OBJECTIVE: To compare functional, radiographic, and complication outcomes among ACDF, PCDF, and laminoplasty for multilevel cervical spondylotic myelopathy (CSM).
SUMMARY OF BACKGROUND DATA: CSM is a major source of patient morbidity in the United States. Three surgical approaches are commonly employed for this degeneration: ACDF, PCDF, and laminoplasty. Comparative data is warranted to guide approach selection.
METHODS: In accordance with PRISMA guidelines, PubMed, Embase, CENTRAL, and Scopus were searched through February 2026 to identify comparative studies reporting outcomes among adult patients undergoing ACDF, PCDF, or laminoplasty for multilevel (≥3 levels) CSM. Twelve studies comprising 1,129 patients met inclusion criteria and were organized into three pairwise comparisons: ACDF versus laminoplasty, PCDF versus laminoplasty, and ACDF versus PCDF. Functional, radiographic, and complication outcomes were comparatively assessed. Continuous outcomes were pooled as mean differences (MD) with 95% confidence intervals (CI). Dichotomous outcomes were pooled as odds ratios (OR) with 95% CI. Heterogeneity was assessed using the I² statistic.
RESULTS: JOA score improvement did not differ between ACDF and laminoplasty (MD=-0.20, P=0.43) or ACDF and PCDF (MD=1.06, P=0.21). VAS neck pain favored ACDF over laminoplasty (MD=-1.05, P=0.03). ACDF demonstrated reduced cervical range of motion (MD=-9.14°, P<0.001) compared with laminoplasty. Hospital stay was shorter after ACDF (MD=-2.62 days, P=0.002) and longer after PCDF (MD=1.19 days, P<0.001) relative to laminoplasty. ACDF was associated with lower rates of axial pain (Peto OR=0.21, P=0.007) and C5 palsy (Peto OR=0.27, P=0.049) but higher rates of dysphagia (Peto OR=5.88, P<0.001) compared with laminoplasty. SSI was more frequent after PCDF than laminoplasty (Peto OR=4.27, P=0.01).
CONCLUSIONS: ACDF, PCDF, and laminoplasty demonstrated similar neurological recovery for multilevel CSM. Procedure-specific differences in cervical range of motion, length of stay, and complication profiles support approach selection guided by preoperative alignment and patient-specific concerns.
STUDY DESIGN: Systematic review and meta-analysis.
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