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Guideline Summary
Guideline Title
Cervical surgical techniques for the treatment of cervical spondylotic myelopathy.
Bibliographic Source(s)
Mummaneni PV, Kaiser MG, Matz PG, Anderson PA, Groff MW, Heary RF, Holly LT, Ryken TC, Choudhri TF, Vresilovic EJ, Resnick DK, Joint Section on Disorders of the Spine and Peripheral Nerves [trunc]. Cervical surgical techniques for the treatment of cervical spondylotic myelopathy. J Neurosurg Spine. 2009 Aug;11(2):130-41. [36 references] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Cervical spondylotic myelopathy

Guideline Category
Treatment
Clinical Specialty
Chiropractic
Family Practice
Geriatrics
Internal Medicine
Neurological Surgery
Neurology
Orthopedic Surgery
Physical Medicine and Rehabilitation
Preventive Medicine
Sports Medicine
Intended Users
Physicians
Guideline Objective(s)
  • To address questions regarding the therapy, diagnosis, and prognosis of cervical degenerative disease using an evidence-based approach
  • To use an evidence-based approach to examine the best surgical approach for the surgical treatment of cervical spondylotic myelopathy (CSM)
Target Population

Patients with cervical spondylotic myelopathy

Interventions and Practices Considered
  1. Anterior cervical discectomy (ACD)
  2. Anterior cervical discectomy with fusion (ACDF)
  3. Anterior cervical corpectomy with fusion (ACCF)
  4. Laminoplasty
  5. Laminectomy
  6. Laminectomy with fusion (arthrodesis)
Major Outcomes Considered
  • Fusion rates
  • Functional improvement
  • Range of motion (ROM)
  • Duration/recurrence of symptoms
  • Postoperative deterioration

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Secondary Sources)
Searches of Unpublished Data
Description of Methods Used to Collect/Select the Evidence

Search Criteria

The expert group completed a computerized search of the National Library of Medicine and the Cochrane Database for literature published between 1966 and 2007 using MeSH headings and keywords. Only English language citations were included. References cited in the qualifying articles were also reviewed to gather any other applicable manuscripts published between 1966 and 2006.

For anterior cervical discectomy with fusion (ACDF) and anterior cervical corpectomy with fusion (ACCF), the search headings included the following terms: "anterior cervical discectomy" and "anterior cervical corpectomy," "cervical discectomy versus corpectomy," "outcome and anterior cervical spine surgery," "fusion rate and anterior cervical spine surgery." These search terms yielded 1,035 citations. The abstracts of these citations were reviewed and applicable articles (which discussed both ACDF and ACCF) were selected.

For cervical laminectomy, the MeSH subject headings of "cervical" and "surgery" were limited to humans, and generated a broad base of studies (9,589 references). The expert group reviewed titles and abstracts with attention to those titles addressing clinical management. They followed the initial search with a secondary search crossing "myelopathy" with "surgery" and "cervical" and "myelopathy."

For cervical laminoplasty, the expert group used standard search terms along with MeSH headings. A search using the subject heading "laminoplasty" yielded 381 citations. The following subject headings were combined: "laminoplasty and outcome," "laminoplasty and cervical spine," "laminoplasty and myelopathy," "laminoplasty and surgery," and "laminoplasty and cervical stenosis." These search terms yielded 155, 269, 266, 347, and 69 citations, respectively. Accounting for redundancy, 314 citations were acquired.

Other search terms included "myelopathy, cervical spine, fusion, laminectomy, laminoplasty, cervical spondylotic myelopathy, and ossification of posterior longitudinal ligament." A search using the subject heading "laminectomy" and "cervical" and "arthrodesis" yielded 345 citations. The following subject headings were combined: "laminectomy and outcome and arthrodesis" (244 citations) and "laminectomy and arthrodesis and myelopathy" (329 citations). A total of 614 citations were acquired after accounting for redundancy.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Strength of the Evidence

Class I: Evidence evolved from well-designed randomized controlled trials (RCTs).

Class II: Evidence arose from RCTs with design problems or from well-designed cohort studies.

Class III: Evidence arose from case series or poorly designed cohort studies.

Methods Used to Analyze the Evidence
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

Quality of Evidence

The guidelines group assembled an evidentiary table summarizing the quality of evidence.

The mainstay of any evidence-based review lies in the assessment of the quality of strength of the data. The group assessed the methodology of each manuscript carefully and assessed each study according to its relevant category—diagnosis, therapy, prognosis, or harm. The group applied a weighting scheme according to the methods delineated by Sackett and colleagues. After review of the study methods, the group determined how well each individual study met the validity requirements within its category and assigned a class to the study. In keeping with prior surgical guidelines, a 3-class system (Classes I, II, and III) was used (see the "Rating Scheme for the Strength of the Evidence" field).

It was the group's conclusion that expert opinion and case reports did not add significantly to the evidence used for the formulation of recommendations and should not be separately classified.

When disagreement arose as to the strength of evidence (that is, determining how well the methods conformed to the weighting scheme), the group resolved said disagreement by expert consensus within itself. To avoid the undue influence of a single individual, each member had the opportunity to list the reason(s) why a study should be downgraded or upgraded. Group members then prioritized each reason. If a reason had low priority, it was eliminated. Ultimately, there was convergence of opinion within the group. The result was unanimity to support publicly the assessment of the quality of evidence and the strength of the guidelines despite potential individual reservations regarding specific details.

Methods Used to Formulate the Recommendations
Expert Consensus (Consensus Development Conference)
Description of Methods Used to Formulate the Recommendations

In March 2006, the Joint Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons/Congress of Neurological Surgeons compiled an expert group to perform an evidence-based review of the clinical literature on the management of cervical degenerative spine disease. Comprising the group were spinal neurosurgeons and orthopedic surgeons active in the Joint Section and/or the North American Spine Society. This combination of specialties ensured the comprehensive participation of both surgical specialties. At least half of the group had participated in prior guidelines development, and several had completed the evidence-based course developed by the North American Spine Society. The multiple recommendations represent the product of this group with input from the Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons.

Formulation and Strength of Recommendations

The group formulated recommendations using expert consensus in a consensus development conference. After assessment of the quality and strength of evidence, the assigned subgroup summarized the studies leading to the basis of the Scientific Foundation section of each chapter. In general, if high-quality (Class I or II) data were available on a particular topic, poorer quality evidence was only briefly summarized. If no high-quality evidence existed, Class III data formed the basis of the scientific foundation. Based on the quality and strength of data, each subgroup formulated initial treatment recommendations. Each subgroup presented these to the entire group whose membership included active members of the Congress of Neurological Surgeons, the American Association of Neurological Surgeons, the North American Spine Society, and the American Academy of Orthopedic Surgery. The presentation was a plenary session acting as a consensus development conference from which final recommendations arose.

The group gave each recommendation a grade for strength based on the quality of the underlying studies. Grading was based on the methods of the Scottish Intercollegiate Guidelines Network and also mirrored that used by the Oxford Centre for Evidence-Based Medicine (www.cebm.net External Web Site Policy) (see the "Rating Scale for the Strength of the Recommendations" field).

Rating Scheme for the Strength of the Recommendations

Strength of the Recommendations

Grade A: Recommendations based on consistent Class I studies.

Grade B: Recommendations based on a single Class I study or consistent Class II studies.

Grade C: Recommendations based on a single Class II study.

Grade D: Recommendations based on Class III or weaker data, or based on inconsistent data.

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons and through external peer review prior to publication.

Recommendations

Major Recommendations

The rating schemes used for the strength of the evidence (Class I-III) and the grades of recommendations (A-D) are defined at the end of the "Major Recommendations" field.

Recommendations

Indication

Cervical Spondylotic Myelopathy (CSM). It is recommended that a variety of techniques be considered in the surgical treatment of CSM including anterior cervical discectomy with fusion (ACDF), anterior cervical corpectomy with fusion (ACCF), laminoplasty, laminectomy, and laminectomy with fusion (Quality of evidence, Class III; Strength of recommendation, D).

Technique

  • ACDF Compared to ACCF. It is recommended that ACDF or ACCF be used in patients undergoing multilevel anterior cervical spine decompression for lesions located at the disc level. The use of anterior plate fixation allows for equivalent fusion rates between these techniques (Quality of evidence, Class III; Strength of recommendation, D).
  • If anterior fixation is not used, it is recommended that ACCF be considered before ACDF because it may provide a higher fusion rate than multilevel ACDF. It should be understood that the use of ACCF is associated with higher graft failure rates than multilevel ACDF (Quality of evidence, Class III; Strength of recommendation, D).
  • ACDF or Anterior Cervical Discectomy (ACD) Versus Laminectomy. There is insufficient evidence to recommend ACD or ACDF over laminectomy in the near term because both approaches have produced comparable improvements in the surgical treatment of CSM; however, because of the association of laminectomy with late deterioration, ACDF or ACD should be considered for short segment decompression for CSM when technically feasible (Quality of evidence, Class III; Strength of recommendation, D).
  • ACDF Versus Laminectomy/Arthrodesis. There is insufficient evidence to recommend ACDF over laminectomy/arthrodesis because both approaches have produced comparable improvement in the surgical treatment of CSM (Quality of evidence, Class III; Strength of recommendation, D).
  • ACDF and ACCF Versus Laminoplasty. There is insufficient evidence to make a recommendation of ACDF or ACCF over laminoplasty because both approaches have produced comparable improvement in the surgical treatment of CSM (Quality of evidence, Class III; Strength of recommendation, D ).
  • Laminectomy Versus Laminoplasty. There is insufficient evidence to recommend laminoplasty over laminectomy because both approaches have produced comparable improvement in the surgical treatment of CSM in the near term; however, because of the association of laminectomy with late deformity, laminoplasty should be considered when stability is an issue over time (Quality of evidence, Class III; Strength of recommendation, D).
  • Laminectomy Versus Laminectomy/Arthrodesis. There is insufficient evidence to recommend laminectomy with arthrodesis over laminectomy because both approaches have produced comparable improvement in the surgical treatment of CSM in the near term; however, because of the association of laminectomy with late deformity, laminectomy with arthrodesis should be considered when stability is an issue over time (Quality of evidence, Class III; Strength of recommendation, D).
  • Laminoplasty Versus Laminectomy/Arthrodesis. There is insufficient evidence to recommend laminoplasty over laminectomy with arthrodesis because both approaches have produced comparable improvement in the surgical treatment of CSM (Quality of evidence, Class III; Strength of recommendation, D).

Summary

Current evidence (Class III) suggests that multilevel ACDF and ACCF offer equivalent treatment strategies and outcomes in the anterior surgical treatment of CSM. If fixation is not used anteriorly, ACCF may offer better fusion rates. In comparison with laminectomy, 4 of 8 Class III studies indicated better improvement with ACF, while 3 Class III studies showed equivalency. One Class III study showed better improvement with laminectomy. Only 1 study compared laminectomy with arthrodesis to ACF in a multigroup comparison. In this study, laminectomy with arthrodesis appeared to have better results.

There is no Class I or II evidence to suggest that laminoplasty is superior to other techniques for decompression. However, Class III evidence has shown equivalency in functional improvement between laminoplasty and ACF. Class III evidence is unclear regarding differences in complication rates between these techniques.

In comparing posterior techniques, there is no Class I or II evidence to suggest that laminoplasty is superior to laminectomy/arthrodesis or laminectomy alone. Class III evidence has shown equivalency between laminoplasty and laminectomy, with the results of 1 study suggesting laminoplasty to be superior. However, laminectomy may better preserve range of motion (ROM). Class III evidence has shown equivalency between laminoplasty and laminectomy/arthrodesis; however, laminoplasty appears to better preserve ROM. Finally, 1 Class III study compared laminectomy to laminectomy/arthrodesis. Both treatment strategies had similar outcomes, but laminectomy was associated with a higher rate of kyphosis.

Although there is no Class I or II evidence to suggest that ACF, laminoplasty, or laminectomy and arthrodesis are superior to laminectomy for CSM, there is Level III evidence indicating that laminectomy may be associated with late deterioration. Although this may not speak completely against laminectomy as a means of treatment, especially if there are technical issues in utilizing other techniques, it does argue for consideration of other techniques in younger patients in whom late deterioration may be more likely to develop.

Definitions:

Strength of the Evidence

Class I: Evidence evolved from well-designed randomized controlled trials (RCTs).

Class II: Evidence arose from RCTs with design problems or from well-designed cohort studies.

Class III: Evidence arose from case series or poorly designed cohort studies.

Strength of the Recommendations

Grade A: Recommendations based on consistent Class I studies.

Grade B: Recommendations based on a single Class I study or consistent Class II studies.

Grade C: Recommendations based on a single Class II study.

Grade D: Recommendations based on Class III or weaker data, or based on inconsistent data.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate surgical treatment of patients with cervical spondylotic myelopathy (CSM)

Potential Harms
  • The occurrence of kyphotic deformity after surgery
  • Laminectomy may be associated with late deterioration compared with other types of anterior and posterior surgeries.

Qualifying Statements

Qualifying Statements
  • During guideline development, the group commonly encountered unsophisticated or poorly designed comparative methods in clinical trials. The most common flaw was the lack of a control group or the utilization of historical controls. Other common flaws were invalid outcome measures, and the lack either of randomization or blinding of outcome assessors. Specific examples are provided in the text of each topic. At the conclusion of each chapter are suggestions for future areas of study and ideas to improve the quality of clinical research.
  • With each recommendation comes the risk of conformational bias. The recommendation of a therapeutic option presumes that functional and economic preferences have been determined. Reliable and valid outcome measures help in this respect. It is hoped that such functional and economic outcome measures represent the values important to the patient and society and less the practitioner. By focusing attention on outcome measures in each study, the values of the patient and society are represented in these guidelines.
  • To minimize any specialty bias, spinal surgeons from both orthopedic and neurosurgery departments participated in the creation of these guidelines. However, although invited, nonsurgical stakeholders did not participate—a circumstance that some might argue would predispose to conformational bias toward strong surgical recommendations. It is hoped in the future that nonsurgical stakeholders will participate. During this process, the entire group made a concerted effort to be unprejudiced. Many authors acknowledged that poor quality or controversial data often formed the basis of their predetermined ideas regarding standard treatment. It is expected that certain practitioners may disagree with the recommendations. However, with careful review of the scientific foundation, the critically thoughtful reader should find the recommendations warranted.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness

Identifying Information and Availability

Bibliographic Source(s)
Mummaneni PV, Kaiser MG, Matz PG, Anderson PA, Groff MW, Heary RF, Holly LT, Ryken TC, Choudhri TF, Vresilovic EJ, Resnick DK, Joint Section on Disorders of the Spine and Peripheral Nerves [trunc]. Cervical surgical techniques for the treatment of cervical spondylotic myelopathy. J Neurosurg Spine. 2009 Aug;11(2):130-41. [36 references] PubMed External Web Site Policy
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2009 Aug
Guideline Developer(s)
American Association of Neurological Surgeons - Medical Specialty Society
Congress of Neurological Surgeons - Professional Association
Source(s) of Funding

Administrative costs of this project were funded by the Joint Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons and Congress of Neurological Surgeons.

Guideline Committee

The Joint Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons and Congress of Neurological Surgeons Expert Group

Composition of Group That Authored the Guideline

Authors: Praveen V. Mummaneni, M.D., Department of Neurosurgery, University of California at San Francisco, California; Michael G. Kaiser, M.D., Department of Neurological Surgery, Neurological Institute, Columbia University, New York, New York; Paul G. Matz, M.D., Division of Neurological Surgery, University of Alabama, Birmingham, Alabama; Paul A. Anderson, M.D., Department of Orthopedic Surgery, University of Wisconsin, Madison, Wisconsin; Michael W. Groff, M.D., Department of Neurosurgery, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts; Robert F. Heary, M.D., Department of Neurosurgery, University of Medicine and Dentistry of New Jersey—New Jersey Medical School, Newark, New Jersey; Langston T. Holly, M.D., Division of Neurosurgery, David Geffen School of Medicine, University of California at Los Angeles, California; Timothy C. Ryken, M.D., Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa; Tanvir F. Choudhri, M.D., Department of Neurosurgery, Mount Sinai School of Medicine, New York, New York; Edward J. Vresilovic, M.D., Ph.D., Department of Orthopedic Surgery, Milton S. Hershey Medical Center, Pennsylvania State College of Medicine, Hershey, Pennsylvania; Daniel K. Resnick, M.D., Department of Neurological Surgery, University of Wisconsin, Madison, Wisconsin

Financial Disclosures/Conflicts of Interest

No author received payment or honorarium for time devoted to this project. Dr. Resnick owns stock in Orthovita. Dr. Matz receives support from the Kyphon Grant for Thoracolumbar Fracture Study, and an advisory honorarium from Synthes for the cadaver laboratory. Dr. Heary receives support from DePuy Spine and Biomet Spine, and receives royalties from DePuy Spine and Zimmer Spine. Dr. Groff is a consultant for DePuy Spine. Dr. Mummaneni is a consultant for and receives university grants from DePuy Spine and Medtronic, Inc., and is a patent holder in DePuy Spine. Dr. Anderson is an owner of, consultant for, and stockholder of Pioneer Surgical Technology; a consultant for and receives non–study related support from Medtronic, Inc.; and is a patent holder in Stryker. The authors report no other conflicts of interest concerning the materials or methods used in this study or the findings specified in this paper.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in from the Journal of Neurosurgery Web site External Web Site Policy.

Print copies: Available from the Journal of Neurosurgery Publishing Group, 1224 Jefferson Park Avenue, Suite 450, Charlottesville, Virginia 22903, USA. Telephone: 434-924-5503

Availability of Companion Documents

The following is available:

  • Introduction and methodology: guidelines for the surgical management of cervical degenerative disease. J Neurosurg Spine. 2009 Aug;11(2):101-3. Electronic copies: Available from the Journal of Neurosurgery Web site External Web Site Policy.
Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on February 11, 2011. The information was verified by the guideline developer on March 20, 2011.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer

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The National Guideline Clearinghouseâ„¢ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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