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Anterior versus Posterior Fusion Surgery for Cervical Ossification of the Posterior Longitudinal Ligament: A
Narihito Nagoshi1,2, Takashi Hirai2,3, Hiroshi Takahashi2,4
1Department of Orthopaedic Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan.
Background:
Cervical ossification of the posterior longitudinal ligament (OPLL) often requires surgical decompression with fusion. Both anterior decompression and fusion (ADF) and posterior decompression and fusion (PDF) are used; however, comparative evidence regarding their clinical outcomes remains limited and inconsistent. This study aimed to systematically review and synthesize evidence comparing ADF and PDF in patients with cervical OPLL.
Methods:
A systematic search of Embase, the Cochrane Library, and MEDLINE was conducted from database inception to November 30, 2024. Randomized controlled trials and cohort studies directly comparing ADF and PDF were included. Outcomes of interest included neurological recovery based on the Japanese Orthopaedic Association score or recovery rate, complication rates, radiographic parameters, pain, reoperation, patient-reported outcome measures (PROMs), and healthcare costs. Pooled analyses were performed using weighted mean differences or odds ratios with 95% confidence intervals. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation framework.
Results:
Eleven studies met the inclusion criteria. The overall certainty of evidence was rated as very low. Pooled point estimates favored ADF for neurological recovery compared with PDF, although differences did not reach statistical significance. Similar findings were observed in subgroup analyses of patients with K-line (-) status or high canal-occupying ratios (≥50% to 60%). Perioperative complications were more frequent after ADF, whereas neurological complications occurred more often after PDF; however, neither comparison showed statistically significant differences. No significant differences were identified in pain reduction, radiographic outcomes, reoperation rates, or PROMs. One study reported higher healthcare costs in the PDF group. Substantial heterogeneity was present across most analyses.
Conclusions:
Current evidence does not demonstrate a clear advantage of either anterior or posterior fusion strategies for cervical OPLL. Given the substantial heterogeneity and very low certainty of evidence, differences between approaches should be interpreted with caution. Further well-designed comparative studies are required to determine the optimal fusion strategy.
