Posterior approaches in the management of cervical spondylosis and ossification of the posterior longitudinal ligament

BACKGROUND: If the cervical lordotic curvature has been well preserved, spondylostenosis or ossification of the posterior longitudinal ligament, with or without instability, may be approached posteriorly in selected older patients (over 65 years of age). Posterior surgical alternatives include the laminectomy with or without fusion, or laminoplasty. However, in younger patients or in geriatric patients with predominantly anterior disease with kyphosis, direct anterior surgical procedures yield better results. METHODS: Laminectomy with medial facetectomy and foraminotomy is classically performed in cases in which stability is preserved. However, posterior stabilization using either facet wiring or lateral mass fusion may be warranted. Although some consider the "open door" laminoplasty a reasonable alternative for dorsal decompression, limitations include restricted access to the hinged side, a potential for "closing of the door," and it does not offer a "real" fusion. RESULTS: Postoperative neurologic improvement may approximate an 85% incidence of good to excellent results. However, where a posterior decompression has been chosen, particularly in younger individuals with or without a lordotic curvature, or in older patients with kyphosis, they will fail to significantly improve, and will be susceptible to early neurologic deterioration. CONCLUSIONS: Posterior approaches to cervical disease may be successful in geriatric individuals in whom the cervical lordotic curvature has been well preserved. However, it is inappropriate for either older or younger patients with predominantly anterior disease, for whom direct anterior decompression with or without posterior stabilization is indicated. In those patients with significant ventral ossification of the posterior longitudinal ligament (OPLL), direct anterior resection will result in improved neurologic outcomes, whereas posterior decompression will fail to achieve a similar degree of neurologic recovery. Furthermore, dorsal decompression of OPLL may promote a more rapid progression of OPLL growth and concomitant neurologic deterioration.