Spine surgeons have two basic approach options when performing surgery on patients with degenerative cervical myelopathy—anterior or posterior. Each approach has advantages and disadvantages, and numerous studies have attempted to elucidate which approach might be better for specific clinical situations.
In the June 21, 2017 edition of The Journal of Bone & Joint Surgery, Kato et al. add to the evidence base regarding this question. They report on results from an analysis comparing the two approaches in 80 pairs of “propensity-matched” patients who had multilevel compression myelopathy. Propensity matching allowed the authors to adjust for multiple baseline factors and MRI characteristics, thus minimizing the risk of selection bias.
After the propensity-matched analysis, there were no two-year between-group differences in mJOA score, Neck Disability Index, or SF-36 Physical Component score. The overall rates of perioperative complications were similar between the two groups, although dysphagia and dysphonia were reported only in the anterior group, while surgical site infection and C5 radiculopathy were reported only in the posterior group.
The authors claim that propensity matching helps to “reflect the ‘real-world’ clinical setting and likely has greater generalizability than a smaller, narrowly randomized controlled trial,” but they ultimately conclude that the surgical approach in such cases “should be carefully chosen by evaluating risk profiles in a shared decision-making process on a case-by-case basis.”
The May 17, 2017 edition of The Journal of Bone & Joint Surgery features a registry-based study by Mjaaland et al. comparing implant-survival/revision outcomes in total hip arthroplasty (THA) among four different surgical approaches:
- Minimally Invasive (MI) Anterior (n=2017)
- MI Anterolateral (n=2087)
- Conventional Posterior (n=5961)
- Conventional Direct Lateral (n=11,795)
Although the authors analyzed a whopping 21,860 THAs from 2008 to 2013, the findings are limited by the fact that all of those procedures used an uncemented stem.
Overall, the revision rates and risk of revision with the MI approaches were similar to those of the conventional approaches. There was a higher risk of revision due to infection in THAs that used the direct lateral approach than in THAs using the other three approaches. “To our knowledge,” the authors write, “this finding has not been previously described in the literature, and we do not have an explanation for it.” The authors also found a reduced risk of revision due to dislocation in THAs that used the MI anterior, MI anterolateral, and direct lateral approaches, relative to those using the posterior approach.
While the authors found all-cause risk of revision to be similar among all four approaches, they note that the follow-up in the study was relatively short (mean of 4.3 years) and that “additional studies are needed to determine whether there are long-term differences in implant survival.”