(I-520) Anterior Cervical Discectomy and Fusion versus Posterior Decompression in Patients with Degenerative Cervical Myelopathy: a Systematic Review and Meta-analysis

Introduction: The optimal surgical approach for patients with multi-level degenerative cervical myelopathy (DCM) remains unknown. This systematic review and meta-analysis sought to compare anterior cervical discectomy and fusion (ACDF) versus posterior decompression (PD) in patients harboring DCM with ≥ 2 level involvement without ossification of posterior longitudinal ligament.

Methods: Medline and PubMed were searched from inception to February 22, 2022. The primary outcomes were neck disability index (NDI), short from-36 physical component summary (SF-36 PCS), modified Japanese Orthopaedic Association (mJOA) scale, visual analog scale (VAS), and EuroQol5Dimensions (EQ-5D). Secondary outcomes were operative bleeding, duration of operation (minute), length of hospital stay (LOS) (day), postoperative morbidity (including hematoma, surgical site infection (SSI), CSF leak, dysphagia, dysphonia, C5 palsy, and fusion failure), mortality, readmission, and reoperation.

Results: 19 studies yielding 8340 patients were included, of which 4118 (49.3%) and 4222 (50.6%) underwent ACDF and PD, respectively. The mean of spinal level involvement was comparable between the groups (3.1 vs. 3.5, p=0.15). The MDs of the primary outcomes were mean of each index in the ACDF group minus those of the PD group. After 1-year follow-up, mean difference (MD) of NDI (MD=-1.67[-3.51, 0.18], p=0.08), SF-36 PCS (MD=2.48[-0.59, 5.55], p=0.11), and VAS (MD=-0.32[-0.97, 0.34], p=0.35) were similar between the groups. While MD of mJOA (MD=0.71[0.27, 1.16], p=0.002) and EQ-5D (MD=0.04[0.01, 0.08], p=0.02) were greater in the ACDF group, the differences were not clinically significant given the meaningful clinically important difference [MCID] of 2 and 0.05, respectively. In the ACDF group, MDs of operative bleeding (MD=-102.77ml [-169.23, -36.30], p=0.002) and LOS (MD=-1.42[-2.01, -0.82], p< 0.00004) were lower; odds ratio (OR) of dysphagia (OR=11.10[5.43, 22.67], p< 0.0001) was higher, and ORs of SSI (OR=0.43[0.24, 0.78], p=0.006) and C5 palsy (OR=0.32[0.15, 0.70], p=0.004) were lower. The other outcomes were similar between the groups. Overall evidence per GRADE approach was moderate.

Conclusion : Two approaches are similar in functional outcomes. The ACDF is beneficial in terms of lower bleeding, shorter LOS, lower odds of SSI, and C5 palsy, while it carries higher odds of dysphagia. We recommend individualized treatment decision-making.

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