A narrative review of surgical approaches in cervical degenerative myelopathy and update of the algorithm for decision making

Background Cervical degenerative myelopathy (CDM) is the leading cause of spinal cord dysfunction in adults, with surgical and non-surgical management strategies being widely debated. Key factors for determining the surgical approach include sagittal spinal alignment, the number of affected levels, and the anterior or posterior dominance of pathology. Objective This review examines the various surgical approaches for CDM, evaluates their associated risks and benefits, and proposes an updated algorithm for surgical decision making. Methods The narrative review synthesizes evidence from prior systematic reviews, meta-analyses, and clinical studies. Information was collated on anterior (e.g., anterior cervical discectomy and fusion) and posterior (e.g., laminoplasty, laminectomy with or without fusion) surgical techniques, along with newer methods such as cervical osteotomies. Outcomes, complications, and patient selection criteria were analyzed. Results Posterior approaches like laminoplasty and laminectomy are associated with longer hospital stays and higher complication rates, such as cerebrospinal fluid leaks and infections. Anterior approaches, such as anterior cervical discectomy and fusion (with or without corpectomy), carry risks of dysphagia and hematoma but are advantageous for anterior-dominant pathology. Laminoplasty is increasingly used for multilevel involvement in patients with lordotic or straight spinal alignment, while cervical osteotomies provide a single-stage posterior solution for severe kyphosis. The choice of approach requires individualized assessment based on patient-specific factors, including spinal alignment, pathology dominance, and level of involvement. Conclusion The updated decision-making algorithm underscores the importance of tailoring surgical approaches to individual patient characteristics and pathology. Laminoplasty is emerging as a preferred option for multilevel cases in specific alignments, whereas cervical osteotomies are reserved for rigid deformities. Personalized surgical planning is essential to optimize outcomes in CDM management.