Is anterior cervical discectomy and fusion sufficient for single-level cervical myelopathy: surgical considerations for combined anterior and posterior cervical cord compression—experience from a case series

Background: Anterior cervical discectomy and fusion (ACDF) is the standard treatment for single-level cervical myelopathy with anterior compression. However, concomitant posterior pathology such as ligamentum flavum (LF) hypertrophy may limit decompression or cause iatrogenic LF buckling after surgery. This case series highlights surgical considerations and technical modifications for such scenarios. Case Description: Four patients with single-level cervical myelopathy underwent ACDF. Case 1: a 68-year-old man with C3/4 disc herniation and LF hypertrophy was treated with short-plate fixation and high-angle screws, achieving indirect posterior decompression and neurological recovery. Case 2: an 80-year-old woman with C3/4 compression achieved excellent clinical and radiologic outcomes after ACDF. Case 3: a 58-year-old woman with OPLL developed postoperative LF buckling after conventional ACDF method. Case 4: a 77-year-old man with rigid segmental motion failed indirect decompression after ACDF and required staged posterior laminectomy. Conclusions: ACDF is effective for most single-level myelopathy with anterior compression. Technical modifications, including short anterior plating with high-angle screws, may achieve indirect posterior decompression and prevent LF buckling. In rigid segments or with severe posterior pathology, combined or staged anterior-posterior approaches should be considered. Careful selection and meticulous technique are essential to optimize outcomes.