Cervical Spondylosis · Anterior vs Posterior

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Type + levels/direction involved
   Radiculopathy or myelopathy? Number of levels and direction of compression?
   • Radiculopathy, not adequately treated conservatively → Radiculopathy → conservative
   • Myelopathy (CSM, progressive/moderate-severe) → Myelopathy · choose approach (levels / K-line / curvature)
   • Radiculopathy conservative failure or single/two-level anterior compression → Anterior (ACDF/corpectomy)
   • Multilevel (≥3)/OPLL/good lordosis/developmental stenosis → Posterior (laminoplasty)
2. [End] Radiculopathy → conservative
   Radiculopathy, no major cord involvement → conservative (physiotherapy, medication, activity modification ± nerve root injection); failure/progressive deficit → surgery.
3. [Decision] Myelopathy · choose approach (levels / K-line / curvature)
   Number of levels of compression, cervical curvature and K-line (for OPLL)? (Progressive/moderate-severe myelopathy warrants surgical decompression. The K-line connects the canal midpoints at C2 and C7 on lateral view: OPLL not crossing the line is K-line(+), crossing it is K-line(-). Posterior approaches rely on posterior cord drift, which depends on cervical lordosis and K-line(+).)
   • 1–2 levels anterior compression, or kyphosis, or K-line(-)/canal occupancy ≥60% → anterior direct decompression → Anterior (ACDF/corpectomy)
   • Multilevel (≥3), preserved lordosis, K-line(+) → posterior (laminoplasty) → Posterior (laminoplasty)
   • Multilevel but kyphosis or K-line(-) (insufficient drift) → posterior decompression + fusion-correction or anterior → Posterior decompression + fusion-correction / anterior
4. [End] Anterior (ACDF/corpectomy)
   Anterior (ACDF discectomy-fusion / ACCF corpectomy-fusion) — preferred for 1–2 levels of anterior (disc/osteophyte) compression, kyphotic deformity, or OPLL with canal occupancy ≥60%, cervical kyphosis >10–11°, K-line(-): directly removes the ventral compression and corrects alignment. Watch for CSF leak, graft migration, pseudarthrosis.
5. [End] Posterior (laminoplasty)
   Posterior laminoplasty — multilevel (≥3), preserved cervical lordosis, K-line(+), developmental canal stenosis: indirect decompression via posterior cord drift, good results with K-line(+)/lordosis; elderly multilevel often choose posterior. C3 laminectomy + C4–C7 laminoplasty can reduce axial symptoms.
6. [End] Posterior decompression + fusion-correction / anterior
   Multilevel but kyphosis or K-line(-): laminoplasty alone gives insufficient cord drift and may worsen kyphosis → posterior laminectomy + lateral mass/pedicle screw fusion-correction (aiming to convert to K-line(+)), or switch to anterior direct decompression; heavy/complex compression may need a combined anterior-posterior approach.

Source guidelines & references

• Cervical spondylosis and cervical spondylotic myelopathy (AOSpine CSM guideline; anterior vs posterior selection)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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