Degeneration of the cervical spine is part of the natural process of aging, with 30% of the population showing degeneration in the 4th decade and 90% by the 7th decade. The most common cause of spinal cord dysfunction in the elderly population is cervical myelopathy (CM), surgery is the primary treatment reporting excellent outcomes in the general population, but there are scarce publications to review the outcomes in the Mexican and Latin-American elderly population [1] [2].

In 1972, Nurick described a six-grade system based on the “difficulty in walking” and postulated that the established disability in CM occurs early in the disease and barely progresses [3].

The optimal management strategy for CM secondary to a cervical degenerative spine disease (CDSD) remains controversial because of the natural history of the disease and the degree of neurological progression [4].

Elderly patients with CM often present with a multilevel disease, the literature considers the treatment with laminoplasty rather than anterior fusion in case of failure of the conservative therapy [5]. This is the first research that describes and compares the outcomes between the Anterior Approach (AA) and Posterior Approach (PA) to treat CM in the elderly in the Mexican population [6].

· Anterior Approach (Figure 1)

AA is the most anatomical technique with minimal collateral soft tissue damage, the indications are clear in spinal pathology between C3 and T1 with the affection in the anterior components of the spine (disk herniation, vertebral osteophytes).

The technique requires a supine position with a slight hyperextension of the head and exposition of the cervical region. The incision is paramedian and can be transverse, oblique, or longitudinal; followed by dissection of subcutaneous tissue and cervical fascia to expose the vertebral bodies. If it is necessary, the surgeon can realize the discectomy and medullary decompression [7].

· Posterior Approach (Figure 2)

This technique is for multisegmental (2 or more) spine levels with degenerative changes and ossification of the posterior longitudinal ligament (OPLL).

The surgical position of the patient is prone, using a Mayfield head clamp or a horseshoe headrest and a slight flex of the cervical spine. This procedure requires a midline incision, dissection, and a detachment of the muscles from the respective spinous process, taking care of lateral dissection because of the trajectory of the vertebral artery.

Posterior to the exposure of vertebral laminae, the following step is to dissect the interlaminar ligament and the laminoplasty or laminectomy to decompress the cervical canal.

The contraindications for this approach are in cases of instability and with diseases of the anterior structures [7].

A retrospective search of electronic health records at the Hospital Central Sur de Alta Especialidad, PEMEX (HCSAE), from January 2010 to May 2020. We selected the cases using the code M500—Myelopathy secondary to the degenerative process of an intervertebral disk from the International Classification of Diseases (ICD-10). For this study, the inclusion criteria were:

· Subjects older than 60 years.

· Myelopathy secondary to degenerative disease.

· Follow-up at 1 year.

· Subjects submitted to surgical treatment previously accepted consents.

We excluded patients with myelopathy secondary to different etiology than degenerative, for example traumatic, infectious, tumors, etc. Also, we removed patients with an incomplete follow-up at 1 year, and those who followed conservative management.

Demographic data were reported as median, range, frequency, and prevalence. We elaborated 2 groups according to the surgical approach: AA vs PA; and analyzed the trans-operative behavior, the immediate outcome, and after 3 months (P3m), 6 months (P6m), and 1 year (P1y) with the following variables:

· Complications: Defined as all the trans-operative and postoperative undesirable events that impact directly in patient evolution and they could be classified by type: neurological (CSF fistulae, laryngeal nerve lesion, nerve roots lesion), systemic (infection, esophageal lesion, hypertension, arrhythmias), related to anesthesia (delirium).

· Neck Disability Index (NDI)—The NDI is an international classification for disability related to CM. This scale has 10 items, seven related to activities of daily living, two related to pain, and one item related to concentration. Each item is scored from 0 to 5 and the total is expressed as a percentage. Higher scores correspond to greater disability [8].

· Nurick Scale: Table 1 describes the clinical criteria of the Nurick scale. This scale grades myelopathy and patients’ performance. For the analysis, we dichotomized the results in <3 or ≥3 according to the severity of myelopathy [3].

· Sensitivity: The term “affected” refers to symptoms during the evolution and follow-up in the patients, characterized by dysesthesia, hypoesthesia, altered proprioception, agraphaesthesia, and absence of two-point discrimination.

· Strength: The International scale of Daniels (see Table 1) describes the grade of affection at muscular strength. For this study, we took dichotomized the results as severe results <3 and mild ≥3 [7].

For the analysis between groups, we performed a Mann-Whitney U test for quantitative variables, and a chi-square test for categorical. The analysis of the results in each approach was realized with Friedman Test for quantitative parameters and Cochran’s test for categorical values.

Calculations were conducted using IBM SPSS 27.0 statistical analysis software, with the significance threshold set at P < 0.05.

The study design conformed to the Declaration of Helsinki and local regulations; patients signed their informed consent for admission and surgery and for reporting their results and data.

We found 145 patients with the inclusion criteria, representing a prevalence of 63.8% of the cases with cervical myelopathy in the HCSAE. Table 2 presents the demographic and general characteristics of our sample. The age of presentation was 69 (64 - 75) years, and masculine was the most prevalent gender.

Laterality of the symptoms with more prevalence was bilateral, presented in 60.7% of our sample. The median number of affected levels was 2 (1 - 3), being C5C6 the most prevalent (40%) followed by C4C5 (36.8%) and C3C4 (21.6%).

For the first treatment, 92.4% of the patients started with conservative treatment like physical therapy and non-steroid anti-inflammatory drugs (NSAIDs) without a significant remission of symptoms; becoming candidates for surgical management.

The comorbidities with major frequency were systemic blood hypertension (51%), Diabetes mellitus type 2 (29%) and urologic diseases (10.3%). Other comorbidities (psychiatric diseases, cardiopathies, nephropathies, neuropathies, cancer, rheumatoid arthritis, osteoporosis, hematologic disorders, and gastropathy) presented a prevalence of less than 5% per each one.

CM is one of the most common diseases in the elderly population, including almost 90% of patients in the seventh decade of life; it is more often in the male population (1.12:1, M:F). The symptoms are sensitive alterations, weakness, urine incontinence, and in the most severe cases, quadriplegia secondary to the stenosis of the spinal canal [9]. Our population has similar demographic aspects to those reported in the current literature.

The pathological changes in the spine during the elderly are a combination of disk herniations that occur because of dysfunction, instability, and spinal stenosis. These changes occur because of the late instability and early stabilization secondary to bony overgrowth, leading to disturbing with more frequency C6C7 (60%), followed by C5C6 (40%) and C4C5 (5%) [10]. In our series, the most affected levels were C4C5 and C5C6; C3C4 occupied third place, derived from the changes in motion at this level [6].

Conservative treatment includes physical therapies, including intermittent cervical traction, heat therapy, and medications; these therapies may offer symptomatic relief with NSAIDs, steroids, and/or muscle relaxants for neck pain or paresthesias. The recommendation is to start the conservative treatment in patients with mild CDSD [18]. The proportion of patients who converted to surgery after failed nonoperative care ranged from 4% to 40% during 3 of 7 years [5].

International literature recommends realizing AA to treat multilevel CM in the elderly when involved in less than 3 surgical segments. PA may be the elective method for treatment multilevel (≥3) [15].

Adequate surgical decompression is necessary to get a favorable long-term outcome, however, is important to recognize the previous functional limitations related to comorbidities.

Appropriate perioperative management is crucial to get a satisfactory result. The selection of the approach should accord to the surgeon’s abilities, the patient’s characteristics, and the anesthetic support. The postsurgical management should include excellent rehabilitation, pain management, and psychological support.

Unlike the international literature reports predictors like comorbidities, age, duration, and severity of symptoms; we could determine that in this series all the patients submitted to surgical medullary decompression presented a favorable outcome despite the age and the higher prevalence of comorbidities in the Mexican population; whereby we favor the surgical treatment in all patients in a case-to-case selection to generate a positive impact on functional outcomes.

The major limitation of this study is that the analysis was carried out retrospectively, limiting the selection of the approach to criteria and treatment of different surgeons. With this article, we want to encourage the scientific community to carry out future projects, eliminating these limitations.

The authors declare no conflicts of interest regarding the publication of this paper.

Sánchez-Calderón, M.D., Córdoba-Mosqueda, M.E., Aguilar- Calderón, J.R., Domínguez-Herz, C.R., Ochoa- Cacique, D., Vega-Moreno, D.A., Reyes- Rodriguez, V.A., García-González, U., Ibarra- de la Torre, A. and Hernández-Reséndiz, R.E. (2021) Paper Title. Open Journal of Orthopedics, 11, 207-219. https://doi.org/10.4236/ojo.2021.117020