. Future work will correlate alignment changes to cord morphology changes and myelopathy outcomes. SUMMARY STATEMENTS: This is the first study to correlate sagittal balance (C2-C7 SVA) to myelopathy severity. We found a moderate negative correlation in kyphotic patients of cord volume and cross-sectional area to mJOA scores. The opposite (positive correlation) was found for lordotic patients, suggesting a relationship of cord volume to myelopathy that differs on the basis of sagittal alignment.

Object: The primary goal of this study was to review the immediate postoperative neurological function in patients surgically treated for symptomatic cervical spine disease without intraoperative neurophysiological monitoring. The secondary goal was to assess the economic impact of intraoperative monitoring (IOM) in this patient population., Methods: This study is a retrospective review of 720 consecutively treated patients who underwent cervical spine procedures. The patients were identified and the data were collected by individuals who were not involved in their care., Results: A total of 1534 cervical spine levels were treated in 720 patients using anterior, posterior, and combined (360°) approaches. Myelopathy was present preoperatively in 308 patients. There were 185 patients with increased signal intensity within the spinal cord on preoperative T2-weighted MR images, of whom 43 patients had no clinical evidence of myelopathy. Three patients (0.4%) exhibited a new neurological deficit postoperatively. Of these patients, 1 had a preoperative diagnosis of radiculopathy, while the other 2 were treated for myelopathy. The new postoperative deficits completely resolved in all 3 patients and did not require additional treatment. The Current Procedural Terminology (CPT) codes for IOM during cervical decompression include 95925 and 95926 for somatosensory evoked potential monitoring of the upper and lower extremities, respectively, as well as 95928 and 95929 for motor evoked potential monitoring of the upper and lower extremities. In addition to the charge for the baseline [monitoring] study, patients are charged hourly for ongoing electrophysiology testing and monitoring using the CPT code 95920. Based on these codes and assuming an average of 4 hours of monitoring time per surgical case, the savings realized in this group of patients was estimated to be $1,024,754., Conclusions: With the continuing increase in health care costs, it is our responsibility as providers to minimize expenses when possible. This should be accomplished without compromising the quality of care to patients. This study demonstrates that decompression and reconstruction for symptomatic cervical spine disease without IOM may reduce the cost of treatment without adversely impacting patient safety.

Study Design. Systematic review and survey. Objective. To perform an evidence synthesis of the literature and obtain information from the global spine care community assessing the frequency, timing, and predictors of symptom development in patients with radiographical evidence of cervical spinal cord compression, spinal canal narrowing, and/or ossification of posterior longitudinal ligament (OPLL) but no symptoms of myelopathy. Summary of Background Data. Evidence for a marker to predict symptom development remains sparse, and there is controversy surrounding the management of asymptomatic patients. Methods. We conducted a systematic review of the English language literature and an international survey of spine surgeons to answer the following key questions in patients with radiographical evidence of cervical spinal cord compression, spinal canal narrowing, and/or OPLL but no symptoms of myelopathy: (1) What are the frequency and timing of symptom development? (2) What are the clinical, radiographical, and electrophysiological predictors of symptom development? (3) What clinical and/or radiographical features influence treatment decisions based on an international survey of spine care professionals? Results. The initial literature search yielded 388 citations. Applying the inclusion/exclusion criteria narrowed this to 5 articles. Two of these dealt with the same population. For patients with spinal cord compression secondary to spondylosis, one study reported the frequency of myelopathy development to be 22.6%. The presence of symptomatic radiculopathy, cervical cord hyperintensity on magnetic resonance imaging, and prolonged somatosensory- and motor-evoked potentials were reported in one study as significant independent predictors of myelopathy development. In contrast, the lack of magnetic resonance imaging hyperintensity was found to be a positive predictor of early myelopathy development (≤12-mo follow-up). For subjects with OPLL, frequency of myelopathy development was reported in 3 articles and ranged from 0.0% to 61.5% of subjects. One of these studies reported canal stenosis of 60% or more, lateral deviated OPLL, and increased cervical range of motion as significant predictors of myelopathy development. In a survey of 774 spine surgeons, the majority deemed the presence of clinically symptomatic radiculopathy to predict progression to myelopathy in nonmyelopathic patients with cervical stenosis. Survey responses pertaining to 3 patient case vignettes are also presented and discussed in the context of the current literature. Conclusion. On the basis of these results, we provide a series of evidence-based recommendations related to the frequency, timing, and predictors of myelopathy development in asymptomatic patients with cervical stenosis secondary to spondylosis or OPLL. Future prospective studies are required to refine our understanding of this topic. Evidence-Based Clinical Recommendations. Recommendation. Patients with cervical canal stenosis and cord compression secondary to spondylosis, without clinical evidence of myelopathy, and who present with clinical or electrophysiological evidence of cervical radicular dysfunction or central conduction deficits seem to be at higher risk for developing myelopathy and should be counseled to consider surgical treatment. Overall Strength of Evidence. Moderate Strength of Recommendation. Strong Summary Statements. * Statement 1: On the basis of the current literature, for patients with cervical canal stenosis and cord compression secondary to spondylosis, without clinical evidence of myelopathy, approximately 8% at l-year follow-up and 23% at a median of 44-months follow-up develop clinical evidence of mye]opathy. * Statement 2: For patients with cervical canal stenosis and cord compression secondary to spondylosis, without clinical evidence of myelopathy, the absence of magnetic resonance imaging intramedu]]ary T2 hyperintensity has been shown to predict early myelopathy development (<12-rno follow-up) and the presence of such signal has been shown to predict late myelopathy development (mean 44-mo follow-up). In light of this discrepancy, no definite recommendation can be made surrounding the utility of this finding in predicting myelopathy development. * Statement 3: For patients with OPLL but without mye]opathy, no recommendation can be made regarding the incidence or predictors of progression to myelopathy. [ABSTRACT FROM AUTHOR]