Anterior approach versus posterior approach for the treatment of multilevel cervical spondylotic myelopathy: a systemic review and meta-analysis

Abstract

To compare the clinical outcomes, complications, and surgical trauma between anterior and posterior approaches for the treatment of multilevel cervical spondylotic myelopathy. Systematic review and meta-analysis. We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials databases for randomized controlled trials or non-randomized controlled trials that compared anterior and posterior surgical approaches for the treatment of multilevel cervical spondylotic myelopathy. Exclusion criteria were non-controlled studies, combined anterior and posterior surgery, follow-up <1 year, cervical kyphosis >15°, and cervical myelopathy caused by ossification of the posterior longitudinal ligament. The main end points included: recovery rate; Japanese Orthopedic Association (JOA) score; reoperation rate; complication rate; blood loss; and operation time. Subgroup analysis was conducted according to the mean number of surgical segments. A total of eight studies were included in the meta-analysis; none of which were randomized controlled trials. All of the selected studies were of high quality as indicated by the Newcastle-Ottawa scale. In five studies involving 351 patients, the preoperative JOA score was similar between the anterior and posterior groups [P > 0.05, WMD: -0.00 (-0.56, 0.56)]. In four studies involving 268 patients, the postoperative JOA score was higher in the anterior group compared with the posterior group [P < 0.05, WMD: 0.79 (0.16, 1.42)]. For recovery rate, there was significant heterogeneity among the four studies involving 304 patients, hence, only descriptive analysis was performed. In seven studies involving 447 patients, the postoperative complication rate was significant higher in the anterior group compared with the posterior group [P < 0.05, odds ratio: 2.60 (1.63, 4.15)]. Of the 245 patients in the 8 studies who received anterior surgery, 21 (8.57%) received reoperation. Of the 285 patients who received posterior surgery, only 1 (0.3%) received reoperation. The reoperation rate was significantly higher in the anterior group compared with the posterior group (P < 0.001). In the 3 studies involving 236 patients compared subtotal corpectomy and laminoplasty/laminectomy, blood loss and operation time were significantly higher in the anterior subtotal corpectomy group compared with the posterior laminoplasty/laminectomy group [P < 0.05, WMD: 150.10 (63.53, 236.66) and P < 0.05, WMD: 59.17 (45.69, 72.66)]. The anterior approach was associated with better postoperative neural function than the posterior approach in the treatment of multilevel cervical spondylotic myelopathy. There was no apparent difference in the neural function recovery rate. The complication and reoperation rates were significantly higher in the anterior group compared with the posterior group. The surgical trauma associated with corpectomy was significantly higher than that associated with laminoplasty/laminectomy.