Spinemathema podcast · Episode 11 · About 8 minutes · October 2026

Episodes are narrated using an AI model of Mr Sadek’s own voice, from scripts he has written and approved.

Read the full article with references: Front or Back Neck Surgery for Cervical Myelopathy? The CSM-S Trial

Transcript

Hello and welcome to the Spinemathema podcast. I’m Ahmed Sadek, a neurosurgeon, and in this episode I’m looking at a landmark trial for people with pressure on the spinal cord in the neck. It’s called the C S M S trial, and it asked whether surgery from the front of the neck works better than surgery from the back.

First, the condition. Cervical spondylotic myelopathy is pressure on the spinal cord in the neck, caused by age related wear and tear. The authors of this trial describe it as the most common cause of spinal cord problems worldwide. It usually creeps up gradually. People notice clumsy hands, unsteady walking, and sometimes problems with the bladder. When the symptoms are severe or getting worse, surgery to take the pressure off the cord is often recommended.

There are two broad ways to do that. From the front of the neck, the surgeon usually removes the worn discs that are pressing on the cord and fuses the bones together with a plate. From the back of the neck, there are two main choices. One is a laminectomy with fusion, where the bony roof of the spinal canal is removed and the bones are fixed with screws and rods. The other is a laminoplasty, where the roof is opened on one side and hinged on the other, a bit like a door, and held open with small plates to give the cord more room.

Before this trial, there was no randomised trial comparing front and back surgery, and practice varies around the world. The authors note that laminoplasty is common in Asia and Europe, whereas fusion operations are favoured in North America.

So how did the trial work? It ran at fourteen hospitals in the United States and one in Canada, between twenty fourteen and twenty eighteen, with the final follow up in twenty twenty. It included people aged forty five to eighty, with at least two signs or symptoms of myelopathy, and pressure on the cord at two or more levels of the neck.

Some people were excluded. That included people whose neck curved forward beyond set limits, people with a ligament behind the spine that had turned to bone, people who’d had neck surgery before, and people with serious other illnesses. A panel of fifteen expert surgeons also reviewed every case, to confirm that either approach would be reasonable before the patient was randomised.

Four hundred and fifty eight people were screened, and one hundred and sixty three were randomly allocated. Sixty three were assigned to front surgery and one hundred to back surgery. More people went into the back group on purpose, because within that group the surgeon could choose between laminectomy with fusion and laminoplasty. In the end, sixty six people had a front fusion, sixty nine had a back fusion and twenty eight had a laminoplasty. The average age was sixty two, and about half were women.

The main measure was a questionnaire called the Short Form thirty six. The researchers used the part of it that scores physical function, and looked at how much it changed after one year. An improvement of five points or more is considered meaningful. The questionnaires were collected by study coordinators who didn’t know which operation the patient had been assigned.

So what did they find? Both approaches helped. At one year, physical function improved by five point nine points after front surgery, and six point two points after back surgery. That difference wasn’t statistically significant. At two years, the improvements were five point two and six point zero. Six of the seven other planned measures showed no significant difference either. And of the people who were working before surgery, about seventy one per cent were back at work by a year, with no real difference between the groups.

Where the groups did differ was complications. Complications happened in forty eight per cent of people after front surgery, compared with twenty four per cent after back surgery. Much of that was difficulty swallowing. That was reported by forty one per cent after front surgery and by nobody after back surgery. Most of the complications after front surgery were minor and settled within three months, although in nine people who had a front fusion, the swallowing difficulty lasted longer.

Back surgery had its own downsides. New neurological problems were more common after back surgery, nine per cent compared with two per cent, and so were readmissions to hospital within thirty days, seven per cent compared with none. Every case of new weakness from a nerve root after surgery involved the C five nerve root, and most of these followed back fusion. Repeat operations were needed in six per cent after front surgery and four per cent after back surgery, and major complications overall weren’t significantly different.

There’s one more finding that caught a lot of attention. Because surgeons chose between the two back operations, the researchers also compared all three operations as they were actually done. In that comparison, laminoplasty was linked with the biggest improvement in physical function at one year, about nine and a half points, and with the fewest complications, about eleven per cent. But, and this matters, that comparison wasn’t randomised. The authors themselves say it should be interpreted with caution, because people chosen for laminoplasty may have had slightly less severe disease.

So what are the limitations? Laminoplasty wasn’t one of the randomised options, so its apparent advantage might partly reflect which patients surgeons picked for it. Patients and surgeons knew which operation had been done. The trial was moderate in size, and by two years about eighty per cent of people were still being followed. Five people had a different operation from the one they were assigned. People with a forward curve of the neck, a bony ligament or previous neck surgery weren’t included, and the authors note that front surgery is preferable to laminoplasty when the forward curve is more than thirteen degrees or the alignment is poor. And it was run in North America, where few surgeons were trained in laminoplasty at the time. Only eight of the twenty four surgeons offered both back operations.

What does this mean for you? For people with myelopathy at several levels who fit this trial’s criteria, front and back surgery led to a similar average improvement in physical function, just above the threshold for a meaningful change. The trade off is mainly in the side effects. Swallowing difficulty is much more likely after front surgery. Back surgery with fusion carried more nerve weakness and more early readmissions.

The shape of your neck, how many levels are affected, and where the pressure on the cord is coming from all influence which operation your surgeon recommends. Not every approach suits every person. The laminoplasty findings are encouraging, but they’re not proof. So ask your surgeon why a particular operation is being advised for you, and what the likely benefits and risks are.

And please, if your hand clumsiness, walking, balance or bladder symptoms are getting worse, tell your doctor promptly.

Thank you for listening. This podcast is general information and not a substitute for advice about your own situation, so please speak to your own doctor or specialist. You’ll find the full article, the diagrams and the references at spinemathema dot com. And if you found this useful, please subscribe to the Spinemathema channel on YouTube.

This podcast is general information and is not a substitute for advice about your own situation. Please speak to your GP or specialist.