A comparative study on surgical management of long-course symptomatic cervical OPLL between anterior en bloc resection and posterior laminectomy with instrumented fusion

The optimal surgical strategy for patients with long-course symptomatic cervical ossification of the posterior longitudinal ligament (OPLL) remains controversial. From January 2012 to August 2021, a single-center retrospective cohort study was conducted to compare anterior cervical OPLL en bloc resection (ACOE) versus posterior laminectomy with instrumented fusion (PLF) in patients with long-course symptomatic cervical OPLL. All patients were followed for 48 months postoperatively. The primary endpoint was postoperative Japanese Orthopedic Association (JOA) score, and the secondary endpoints were the JOA recovery rate (JOA-RR), Visual Analogue Scale (VAS) of neck pain, and complications. Analyses used ANCOVA adjusted for preoperative JOA with overlap (ATO) weighting. Prespecified subgroups were defined by the canal occupying ratio (COR), K-line, OPLL index (OP-index), OPLL morphology, and operated levels. Sensitivity analyses included IPTW (ATE) and restriction sets. A total of 112 patients were analyzed (64 in ACOE, 48 in PLF). Operative metrics favored ACOE with fewer fused levels, shorter operative time and less blood loss. Primary weighted analysis showed that postoperative JOA in ACOE group was higher than that in PLF group, with an adjusted mean difference of 1.68 calculated as ACOE minus PLF (95% CI, 0.15–3.22; P = 0.033). There was no significant difference in JOA-RR and VAS between the two groups. Overall complication rates were low and comparable between the two groups. Cerebrospinal fluid leak occurred more frequently after ACOE, with wide confidence intervals. Treatment effects were directionally consistent across prespecified subgroups without significant interaction, and sensitivity analysis supported the primary findings. In long-course symptomatic cervical OPLL, ACOE provided a modest but clinically meaningful improvement in neurological recovery at 48 months compared with PLF, with low and broadly similar complication rates. ACOE may be more preferrable when maximizing neurological recovery is the priority, particularly in patients with high COR or K-line negativity, while posterior strategies remain reasonable for extensive continuous multilevel OPLL. Prospective studies are warranted to verify these findings and conclusions.