Cervical Spondylotic Myelopathy Surgical Trial

Patients' images will be transmitted electronically (without identifying information) to a
group of 15 CSM surgeon investigators for their expert opinion. They will provide their
opinion on surgical strategy. Equipoise for randomization will be established using this
spinal experts network polling mechanism.

If randomized, the patient will be randomized to one of the two treatment approaches - either
Ventral (front) (treatment A) or Dorsal (back) (treatment B) approach. If randomized to
treatment A (front surgery), the patient will receive decompression/fusion from the front of
the neck. If randomized to treatment B (dorsal/back surgery), then the patient and their
surgeon will select which posterior procedure they will receive (either dorsal
decompression/fusion or dorsal laminoplasty).

Treatment A: Decompression/fusion from the front of the neck.

Treatment B: Dorsal/posterior neck surgery (one of the two surgical procedures listed below):

Dorsal decompression/fusion or dorsal laminoplasty (no fusion)

Functional outcomes will be determined using well-known quantitative scales (SF-36, Oswestry
Neck Disability Index (NDI), mJOA, and EuroQol-5D). These instruments will be administered
pre-op, 3 months, 6 months, and at 1 year. Additionally, functional outcomes instruments
(SF-36, Oswestry Neck Disability Index, and EuroQol-5D) will be collected annually at years
2,3,4 and 5.

Pre-op imaging will include a cervical MRI and cervical CT as well as cervical
flexion/extension films and standing cervical-thoracic-lumbar-sacral x-ray . A cervical MRI
will be performed at 3 months. At 1 year (randomized patients only) will undergo cervical
flexion/ extension xrays and standing cervical-thoracic-lumbar-sacral x-ray . A cervical CT
will be performed only if the Oswestry NDI score is > 30.

Inclusion Criteria:

- CSM (≥2 levels of spinal cord compression from C3 to C7)

- Present with ≥2 of the following symptoms/signs: clumsy hands, gait disturbance,
hyperreflexia, up going toes, bladder dysfunction.

Exclusion Criteria:

- C2-C7 kyphosis>5º (measured in standing neutral cervical spine radiograph),

- Segmental kyphotic deformity (defined by ≥3 osteophytes extending dorsal to a C2-C7
dorsal-caudal line measured on cervical spine CT),

- Structurally significant ossification of posterior longitudinal ligament (OPLL -
measured on cervical spine CT),

- Previous cervical spine surgery

- Significant active health-related co-morbidity (Anesthesia Class IV or higher).