ACDF offers benefits over PCLF for cervical spondylotic myelopathy but postoperative neck pain improvement comparable

Andrew Chan

Anterior cervical discectomy and fusion (ACDF) and posterior cervical laminectomy and fusion (PCLF) provide comparable postoperative neck pain improvement at three, 12, and 24 months following three- or four-segment surgery of patients who suffer from cervical spondylotic myelopathy (CSM) and severe neck pain. However, multilevel ACDF is associated with superior functional status, quality of life, and return to baseline activities at 24 months in multivariable adjusted analyses.

This are they key messages to come out of a recent study—published in the Journal of Neurosurgery: Spine by Andrew Chan (Columbia University, New York, USA) et al—which sought to determine whether ACDF or PCLF is superior for patients with CSM and high preoperative neck pain.

Speaking to Spinal News International, Chan said: “This is an interesting investigation for several reasons. First, many physicians learn a ‘classical’ description of cervical myelopathy which does not include neck pain as a chief symptom. However, clearly it is an important problem for these patients as over 40% present with severe neck pain.

“Secondly, some surgeons advise multilevel ACDF for these patients given the lack of extensive muscle dissection that is needed from the posterior approach (in a hope to decrease postoperative neck pain).

“However, the data from our prospective Quality Outcomes Database (QOD) registry does not support this hypothesis. Therefore, surgeons and patients can be reassured that either procedure is associated with similar neck pain outcomes and that other factors may dictate whether an anterior or posterior approach is chosen.”

The retrospective study of prospectively collected data using the QOD CSM module included patients who received a subaxial fusion of three or four segments and had a Visual Analogue Scale (VAS) neck pain score of seven or greater at baseline.

Overall, 1,141 patients with CSM were included in the database. Of these, 495 (43.4%) presented with severe neck pain (VAS score >6). After applying inclusion and exclusion criteria, a total of 65 patients (54.6%) undergoing three- and four-level ACDF and 54 patients (45.4%) undergoing three- and four-level PCLF were included.

Patients undergoing ACDF had worse Neck Disability Index scores at baseline (52.5 ± 15.9 vs. 45.9 ± 16.8, p=0.03) but similar neck pain (p>0.05). Otherwise, the groups were well matched for the remaining baseline patient-reported outcomes. The rates of 24-month follow-up for ACDF and PCLF were similar (86.2% and 83.3%, respectively).

The study found that at 24-month follow-up, both groups demonstrated mean improvements in all outcomes, including neck pain (p<0.05). In multivariable analyses, there was no significant difference in the degree of neck pain change, rate of neck pain improvement, rate of pain-free achievement, and rate of reaching minimal clinically important difference (MCID) in neck pain between the two groups (adjusted p>0.05).

However, ACDF was associated with a higher 24-month modified Japanese Orthopaedic Association scale (mJOA) score (β = 1.5 [95% confidence interval [CI], 0.5–2.6], adjusted p=0.01), higher EQ-5D score (β = 0.1 [95% CI, 0.01–0.2], adjusted p=0.04), and higher likelihood for return to baseline activities (odds ratio 1.2 [95% CI, 1.1–1.4], adjusted p=0.002).


  1. No surprise in these findings from retrospective review. In my practice, I found primary anterior decompression and fusion best for direct spinal cord decompression and maintenance of better long term cervical spine alignment


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