Posterior midline cervical · intermediate
- Multilevel cervical stenosis (3 or more levels) with PRESERVED LORDOSIS is the indication — a kyphotic spine is an absolute contraindication to laminectomy alone, because the cord cannot drift back off the anterior compression.
- Preserve greater than 50 percent of each facet joint and its capsule bilaterally — resecting more destabilises the segment and causes post-laminectomy instability requiring fusion.
- C5 nerve root palsy occurs in 5–10 percent: deltoid and biceps weakness appearing POD 1–3, usually transient with about 80 percent spontaneous recovery by 6 months.
- Post-laminectomy kyphosis risk is 15–30 percent — prevent by preserving the facets, avoiding a kyphotic spine, and adding fusion when instability or more than 3 levels is present.
- Confirm the level with intraoperative fluoroscopy BEFORE any bone removal — wrong-level surgery is a never event.
When & Why
Indication. Symptomatic multilevel cervical stenosis — most commonly cervical myelopathy with progressive hand clumsiness, gait instability and numbness — caused by posterior or circumferential cord compression across 3 or more levels, with preserved lordosis on a standing lateral radiograph. The principle is simple: a posterior decompression works only if the spinal cord can drift posteriorly away from anterior compression, which requires lordosis. Absolute indications
- Multilevel cervical myelopathy (3 or more levels) with preserved lordosis and posterior cord compression
- Ossification of the posterior longitudinal ligament (OPLL) with posterior element hypertrophy
- Cervical stenosis with a congenitally narrow canal (developmental diameter less than 13 mm on CT)
- Multilevel cervical tumours requiring posterior decompression (for example intradural tumours) Relative indications
- Multilevel cervical radiculopathy with lateral recess stenosis at 3 or more levels
- Multilevel facet arthropathy causing foraminal stenosis (combined with foraminotomy)
- Recurrent stenosis after anterior procedures at multiple levels
- Thoracic myelopathy extending to the lower cervical spine Absolute contraindications
- Cervical kyphosis (loss of lordosis mandates an anterior or combined approach)
- Pre-existing instability or spondylolisthesis without planned fusion
- Active cervical spine infection (osteomyelitis, epidural abscess)
- Uncorrected coagulopathy or bleeding disorder
- Single-level stenosis (anterior cervical discectomy and fusion preferred) Relative contraindications
- Previous posterior cervical surgery with scarring (increased dural tear risk)
- Severe osteoporosis (consider fusion for stability)
- Age less than 18 years (growing spine, higher post-laminectomy kyphosis risk)
- Predominant anterior cord compression (anterior approach more direct)
- Patient unable to tolerate prone positioning (cardiopulmonary disease) How it compares. The choice between laminectomy, laminoplasty and multilevel anterior surgery rests on sagittal alignment, the number of levels and the direction of compression.
- Laminectomy
- Removed
- Laminoplasty
- Hinged and preserved
- Laminectomy
- Lost
- Laminoplasty
- Maintained
- Laminectomy
- Up to 21–30%
- Laminoplasty
- Lower
- Laminectomy
- About 11.3%
- Laminoplasty
- About 4.5% open-door / 3.1% double-door
- Laminectomy
- Less
- Laminoplasty
- More
- Laminectomy
- Straightforward
- Laminoplasty
- More demanding
- Laminectomy
- Kyphosis, instability
- Laminoplasty
- Ossified ligamentum flavum, fixed kyphosis
- Multilevel laminectomy
- 3 or more levels with lordosis
- Multilevel ACDF
- Kyphotic alignment, single/two-level disease
- Multilevel laminectomy
- Low
- Multilevel ACDF
- 20–30% with multilevel constructs
- Multilevel laminectomy
- Avoids dysphagia and adjacent-segment disease
- Multilevel ACDF
- Dysphagia, adjacent-segment disease
- Multilevel laminectomy
- Easy to add foraminotomy
- Multilevel ACDF
- Limited
Consent specifically for C5 palsy (5–10 percent, usually transient), post-laminectomy kyphosis, dural tear and CSF leak, epidural haematoma with acute deterioration, wound infection, and the possibility of adding instrumented fusion if instability is found intraoperatively. Setup. Prone on a Jackson table or chest rolls, Mayfield 3-pin head holder, neck neutral or slight flexion (10–15 degrees) to open the interspinous spaces, abdomen free to reduce venous congestion, shoulders taped caudally for lower-cervical imaging. Avoid excessive flexion, which stretches the cord and can cause hypoperfusion.
The Operation
The goal is to decompress the spinal cord and nerve roots by removing the laminae and the hypertrophied ligamentum flavum across the stenotic levels, while preserving greater than 50 percent of each facet joint and the posterior tension band, and protecting the cord, dura, nerve roots and vertebral artery throughout. The exposure — positioning, midline approach, subperiosteal dissection to the lateral masses and facet identification — is laid out as the first steps below; it is the heart of the operation.
Operative sequence
- Prone on a Jackson table or chest rolls; Mayfield 3-pin head holder (2 frontal pins about 1 cm above the orbital rim, 1 occipital pin above the superior nuchal line) or a horseshoe headrest.
- Neck neutral or slight flexion (10–15 degrees) to open the interspinous spaces; avoid excessive flexion, which stretches the cord and risks hypoperfusion.
- Arms tucked with padding at every pressure point; shoulders taped caudally to improve C7–T1 visualisation on lateral fluoroscopy; keep the abdomen free to reduce epidural venous engorgement.
- Mayfield pins avoid the supraorbital nerve (about 2 cm above the orbital rim), the temporal vessels and the thin temporal bone; the frontal pins diverge to avoid the frontal sinus; test stability before draping.
- Midline posterior incision centred over the pathological levels, typically extending from the C2 spinous process to C7/T1 (about 11–13 cm).
- Palpate C2 (the most prominent cervical spinous process, bifid) and C7 (the vertebra prominens, non-bifid) to plan and mark the incision before draping; extend inferiorly if lower cervical or upper thoracic levels are involved.
- Divide skin and subcutaneous tissue in the midline and deepen through the avascular raphe of the ligamentum nuchae (the avascular midline structure from occiput to C7) with electrocautery for haemostasis.
- Local anaesthetic with epinephrine to the skin edges reduces bleeding. Avoid lateral deviation, which enters paraspinal muscle and causes bleeding.
- Sharp subperiosteal dissection with a Cobb elevator from the spinous process along the lamina to the lateral mass; stay on bone to avoid paraspinal bleeding.
- Expose laterally to the lateral mass (about 15–20 mm from the midline), stopping at the medial border of the facet joint.
- The foramen transversarium — transmitting the vertebral artery (V2 segment, C6–C2) — lies further lateral and must not be breached. The cervical pedicles (C3–C6) are small, only 3–5 mm in diameter.
- Place deep self-retaining retractors (Taylor or Beckman) under the paraspinal muscles.
- Confirm the level with lateral fluoroscopy using a marker on a spinous process BEFORE any bone removal — wrong-level surgery is a never event. Count from C2 (most prominent) or from C7 (vertebra prominens).
- Identify the facet joints lateral to the lamina; preserve the facet capsule and articular cartilage.
- Resecting greater than 50 percent of a facet, or violating its capsule, destabilises the segment and causes post-laminectomy instability requiring fusion.
- If fusion is planned, the exposure can be extended further lateral for lateral-mass (C3–C6) and pedicle (C7) screw placement.
- Use a high-speed burr (3 mm matchstick or 4 mm diamond) to thin the laminae bilaterally at the lamina–facet junction, creating bilateral troughs from medial to lateral.
- Thin to eggshell consistency until a bluish discolouration and softening are felt; start inferiorly and work cephalad. The burr is safer than a rongeur for the initial thinning.
- Copious irrigation prevents thermal injury to the dura and cord.
- Use a 2–3 mm Kerrison rongeur to complete lamina removal, working from inferior to superior with the footplate passed under the thinned lamina.
- The Kerrison jaw opens AWAY from the cord; use a 2 mm Kerrison at C2 where the cord is closest to bone. If the footplate meets resistance, thin further with the burr rather than forcing it.
- Remove the spinous process and lamina, ideally as a single piece where possible.
- Grasp the thickened, yellow ligamentum flavum — hypertrophied to 3–5 mm in stenosis versus 2–3 mm normally — with a small pituitary rongeur and remove it carefully and completely; it is a major contributor to the stenosis.
- It attaches to the anterior surface of the superior lamina and the postero-superior margin of the inferior lamina, and is often adherent to the dura in stenosis, requiring sharp dissection.
- Use a 45-degree angled Kerrison or the burr to undercut the medial facet bilaterally, decompressing the lateral recess and foramen without resecting greater than 50 percent of the facet.
- For foraminal stenosis, remove the medial half of the superior articular process; visualise and protect the nerve root before any manipulation.
- Confirm the dura and cord are adequately decompressed; the dura should pulsate with respiration and the nerve roots should be mobile and soft on a nerve hook.
- Absence of pulsation suggests incomplete decompression or an epidural haematoma — inspect all levels systematically.
- Judge stability from facet preservation, pre-existing instability and the number of levels.
- Add instrumented fusion (lateral mass screws C3–6, pedicle screws C7, rod construct) if there is pre-existing instability, greater than 50 percent bilateral facet resection, kyphotic alignment, or (controversially) more than 3 contiguous levels.
- Meticulous haemostasis with bipolar cautery at a low setting on epidural vessels, bone wax sparingly to bleeding bone edges, and topical agents (Gelfoam, Surgicel, FloSeal) for persistent epidural venous ooze. Excess bone wax risks a foreign-body reaction.
- Place a deep suction drain in the epidural space exiting through a separate stab incision; a watertight fascial closure reduces the CSF leak risk if an incidental durotomy occurred.
- Close paraspinal muscles and fascia with 0 Vicryl, the subcutaneous layer with 2-0 Vicryl, and the skin with staples or nylon.
- Immediate postoperative neurological examination compared with the preoperative baseline; early mobilisation once awake.
- A soft collar is for comfort only, not structural support. Any new deficit demands urgent imaging to exclude a haematoma.
- Location
- Within the canal; the C5–T1 enlargement is most vulnerable, and the cord is closest to bone at C2
- How to protect
- Gentle technique; burr the lamina to eggshell before Kerrison; never retract the cord; confirm dural pulsations
- Location
- Foramen transversarium C6–C2, about 15–20 mm lateral from the midline at the uncinate process; enters the C6 transverse foramen
- How to protect
- Limit lateral dissection to the medial border of the lateral mass; stay subperiosteal; avoid greater than 50% facet resection
- Location
- Exit ABOVE the corresponding vertebra (the C5 root exits above the C5 pedicle); 3–5 mm from the lateral mass
- How to protect
- Gentle foraminotomy with a 45° Kerrison; undercut the medial facet only; visualise the root before manipulation
- Location
- Surrounds the cord and roots; adherent to the ligamentum flavum in stenosis; about 1 mm thick at the cervical level
- How to protect
- Burr the lamina to eggshell; remove the ligamentum flavum carefully with a pituitary rongeur; primary repair if violated
- Location
- Anterior and lateral epidural space; valveless; engorged with prone positioning and stenosis
- How to protect
- Meticulous haemostasis with bipolar at a low setting; avoid excessive manipulation; use topical haemostatic agents
The spinal cord and the vertebral artery are the two catastrophic-risk structures. Protect the cord by burring each lamina to eggshell before any Kerrison work, never using the cord as a fulcrum, and confirming dural pulsations at the end. Protect the vertebral artery by never dissecting lateral to the medial border of the lateral mass and by preserving greater than 50 percent of every facet. A new, immediate, dense deficit postoperatively is an epidural haematoma until proven otherwise — urgent imaging and re-exploration within 6–8 hours.
Thin each lamina with the high-speed burr until a bluish discolouration and softening are felt, with copious irrigation, before completing the cut with the Kerrison. The Kerrison footplate should then pass easily under the lamina; if it meets resistance, thin more rather than forcing it. This single habit prevents most burr- and Kerrison-related cord and dural injuries.
Examiners expect you to volunteer two things unprompted: the greater-than-50-percent facet rule (resecting more destabilises the segment and mandates fusion), and wrong-level surgery prevention (mandatory intraoperative fluoroscopy, counting from C2 or C7, before any bone removal).
In lordosis the cord drifts posteriorly into the decompression void, away from anterior compression. In kyphosis it remains draped over the vertebral bodies, so posterior decompression alone neither relieves the compression nor restores alignment — and it removes the posterior tension band, accelerating kyphosis. A kyphotic spine needs an anterior or combined approach.
Aftercare & Complications
Rehabilitation | Phase | Timing | Collar / activity | Focus | |-------|--------|-------------------|-------| | 1 | 0–2 weeks | Soft collar for comfort only (not structural); drain removed when output less than 30 ml/24 h (POD 1–2) | Immediate neurological exam vs baseline; early mobilisation once awake | | 2 | 2–6 weeks | Soft collar as needed | Gentle range of motion; wound review | | 3 | 6 weeks–3 months | Wean collar | Flexion-extension radiograph at 6 weeks; progressive activity and strengthening | | 4 | 3–12 months | Return to function | Flexion-extension radiographs at 3 months and 1 year to detect kyphosis or instability | Most patients mobilise the day after surgery. The soft collar is comfort-only. Red flags are an acute neurological deterioration (an epidural haematoma — emergency re-exploration) and a progressive kyphotic deformity (revision fusion). Complications
- Recognition
- Progressive neck pain and neurological deterioration; lateral radiograph shows loss of lordosis or kyphosis greater than 10 degrees
- Prevention
- Preserve greater than 50% of the facets; avoid in a kyphotic spine; consider fusion if more than 3 levels; maintain the posterior tension band
- Management
- Mild: observation and physiotherapy. Progressive: anterior-posterior fusion and instrumentation with deformity correction
- Recognition
- Postoperative deltoid and biceps weakness (4/5 or less) with limited shoulder abduction, usually POD 1–3, hand function preserved
- Prevention
- Gentle cord handling; adequate multilevel decompression; avoid excessive retraction (mechanism unclear, so prevention is limited)
- Management
- EMG at 3 weeks confirms neuropraxia; physiotherapy for deltoid strengthening; about 80% spontaneous recovery by 6 months; observation only
- Recognition
- Intraoperative CSF flow; postoperative clear wound drainage; headache worse upright; pseudomeningocele on MRI
- Prevention
- Careful ligamentum-flavum removal; burr lamina to eggshell; sharp dissection when the dura is adherent
- Management
- Primary repair with 5-0 or 6-0 Prolene, fibrin glue, layered watertight closure, bed rest 24–48 h, acetazolamide if persistent; revision for pseudomeningocele
- Recognition
- Progressive kyphosis on flexion-extension radiographs (greater than 3.5 mm translation or greater than 11 degrees angulation); recurrent symptoms
- Prevention
- Preserve the facet joints and capsule; limit resection to less than 50% bilaterally; consider prophylactic fusion if borderline
- Management
- Revision with instrumented posterior fusion (lateral mass screws C3–6, pedicle screws C7) if symptomatic progressive deformity
- Recognition
- Acute postoperative neurological deterioration; complete or incomplete cord syndrome; MRI shows an epidural collection compressing the cord
- Prevention
- Meticulous haemostasis with bipolar; correct coagulopathy; drain placement; early drain removal when output less than 30 ml/24 h
- Management
- Emergency re-exploration and evacuation within 6–8 hours; steroids controversial; prognosis depends on timing
- Recognition
- Fever, wound erythema, purulent drainage, raised inflammatory markers (CRP, ESR, WBC); MRI shows a fluid collection
- Prevention
- Perioperative antibiotics (cefazolin 2 g), sterile technique, minimise operative time, glucose control, avoid haematoma
- Management
- Surgical debridement, send cultures, IV antibiotics for 6 weeks (vancomycin plus gram-negative cover); retain hardware if possible
- Recognition
- Immediate postoperative complete or incomplete cord syndrome; MRI excludes haematoma and shows cord signal change on T2
- Prevention
- Gentle technique; decompress before any manipulation; never retract the cord; copious irrigation to prevent thermal injury
- Management
- High-dose steroids controversial (NASCIS III); MRI to exclude haematoma; supportive care and rehabilitation. Catastrophic, poor prognosis
Specific complication protocols C5 palsy protocol — document deltoid and biceps strength postoperatively (usually 3–4/5); EMG/NCS at 3 weeks to confirm neuropraxia versus axonotmesis; physiotherapy for shoulder range of motion and strengthening; reassurance with about 80 percent spontaneous recovery by 6 months; permanent severe weakness is rare (less than 5 percent) and most retain at least 4/5 function. Post-laminectomy kyphosis prevention — careful patient selection (avoid a kyphotic spine); preserve greater than 50 percent of the facets bilaterally; consider prophylactic fusion if more than 3 levels or borderline stability; a postoperative soft collar for comfort only; surveillance flexion-extension radiographs at 6 weeks, 3 months and 1 year. Dural tear management — recognise the tear intraoperatively and identify its location; primary repair with 5-0 or 6-0 Prolene (running or interrupted); fibrin glue or DuraSeal over the repair; watertight muscle and fascial closure; bed rest 24–48 hours with acetazolamide 500 mg twice daily if the leak persists; revision exploration if a pseudomeningocele develops.
Viva & Exam Focus
FACETSFACETS — laminectomy stability criteria
CORDCORD — preventing C5 nerve palsy
Clinical Decision Scenarios
Practise clinical reasoning and management decisions out loud
“A 62-year-old man presents with an 18-month history of progressive hand clumsiness, gait instability and numbness in both hands. MRI shows multilevel cervical stenosis from C3 to C6 with cord signal change. Sagittal alignment shows preserved lordosis. How would you manage this patient and what surgical options would you consider?”
“What is C5 nerve root palsy, how do you manage it, what is the proposed mechanism, and what is the prognosis?”
“When would you add instrumented fusion to laminectomy? What are the specific biomechanical indications, and what does the evidence show about outcomes?”
Indications (know cold)
- Multilevel cervical stenosis (3 or more levels) with PRESERVED LORDOSIS — a kyphotic spine is a contraindication
- Cervical myelopathy with posterior cord compression and canal diameter less than 13 mm (congenital stenosis)
- OPLL (ossification of the posterior longitudinal ligament) with posterior element hypertrophy
- Multilevel cervical tumours requiring posterior decompression (intradural tumours)
- NOT for single-level stenosis (ACDF preferred); NOT for a kyphotic spine (anterior approach required)
Key anatomy (danger zones)
- Spinal cord: cervical enlargement C5–T1, most vulnerable at C2 (cord closest to bone)
- Vertebral artery: V2 segment in the foramen transversarium C6–C2, 15–20 mm lateral from the midline at the uncinate
- Cervical nerve roots: exit ABOVE the corresponding vertebra (the C5 root exits above the C5 pedicle), 3–5 mm from the lateral mass
- Facet joints: preserve greater than 50% of the articular surface bilaterally or instability results, requiring fusion
- Ligamentum flavum: hypertrophies in stenosis (3–5 mm vs 2–3 mm normal), often adherent to the dura needing sharp dissection
Critical steps (15 total)
- Positioning: Mayfield 3-pin (2 frontal, 1 occipital), neck neutral or slight flexion, shoulders taped for C7–T1 imaging
- Level confirmation: MANDATORY intraoperative fluoroscopy, count from C2 or C7, mark levels before any bone removal
- Subperiosteal dissection: midline through the avascular ligamentum nuchae, lateral to the facet joints (15–20 mm from the midline)
- Burr: thin the lamina to eggshell bilaterally; bluish discolouration signals adequate thinning; copious irrigation
- Kerrison laminectomy: 2–3 mm rongeur inferior to superior, footplate under the lamina, jaw opening away from the cord
- Ligamentum flavum: pituitary rongeur, complete removal essential, often adherent to the dura in stenosis
- Foraminotomy: undercut the medial facet with a 45° Kerrison, preserve greater than 50% of the facet, decompress the lateral recess and foramen
- Confirm: dural pulsations with respiration, nerve roots mobile and soft, no residual compression
Danger-zone protection
- Spinal cord: burr to eggshell before Kerrison, gentle technique, avoid retraction, confirm pulsations
- Vertebral artery: limit dissection to the medial border of the lateral mass, stay subperiosteal, avoid greater than 50% facet resection
- Nerve roots: gentle foraminotomy with a 45° Kerrison, visualise the root before manipulation, preserve greater than 50% of the facet
- Dura: remove the ligamentum flavum carefully (adherent in stenosis), sharp dissection if needed, primary repair if violated
- Epidural veins: meticulous haemostasis with bipolar at a low setting, topical agents, drain placement for significant bleeding
Technique pearls (high-yield)
- Facet preservation greater than 50% is CRITICAL — violation causes instability requiring fusion; mark the facet borders before decompression
- Burr is safer than a rongeur for the initial laminectomy — thin to eggshell, bluish discolouration, copious irrigation prevents thermal injury
- Dural pulsations confirm adequate decompression — their absence suggests incomplete decompression or an epidural haematoma
- C5 palsy 5–10% — deltoid and biceps weakness POD 1–3, mechanism unclear (cord shift, traction, reperfusion), about 80% recover spontaneously
- Wrong-level surgery is a NEVER EVENT — mandatory intraoperative imaging, count from C2 (prominent) or C7 (vertebra prominens)
Complications (memorise the rates)
- Post-laminectomy kyphosis 15–30% — prevent by preserving greater than 50% of the facets, avoiding a kyphotic spine, considering fusion if more than 3 levels
- C5 palsy 5–10% — deltoid and biceps weakness, transient, about 80% spontaneous recovery by 6 months, EMG at 3 weeks for prognosis
- Dural tear 3–5% — primary repair with 5-0 Prolene, fibrin glue, bed rest 24–48 h, acetazolamide if the leak persists
- Instability 10–20% if greater than 50% of the facet is resected — revision with instrumented fusion if symptomatic progressive deformity
- Epidural haematoma 1–2% — acute neurological deterioration, emergency re-exploration within 6–8 hours
- Deep infection 0.5–1% — debridement, IV antibiotics for 6 weeks, retain hardware if possible
- Cord injury 0.1–0.5% — catastrophic; gentle technique, avoid retraction, steroids controversial
Post-op protocol
- Immediate neurological exam: compare to the preop baseline, document motor and sensory function, assess for C5 palsy
- Drain: remove when output is less than 30 ml/24 h (typically POD 1–2), reducing the epidural haematoma risk
- Early mobilisation: soft collar for comfort only (not structural), mobilise once awake and neurologically intact
- Surveillance: flexion-extension radiographs at 6 weeks, 3 months and 1 year to detect kyphosis or instability
- Red flags: acute neurological deterioration (haematoma — emergency re-exploration), progressive kyphosis (revision fusion)
Exam tips (what the examiner expects)
- Laminectomy vs laminoplasty: laminoplasty preserves the posterior elements (less kyphosis), causes more neck pain, and is more technically demanding
- Fusion indications: pre-existing instability, greater than 50% facet resection, kyphotic alignment, more than 3 levels (controversial), revision surgery
- C5 palsy mechanism: a meta-analysis shows no anterior-versus-posterior difference, favouring cord reperfusion injury over the older cord-shift/tethering theory (Yoshihara 2018)
- Post-laminectomy kyphosis: up to 21–30% (highest with a preoperatively straight spine); needs anterior-posterior fusion if progressive and symptomatic (Kaptain 2000)
- Guidelines: AOSpine/AANS-CNS recommend decompression for moderate-to-severe DCM; surgery or supervised rehab for mild disease (Fehlings 2017)
- Evidence: 70–80% good neurological outcomes; the AOSpine North America cohort improved across all severities with an 18.7% complication rate; better results with earlier surgery and shorter symptom duration
Background & Evidence
Epidemiology and pathoanatomy. Degenerative cervical myelopathy is the most common cause of non-traumatic spinal cord dysfunction in adults, and OPLL is a well-recognised cause — more prevalent in East Asian populations. The pathological substrate is progressive cord compression from degenerative disc and osteophyte, ligamentum-flavum hypertrophy and OPLL, narrowing a canal that may already be congenitally small (less than 13 mm). The cervical cord enlarges at C5–T1 (about 13–14 mm in diameter), so even modest encroachment produces myelopathy at this level. Maintenance of lordosis is the dominant prognostic variable: the cord drifts posteriorly away from anterior compression only in lordosis; in kyphosis it remains draped over the vertebral bodies, which is why alignment governs approach selection.
Classic teaching attributed C5 palsy to posterior cord drift "tethering" the C5 root. A meta-analysis of 107 studies found NO difference in incidence between anterior and posterior decompression for myelopathy, but a higher rate in myelopathy than radiculopathy — favouring spinal-cord reperfusion injury over the tethering hypothesis (Yoshihara 2018).
Most C5 palsies are delayed (typically POD 1–7) rather than immediate. Posterior fusion with deformity correction carries the highest early-onset rate; isolated laminectomy or laminoplasty has a lower early-onset rate (Takenaka 2016). An immediate dense deficit should prompt urgent imaging to exclude a haematoma.
Key evidence and outcomes. Posterior decompression for cervical myelopathy yields significant, durable improvement in mJOA and Nurick scores; the AOSpine North America prospective cohort showed significant gains across all severity strata at one year (Fehlings 2013), with an overall treatment-related complication rate of 18.7 percent. Around 70–80 percent of patients achieve good-to-excellent neurological outcomes, and radiculopathy relief reaches 85–90 percent with adequate foraminotomy. Better outcomes correlate with shorter symptom duration and earlier surgery. Laminectomy versus laminoplasty. Matched and pooled cohorts show broadly similar neurological recovery. Laminoplasty preserves the posterior tension band and so carries a lower kyphosis rate (laminectomy-alone kyphosis up to 21–30 percent), but causes more axial neck pain and is limited by severe ossified ligamentum flavum or fixed kyphosis. C5 palsy is more frequent after laminectomy than laminoplasty in pooled data — laminectomy about 11 percent versus open-door laminoplasty about 4.5 percent (Gu 2014). Fusion versus no fusion. Add instrumented fusion for pre-existing instability, greater than 50 percent bilateral facet resection, kyphotic or straightened alignment, or extensive multilevel decompression. Posterior cervical fusion with decompression achieves a pooled fusion rate of about 98 percent with low revision (about 1 percent) and a pooled complication rate around 9 percent (Youssef 2019). Adjacent-segment disease and reoperation accrue over a decade, so reserve fusion for biomechanical indications rather than routine use when the facets are preserved and lordosis maintained. Global practice and guidelines. AOSpine/AANS-CNS guidance recommends surgical decompression for moderate and severe degenerative cervical myelopathy, and either surgery or supervised rehabilitation for mild disease (Fehlings 2017). Procedure selection — anterior versus posterior, laminectomy versus laminoplasty, with or without fusion — is driven by sagittal alignment, the number of levels and the compression vector rather than by region; named-society guidance (AOSpine, NASS, BASS/BOA, Japanese OPLL guidelines) converges on these principles.
References
Clinical Practice Guideline for the Management of Degenerative Cervical Myelopathy
- Recommends surgical decompression for moderate and severe degenerative cervical myelopathy
- For mild myelopathy: offer surgery or a supervised trial of structured rehabilitation, with surgery if neurological deterioration occurs
- Advises against prophylactic surgery for non-myelopathic cord compression without radiculopathy
Efficacy and Safety of Surgical Decompression in Cervical Spondylotic Myelopathy: AOSpine North America Prospective Multicentre Study
- 278 patients across 12 North American centres with symptomatic CSM and MRI cord compression
- Significant improvement in mJOA, Nurick grade, NDI and SF-36v2 at 1 year across all severity strata
- Overall treatment-related complication rate 18.7%
Incidence and Outcome of Kyphotic Deformity Following Laminectomy for Cervical Spondylotic Myelopathy
- Post-laminectomy kyphosis developed in 21% (9 of 42) of patients with preoperative straight or lordotic alignment
- Kyphosis in 30% (6 of 20) with a preoperatively straight spine versus 14% (3 of 22) with preoperative lordosis
- Preoperative straightening more than doubled the risk of postoperative kyphotic progression
Laminoplasty versus Laminectomy and Fusion for Multilevel Cervical Myelopathy: An Independent Matched Cohort Analysis
- 13 matched pairs treated for multilevel cervical myelopathy by laminoplasty or laminectomy with fusion
- Functional (Nurick) and subjective improvement trended greater in the laminoplasty cohort
- 14 complications in 9 laminectomy-with-fusion patients (including nonunion, kyphotic malalignment, deep infection) versus none in the laminoplasty cohort
Incidence of C5 Palsy: Meta-Analysis and Potential Etiology
- Pooled C5 palsy incidence approximately 7% for posterior and 4% for anterior decompression in myelopathy (107 studies)
- No significant difference between anterior and posterior approaches in myelopathy (argues against the cord-tethering hypothesis)
- Significantly higher incidence in myelopathy than radiculopathy, supporting spinal-cord reperfusion injury as a key mechanism
Incidence and Risk Factors of C5 Palsy Following Posterior Cervical Decompression: A Systematic Review
- Pooled C5 palsy incidence after posterior decompression 5.8% (95% CI 4.4–7.2%) across 25 studies
- Incidence by procedure: laminectomy 11.3% versus open-door laminoplasty 4.5% and double-door laminoplasty 3.1%
- Independent risk factors: OPLL, narrow intervertebral foramen, laminectomy, excessive cord drift and male sex
Outcomes of Posterior Cervical Fusion and Decompression: A Systematic Review and Meta-Analysis
- 1,238 patients across 31 studies of subaxial posterior cervical fusion with decompression
- Pooled fusion rate 98.25%, revision 1.09%, and complication/adverse-event rate 9.02%
- Common complications were axial pain, C5 palsy, transient neurological worsening and wound infection
Differences in the Time of Onset of Postoperative Upper Limb Palsy Among Surgical Procedures: A Meta-Analysis
- Meta-analysis showing that the onset timing of postoperative C5 palsy differs by surgical procedure
- Posterior fusion with deformity correction carries the highest early-onset rate
- Isolated laminectomy and laminoplasty carry a lower early-onset palsy rate
C5 Palsy Following Anterior Decompression and Spinal Fusion for Cervical Degenerative Diseases
- Reported C5 palsy occurring after anterior cervical decompression and spinal fusion
- Demonstrated that C5 palsy is not confined to posterior approaches
- Informs the reperfusion-versus-tethering debate around C5 palsy mechanism
Neurological Complications of Cervical Spine Surgery: C5 Palsy and Intraoperative Monitoring
- Review of the neurological complications of cervical spine surgery focused on C5 palsy
- Discusses intraoperative neuromonitoring as a tool to limit nerve injury
- Contextualises C5 palsy within the broader profile of cervical surgery complications
Clinical Course of Patients with Ossification of the Posterior Longitudinal Ligament: A Minimum 10-Year Cohort Study
- Minimum 10-year cohort study defining the long-term clinical course of OPLL
- Characterised the natural history that informs the timing of decompression
- Supports posterior decompression in OPLL with preserved lordosis