Cervical Spondylosis: Treatment (Non-Operative & Operative) with Surgical Approaches

Overview of Treatment Strategy

1. Failure of nonoperative pain management
2. Increasing or significant neurological deficit
3. Cervical myelopathy (which predictably progresses based on natural history studies)

• Campbell's Operative Orthopaedics 15th Ed 2026, p. 2294

Part I: Non-Operative Treatment

1. Rest & Activity Modification

• Short periods of rest, massage, ice, and anti-inflammatory agents (glucocorticoids or NSAIDs)
• Active mobilization as soon as possible
• Comfortable positioning of the neck is essential for pain relief
• Patients with spondylosis (hard disc) are most comfortable with neck in flexion
• Patients with hyperflexion injuries prefer the neck extended with a small roll under the neck

2. Pharmacotherapy

• NSAIDs - first-line for axial neck pain and radiculopathy
• Oral corticosteroids - short course for acute flares with radicular symptoms
• Neuropathic agents - gabapentin, pregabalin for radicular pain
• Miller's Review of Orthopaedics 9th Ed, p. 761: NSAIDs, cervical epidural injections, isometric exercises, traction, and occasionally temporary collar immobilization for cervical myelopathy

3. Cervical Traction

• Helpful in selected patients; traction applied to the head in the position of maximal pain relief
• Caution: Traction should never be continued if it increases pain
• Weights rarely exceed 10 pounds (weight of the head)
• Proper head halter and duration of traction sessions necessary to prevent temporomandibular joint irritation

• Uses the weight of the unsupported head (≤10 lbs)
• For extension traction: patient placed supine and head allowed to extend gently off examining table
• For flexion traction: same procedure in prone position
• Exercise in the most comfortable position performed several times daily for 5-10 minutes

4. Cervical Braces / Orthoses

• Limit excessive motion; useful in very active patients
• A soft collar to restrict anteroposterior motions is reasonable and may reduce neck and arm discomfort
• Use of an orthosis should be limited (except in trauma) to prevent muscle atrophy
• Adams and Victor's Principles of Neurology 12th Ed, p. 914: The soft collar has been used as standard conservative management, though many patients are unable to wear it for prolonged periods

5. Posture Correction & Ergonomics

• More frequent changes in position
• Ergonomic changes in the work area to prevent fatigue and encourage good posture
• Techniques to minimize or relieve tension

6. Physical Therapy & Exercises

• Neck and shoulder exercises most beneficial as acute pain subsides
• Isometric exercises are helpful in the acute phase
• If concomitant shoulder problems exist (e.g., adhesive capsulitis), complete immobilization of the painful extremity should be avoided
• Bradley and Daroff's Neurology in Clinical Practice: No significant difference between outcomes of surgical vs. conservative management (physical therapy or hard cervical collar immobilization) for uncomplicated radiculopathy in some studies

7. Cervical Epidural Steroid Injections (CESI)

• Indicated for radiculopathy refractory to medications and PT
• Provides short- to medium-term relief of radicular pain
• Performed under fluoroscopic guidance
• Miller's Review of Orthopaedics 9th Ed: listed among standard non-surgical treatment options

Patient Education

• Emphasizing the self-limiting nature of symptoms is important for axial neck pain
• For discogenic neck pain (axial only, no neurological signs): surgical options are limited and should be avoided

Part II: Operative Treatment

Surgical Indications

Surgical Approach Decision Algorithm

Radiological appearance of cord compression requiring surgery

Operative Approaches

A. ANTERIOR APPROACHES

1. Anterior Cervical Discectomy and Fusion (ACDF) - Smith-Robinson Approach

• 1-2 levels of compression (soft central or lateral hard disc)
• Kyphotic or lordotic alignment (versatile)
• Radiculopathy from hard disc / discoosteophytic spur
• Myelopathy from 1-3 levels

• Transverse (single level) or oblique skin incision along the anterior border of the SCM
• Medial retraction of the carotid sheath, lateral retraction of the trachea/esophagus
• Smith-Robinson interval used to reach the anterior vertebral bodies and discs
• Fluoroscopic confirmation of level
• Discectomy with or without posterior osteophyte removal
• Interbody fusion with autograft (iliac crest), allograft, or titanium/PEEK cage + anterior plate

2. Anterior Cervical Corpectomy and Fusion (ACCF)

• Multilevel disc disease with retrovertebral spondylotic bars
• OPLL extending behind the vertebral body
• Preferred when osteophytes are predominantly posterior to the vertebral body

• Same anterior Smith-Robinson approach
• Corpectomy (removal of vertebral body) performed with Kerrison rongeurs and high-speed drill
• Strut graft (fibular allograft or titanium mesh cage) placed in corpectomy defect
• Anterior plate fixation spanning the construct

3. Anterior Cervical Disc Replacement (ACDR / Total Disc Replacement)

• Single-level radiculopathy in a patient with preserved disc height and lordotic or neutral alignment
• Alternative to ACDF when adjacent segment disease is a concern

• Preserves motion at the operated level
• Lower rates of adjacent segment disease
• No need for bone graft or external orthosis

B. POSTERIOR APPROACHES

4. Posterior Cervical Foraminotomy (Keyhole Laminoforaminotomy)

• Radiculopathy secondary to posterior compression (facet hypertrophy) or lateral soft disc herniation
• Persistent/recurrent nerve root symptoms after ACDF
• Patients in whom anterior approaches are contraindicated (tracheostomy, prior irradiation, neck infection, previous radical neck surgery)
• Contraindication: Central disc herniation (cannot safely access from posterior), cervical kyphosis, gross instability

1. Patient prone in Mayfield positioner, neck flexed to decrease cervical lordosis
2. Midline incision ~2 cm, centered on spinous process tip of cephalad level
3. Divide ligamentum nuchae longitudinally to expose spinous processes above and below
4. Subperiosteal dissection of paravertebral muscles on the side of the lesion

1. With a small high-speed burr, drill away the caudal edge of the lateral portion of the lamina (the "keyhole"). Only a small amount of the medial facet needs removal.
2. Sharply excise the ligamentum flavum with a 1-2 mm Kerrison rongeur

1. Identify nerve root (commonly displaced posteriorly by disc fragments)
2. Use operative microscope for remainder of procedure
3. Gently retract nerve root superiorly (never caudally - risk of injury)
4. Incise PLL in cruciate manner over herniated nucleus pulposus; remove disc fragments
5. Confirm thorough decompression by probing the intervertebral foramen

5. Minimally Invasive Posterior Cervical Foraminotomy (Technique 45.5)

• Patient in semi-sitting position (Mayfield three-point fixation, head flexed perpendicular to floor)
• 18 mm longitudinal incision ~1.5 cm off midline
• Kirschner wire docked at inferomedial edge of the rostral lateral mass under fluoroscopy
• Sequential tubular dilators advanced; 16-mm working channel tubular retractor placed
• Same keyhole bone removal and disc/fragment removal under endoscope

• Significantly greater improvement in VAS pain scores
• Improved postoperative cervical lordosis
• Better quality of life
• Similar complication and reoperation rates to ACDF

6. Posterior Laminectomy ± Fusion (PCF)

• Multilevel (3+) spondylotic myelopathy with neutral or lordotic alignment
• When posterior decompression across multiple levels is required

• Midline posterior incision, subperiosteal dissection bilaterally
• Spinous processes removed with rongeur
• Laminectomy performed with Kerrison rongeur and high-speed drill at each level
• Severance of dentate ligaments helps prevent further cord injury
• Fusion (posterior instrumentation with lateral mass screws and rods) added to prevent postlaminectomy kyphosis
• Adams and Victor's, p. 918: In fully two-thirds of patients, improvement in leg function occurs; in most others, progression of myelopathy is halted. Risk of acute quadriplegia (rare) from cord manipulation.

7. Laminoplasty (Open-Door or French Door)

• Multilevel (3+) cervical spondylotic myelopathy
• Preferred over laminectomy alone when alignment is neutral/lordotic
• Contraindicated in patients with fixed cervical kyphosis

• Open-door (Hirabayashi): Hinge created on one side, "door" opened on the other, maintained with sutures, bone graft, or plate/spacer
• French-door (Kurokawa): Midline split of spinous processes, bilateral hinges opened symmetrically

• Preserves posterior tension band
• Reduces risk of postlaminectomy kyphosis
• Allows re-operation if needed

8. Combined Anterior + Posterior (Circumferential Surgery)

• Multilevel kyphosis (3+ levels) requiring corpectomy with strut reconstruction
• Highly unstable cervical spine requiring 360° fixation
• Patients requiring multilevel corpectomy who need additional posterior stabilization

Postoperative Complications to Know

Summary Table

All Spinal Surgical Approaches - Step by Step with Images

Anatomical Landmarks for All Spinal Approaches

Relation of Spinal Nerve Roots to Vertebrae

Master Reference Table: Spinal Approaches

CERVICAL SPINE APPROACHES

APPROACH 1: Anterior Cervical Approach (Smith-Robinson)

Cross-Sectional Anatomy at C4

Step-by-Step Technique

• Supine with a small roll under the shoulders to extend the neck
• Head slightly turned to the contralateral side (usually right-sided approach to protect the recurrent laryngeal nerve)

• Transverse skin incision based on desired level, in a natural skin crease
• Level landmarks: hyoid = C3, thyroid cartilage = C4-5, cricoid ring = C6
• For C5: enter the carotid triangle

• Retract the platysma with the skin (subplatysmal flaps superiorly and inferiorly)

• Expose the pretracheal fascia
• Develop the interval between:
  • Laterally: carotid sheath (containing internal/common carotid artery, internal jugular vein, vagus nerve CN X)
  • Medially: trachea and esophagus
• Use blunt finger dissection to develop this plane

• Incise the prevertebral fascia sharply
• Retract the longus colli muscle gently laterally (protecting the recurrent laryngeal nerve which lies just outside the sheath)
• Anterior surface of the vertebral body is now exposed

• Fluoroscopic confirmation of correct level with a spinal needle

• Caspar retractor pins placed into adjacent vertebral bodies
• Discectomy with rongeur, curettes, high-speed drill
• Posterior osteophytes removed with angled curettes/Kerrison rongeurs
• Posterior longitudinal ligament removed if indicated

• Autograft (iliac crest), allograft, or PEEK/titanium cage placed
• Anterior cervical plate applied across construct

• Right-sided approach: Recurrent laryngeal nerve (RLN) injury (hoarse voice, unilateral vocal cord palsy). RLN arises from vagus at subclavian artery level on right (shorter course, more vulnerable)
• Left-sided approach (lower): Thoracic duct injury (posterior to carotid sheath)
• Horner syndrome: stellate ganglion at C7-T1, protected by subperiosteal dissection of longus muscles
• Postoperative: upper airway edema, hematoma, vocal cord paralysis

APPROACH 2: Posterior Cervical Approach

Step-by-Step Technique

• Prone in Mayfield three-pin head fixation
• Neck flexed to decrease cervical lordosis and open interlaminar spaces
• Reverse Trendelenburg position reduces venous bleeding
• Shoulders retracted inferiorly with tape (for lower cervical levels)

• Midline longitudinal incision
• Centered on the spinous process(es) of interest
• For single-level foraminotomy: ~2 cm incision centered on spinous process tip of cephalad level

• Divide the ligamentum nuchae longitudinally in the midline (avascular midline raphe)
• Expose tips of spinous processes above and below designated area

• Reflect the superficial layer (trapezius) and intermediate layer (splenius cervicis, semispinalis, longissimus capitis) laterally using subperiosteal dissection
• Use a self-retaining retractor to maintain exposure of the laminae

• Palpate the last bifid spinous process (usually C6)
• Fluoroscopic confirmation with a marker on the spinous process

• Access to the spinal canal through laminectomy or facetectomy
• For foraminotomy: high-speed burr removes caudal edge of lateral lamina ("keyhole")
• Ligamentum flavum excised with small Kerrison rongeur

• Nerve root identified (displaced posteriorly by disc/osteophyte)
• Root retracted superiorly (never caudally)
• Disc fragments/osteophytes removed under microscope

• Vertebral artery: especially vulnerable where it leaves the foramen transversarium and travels superiorly/medially to pierce the atlantooccipital membrane
• Greater occipital nerve (C2) and third occipital nerve (C3) in the suboccipital region
• C5 palsy: most common postoperative complication, particularly with laminoplasty (due to tethering and "drift" of cord after posterior decompression)

Minimally Invasive Posterior Cervical Foraminotomy (Tubular Retractor System)

1. Semi-sitting position: Mayfield three-point fixation; neck flexed, long axis of cervical spine perpendicular to floor
2. Fold arms across lap; pad all pressure points
3. Confirm operative level on lateral fluoroscopy
4. Mark 18 mm longitudinal incision ~1.5 cm off midline on operative side; inject local anesthetic
5. Through stab incision, advance K-wire under fluoroscopy; dock at inferomedial edge of rostral lateral mass
6. Advance sequential tubular dilators (16 mm working channel)
7. Dock tubular retractor; attach to table-mounted arm
8. Confirm position with fluoroscopy
9. Use angled curette to detach ligamentum flavum from undersurface of inferior laminar edge
10. Kerrison punch begins laminotomy; high-speed drill if significant facet hypertrophy
11. After laminotomy, remove ligamentum flavum medially to identify lateral dural edge and nerve root
12. Bony resection follows the nerve root into the foramen (partial medial facetectomy; preserve ≥50% of facet for stability)
13. Coagulate and incise venous plexus overlying nerve root
14. Fine angled dissector palpates space ventral to nerve root for osteophytes/fragments
15. Osteophyte: down-angled curette tamps material into disc space. Soft disc: nerve hook teases fragment; pituitary rongeur removes it
16. Final inspection of foramen; irrigation; hemostasis
17. Remove tube; inject local anesthetic into surrounding fascia/muscles
18. Close: absorbable fascia stitch, inverted subcutaneous stitches, running subcuticular + skin adhesive
19. Postop: Patient mobilized immediately; no collar required; discharge after 2-3 hours

THORACIC SPINE APPROACHES

APPROACH 3: Anterior Transthoracic Approach (Thoracotomy)

Step-by-Step Technique

• Lateral decubitus (right side preferred to avoid aorta, segmental arteries, artery of Adamkiewicz, and thoracic duct)
• Double-lumen endotracheal tube for single-lung ventilation (deflate ipsilateral lung for exposure)

• Transverse incision made approximately two ribs above the level of interest
• Example: T8 disc = incision at T6 rib

• Dissect over the top of the selected rib to avoid the intercostal neurovascular bundle (which lies on the inferior internal surface of the rib: vein, artery, nerve from top to bottom)
• Subperiosteal dissection of the rib

• Detach rib from costochondral junction anteriorly and at rib head posteriorly
• Remove rib from the surgical field (may serve as bone graft)

• Enter the thoracic cavity through the periosteum/pleura
• Deflate the ipsilateral lung
• Place self-retaining rib spreader

• Incise parietal pleura longitudinally over the target vertebra
• Ligate segmental vessels at the midpoint of the vertebral body (avoid artery of Adamkiewicz, typically T9-L1 on left)

• Expose disc/vertebral body anterolaterally
• Perform discectomy, corpectomy, or stabilization as planned

• Intercostal neuralgia (most common complication)
• Injury to the artery of Adamkiewicz (anterior spinal artery supply, mainly T9-L1 left side) → anterior spinal artery syndrome
• Aortic injury (left-sided approaches)
• Chylothorax from thoracic duct injury
• Pneumothorax requiring chest drain postoperatively

APPROACH 4: Costotransversectomy (Posterolateral Thoracic)

Step-by-Step Technique

• Paramedian or hockey-stick incision ipsilateral to pathology

• Subperiosteal dissection of paravertebral muscles from spinous processes and laminae
• Expose transverse process and posterior rib head at target level

• Resect ~6-8 cm of the posterior rib including the rib head (costotransversectomy)
• Remove the transverse process

• Work around the lateral wall of the vertebral body and disc through this posterolateral corridor
• Limited access compared to full thoracotomy but avoids thoracic cavity

• Removal of disc herniation, abscess, or tumor through this channel
• Packing of defect / stabilization as needed

• Sacrifice of one thoracic nerve root often required for adequate exposure
• Intercostal neuralgia
• Limited anterior visualization compared to thoracotomy

LUMBAR SPINE APPROACHES

APPROACH 5: Posterior Lumbar Approach (Standard Open / Midline)

Lumbar Nerve Root Anatomy

Step-by-Step Technique

• Prone with abdomen hanging free (reduces epidural venous pressure and bleeding - Andrew's frame, Wilson frame, or Relton-Hall frame)
• Hips extended if fusion is planned (prevents positional kyphosis)

• Straight midline incision over the spinous processes
• Length depends on number of levels
• Carried down through thoracolumbar fascia to spinous processes

• Count from sacrum superiorly (S1 = first non-bifid spinous process)
• Fluoroscopic confirmation with marker at spinous process level

• Incise the supraspinous and interspinous ligaments
• Subperiosteal dissection of the paravertebral muscles (erector spinae) off the spinous processes and laminae bilaterally
• Self-retaining retractors placed; expose laminae and facet joints

• Laminotomy (fenestration): Partial removal of one or both laminae using Kerrison rongeurs; preserves midline structures
• Laminectomy: Complete removal of spinous process and bilateral laminae; wide decompression
• Ligamentum flavum excised to enter the epidural space

• Identify thecal sac and nerve root at disc level
• Traversing root runs medially (at risk with posterolateral disc herniation)
• Exiting root runs laterally in foramen (at risk with foraminal/extraforaminal herniation)

• Gently retract nerve root medially with a nerve root retractor
• Do not retract caudally
• Incise posterior annulus fibrosus
• Remove disc fragments with pituitary rongeur and curettes

• Thorough irrigation; bipolar haemostasis; Gelfoam/thrombin for epidural veins
• Layered closure: thoracolumbar fascia, subcutaneous tissue, skin
• Drain optional

Spinal Stenosis - Algorithm for Surgical Approach

• Dural tear (CSF leak, pseudomeningocele)
• Nerve root injury / retraction neuropraxia
• Epidural hematoma
• Cauda equina syndrome if bilateral retraction or missed fragment
• Posterior primary rami injury (muscle denervation) → chronic paraspinal atrophy
• Segmental vessel injury

APPROACH 6: Anterior Lumbar Approach (Transperitoneal / ALIF)

Step-by-Step Technique

• Longitudinal midline incision from just below the umbilicus to just above the pubic symphysis
• Or: transverse Pfannenstiel incision (lower, cosmetically preferred for L5-S1 only)

• Split the rectus abdominis muscles in the midline (linea alba)
• Incise the posterior rectus sheath / peritoneum

• Protect and retract the bladder distally
• Retract the bowel cephalad with moist laparotomy pads

• Incise the posterior peritoneum longitudinally over the sacral promontory

• The aortic bifurcation is revealed (typically at L4 vertebral body)
• Ligate the middle sacral artery (runs in the midline over L5-S1)
• The L5-S1 disc space lies below the bifurcation and is directly accessible
• For L4-5: mobilize the aorta and inferior vena cava to the left

• Remove L5-S1 or L4-5 disc
• Place large interbody cage (PEEK or titanium) packed with bone graft
• Supplementary posterior pedicle screw fixation often added

• Presacral sympathetic plexus (superior hypogastric plexus) lies over the L5 vertebral body: injury causes retrograde ejaculation (sympathetic), NOT erection (parasympathetic)
• Vascular injury to aorta, IVC, iliac vessels
• Ureter injury
• Ileus / bowel obstruction

APPROACH 7: Anterolateral Lumbar Approach (Retroperitoneal / XLIF/LLIF)

Step-by-Step Technique

• Oblique incision centered over the 12th rib to the lateral border of the rectus abdominis muscle

• Incise in sequence:
  1. External oblique
  2. Internal oblique
  3. Transversus abdominis
• All incised in line with the skin incision

• Develop the retroperitoneal fat plane by blunt dissection
• The retroperitoneal space is entered anterior to the transversus abdominis
• Reveals the psoas major muscle and genitofemoral nerve on its anterior surface

• Ligate segmental lumbar vessels (running transversely at the midpoint of each vertebral body)
• Mobilize the aorta (left) and vena cava (right) to expose the desired vertebral level
• Great vessels typically bifurcate at L4-5: requires larger dissection area; L5-S1 lies below bifurcation

• Split psoas muscle using sequential tubular dilators under neuromonitoring (EMG)
• Tubular retractor docked at lateral disc space
• Discectomy and interbody cage placement through lateral corridor

• Sympathetic chain (medial to psoas, lateral to vertebral body): injury causes vasodilation, warmth, and dry foot
• Ureters (between peritoneum and psoas fascia): injury causes urinoma
• Genitofemoral nerve (on psoas): injury causes groin/medial thigh numbness and dysesthesia
• Lumbar plexus injury during psoas splitting (particularly L4 root)

Summary: Approach Selection by Region and Pathology