IMPACT OF SURGICAL APPROACH (ANTERIOR VS POSTERIOR) ON OUTCOMES IN CERVICAL SPONDYLOTIC MYELOPATHY: A META-ANALYSIS

Cervical spondylotic myelopathy (CSM) is the leading cause of non-traumatic spinal cord dysfunction in older adults. Surgical decompression is the standard treatment for moderate to severe cases, but the optimal approach anterior versus posterior remains debated, particularly in multilevel disease. To compare the clinical outcomes of anterior and posterior surgical approaches in the treatment of multilevel cervical spondylotic myelopathy through a systematic review and meta-analysis of recent studies.A systematic search of PubMed, Scopus, Web of Science, and Cochrane Library was conducted for comparative studies published between January 2020 and October 2025. Eligible studies compared anterior cervical discectomy and fusion (ACDF) to posterior decompression (laminoplasty or laminectomy with/without fusion) for multilevel CSM. Primary outcomes were Japanese Orthopaedic Association (JOA) score, complication rates, revision surgery and length of stay. Meta-analysis was conducted using RevMan 5.4. Seven studies (n = 12,810 patients) met the inclusion criteria. There was no significant difference in neurological recovery between anterior and posterior approaches (mean difference in JOA score = 0.29, 95% CI: –0.10 to 0.69; p = 0.15; I² = 0%). The anterior group showed a non-significant trend toward fewer complications (RR = 0.67, 95% CI: 0.38–1.20; p = 0.18; I² = 52%) but had a significantly lower revision surgery rate (RR = 0.46, 95% CI: 0.39–0.54; p < 0.00001; I² = 0%). Anterior surgery was also associated with a shorter hospital stay (mean difference = –2.02 days, 95% CI: –2.37 to –1.67; p < 0.00001; I² = 49%). In patients with multilevel CSM, anterior approaches particularly ACDF provide comparable neurological recovery but result in lower revision rates and shorter hospitalization compared to posterior approaches. While anterior surgery may be preferred when anatomically feasible, surgical decisions should remain patient-specific based on alignment, pathology, and comorbidities.