Anterior versus posterior decompression and fusion for multilevel cervical myelopathy: a systematic review and meta-analysis.

Abstract

Optimal surgical strategy for multilevel cervical myelopathy remains debated. We compared anterior decompression and fusion (ADF) versus posterior decompression with fusion (PDF) across functional, health-related quality of life, radiographic, perioperative, and safety outcomes. We updated a prior review with searches of PubMed, Scopus, and Web of Science (January 2023-24 August 2025). Comparative adult studies of multilevel disease treated with ADF or PDF were pooled using random-effects models to estimate mean differences (MD) or odds ratios (OR) with 95% CIs. Heterogeneity (I²), leave-one-out analyses, and Egger's tests assessed robustness and small-study effects. Thirty-one studies (2 RCTs, 29 cohorts; 5,613 patients: 2,427 ADF; 3,186 PDF) met criteria. ADF was associated with higher postoperative JOA (MD 0.76; 95% CI 0.36-1.16; I²=81.7%) and greater JOA recovery (MD 9.12%; 1.34-16.89; I²=93.4%), although the recovery benefit was not robust after removing one study or under Hartung-Knapp adjustment. NDI favored ADF (MD - 1.24; -2.30 to - 0.17; I²=72.2%) but attenuated in sensitivity and was sensitive to small-study effects. EQ-5D favored ADF (MD 0.07; 0.03-0.11; I²=0%); SF-36 did not differ overall (MD 3.48; -0.43 to 7.38) but favored ADF on sensitivity. Cervical lordosis improved more with ADF (C2-C7 Cobb MD 4.15°; 1.29-7.00; I²=89.7%). LOS was shorter with ADF (MD - 1.92 days; -2.32 to - 1.52; I²=49.9%), while operative time and blood loss were overall similar. Overall complications did not differ significantly between approaches (OR 1.48; 1.00-2.20; I²=65.9%); dysphagia was higher with ADF (OR 7.28; 4.19-12.64; I²=0%) and C5 palsy lower (OR 0.35; 0.15-0.82; I²=0%) versus PDF. Revision and axial pain were comparable. Egger's tests suggested small-study effects for NDI and LOS only; in meta-regression, OPLL status and study quality explained much of the between-study heterogeneity, and GRADE certainty was low to very low for most outcomes. For multilevel cervical myelopathy, ADF was associated with modest improvements in neurological function, health-related quality of life, cervical alignment, and shorter hospitalization compared with PDF, although several between-group differences were below minimal clinically important difference thresholds and some were sensitive to influential studies. Trade-offs were approach-specific: dysphagia was higher after ADF, whereas C5 palsy was more frequent after PDF; overall complications did not differ significantly. Given the predominance of observational data and low-to-very-low GRADE certainty, approach selection should remain patient-tailored.