• Aria Nouri, Allan R Martin, Anick Nater, Christopher D Witiw, So Kato, Lindsay Tetreault, Hamed Reihani-Kermani, Carlo Santaguida, and Michael G Fehlings.
• Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA; Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.
• World Neurosurg. 2017 Sep 1; 105: 864-874.

ObjectiveWe conducted a survey to understand how specific pathologic features on magnetic resonance imaging (MRI) influence surgeons toward an anterior or posterior surgical approach in degenerative cervical myelopathy (DCM).MethodsA questionnaire was sent out to 6179 AOSpine International members via e-mail. This included 18 questions on a 7-point Likert scale regarding how MRI features influence the respondent's decision to perform an anterior or posterior surgical approach. Influence was classified based on the mean and mode. Variations in responses were assessed by region and training.ResultsOf 513 respondents, 51.7% were orthopedic surgeons, 36.8% were neurosurgeons, and the remainder were fellows, residents, or other. In ascending order, multilevel bulging disks, cervical kyphosis, and a high degree of anterior cord compression had a moderate to strong influence toward an anterior approach. A high degree of posterior cord compression had a moderate to strong influence, whereas multilevel compression, ossification of the posterior longitudinal ligament, ligamentum flavum enlargement, and congenital stenosis had a moderate influence toward a posterior approach. Neurosurgeons chose anterior approaches more and posterior approaches less in comparison with orthopedic surgeons (P < 0.01). Of note, 59.8% of respondents were equally comfortable performing multilevel (3 or more levels) anterior and posterior procedures, whereas 61.5% did not feel comfortable in determining the surgical approach based on MRI alone.ConclusionsSpecific DCM pathology influences the choice for anterior or posterior surgical approach. These data highlight factors based on surgeon experience, training, and region of practice. They will be helpful in defining future areas of investigation in an effort to provide individualized surgical strategies and optimize patient outcomes.Copyright © 2017 Elsevier Inc. All rights reserved.

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