Efficacy and safety of different surgical approaches in the treatment of multilevel cervical ossification of the posterior longitudinal ligament: a network meta-analysis.

objectiveThis network meta-analysis (NMA) compares the efficacy and safety of four major surgical approaches for multilevel (≥ 3 segments) cervical ossification of the posterior longitudinal ligament (C-OPLL) at ≥ 12 months postoperatively, aiming to guide clinical decision-making in complex surgical cases.

methodsA systematic search was conducted across PubMed, Embase, Web of Science, Cochrane Library, CNKI, and Wanfang from inception to October 2024. Eligible studies included comparative trials of anterior controllable antedisplacement and fusion (ACAF), anterior cervical corpectomy and fusion (ACCF), laminoplasty (LP), and laminectomy with fusion (LF), reporting at least one prespecified outcome. A frequentist random-effects NMA was performed, estimating mean differences (MD) and odds ratios (OR) with 95% confidence intervals (CIs). Global and local inconsistency, heterogeneity (with prediction intervals), small-study effects, transitivity, and certainty (CINeMA) were assessed.

resultsThis study evaluated four surgical techniques for multilevel C-OPLL: ACAF, ACCF, LP, and LF, based on 23 studies involving 2,413 patients. ACAF and ACCF demonstrated superior neurological improvement (JOA scores) compared to LP, with no significant difference between ACAF and ACCF. ACAF also showed a higher JOA improvement rate than LP, while ACCF outperformed both LP and LF. In terms of pain relief, ACAF provided better results than both LP and LF. LP better preserved cervical range of motion (ROM) compared to LF. ACAF and LP had fewer postoperative complications compared to LF, with more CSF leakage and hoarseness/dysphagia observed in the ACAF/ACCF groups. LP had the shortest operative time, and ACAF resulted in less intraoperative blood loss than ACCF. Significant global inconsistencies were found in improvement rates, cervical ROM, and blood loss, with substantial heterogeneity across studies. No publication bias was detected.

conclusionsIn multilevel C-OPLL, anterior approaches (ACAF/ACCF) were associated with greater neurological improvement than laminoplasty, although the certainty of evidence was generally low and rankings should be interpreted cautiously. ACAF may offer a favorable overall balance between neurological benefit and complication burden, with less blood loss but longer operative time. Laminoplasty tended to preserve cervical motion and reduce operative time, whereas laminectomy and fusion showed higher overall complication rates and ROM loss in pooled analyses. Procedure selection should remain individualized and anatomy-informed.