ACDF vs PCDF vs Laminoplasty for Multilevel Cervical Myelopathy: A Systematic Review and Meta-Analysis.

STUDY

DESIGN

Systematic review and meta-analysis.

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.