Evaluating whether adding laminoplasty to ACDF provides superior neurological recovery compared to ACDF alone in High-Risk patients with multilevel cervical spondylotic myelopathy and cervical canal stenosis.

Purpose: Multilevel cervical spondylotic myelopathy (CSM) with severe stenosis and anterior compression is challenging in high-risk patients (e.g., positive ISI, low compression ratio) where ACDF alone may be inadequate. We evaluated if combined laminoplasty and ACDF (LP-A) improves neurological recovery over ACDF in this population, as comparative evidence is limited.

Methods: This retrospective study analyzed 82 patients (LP-A = 26, ACDF = 56) treated between January 2017 and June 2023 for multilevel CSM (≥ 3 levels) with canal stenosis (< 13 mm) and anterior-predominant compression (modified K-lineINT < 4 mm), indicating suitability for anterior decompression. Focusing on high-risk individuals where ACDF may be insufficient, a high-risk cohort was defined using prognostic factors (positive increase signal intensity, compression ratio < 34%) identified from ACDF outcomes. Clinical outcomes (mJOA, recovery, MCID, VAS, NDI, radiographic, complications) were compared statistically between high-risk LP-A (n = 24) and ACDF (n = 27) patients.

Results: In the high-risk cohort, LP-A demonstrated significantly greater neurological improvement than ACDF. LP-A patients had larger mJOA improvement (4.2 ± 1.8 vs. 2.6 ± 1.7, p = 0.002), higher recovery rates (74.9% vs. 58.7%, p = 0.03), and significantly more MCID exceedance (95.8% vs. 70.4%, p = 0.02; OR = 9.68). VAS/NDI also significantly improved postoperatively in both groups, with no significant group difference. Radiographic alignment and complication rates were similar. Notably, two ACDF patients required secondary posterior decompression due to neurological deterioration, suggesting potential under-decompression with ACDF alone in complex cases.

Conclusion: In high-risk multilevel CSM patients with canal stenosis, LP-A resulted in significantly better neurological recovery than ACDF alone. These findings suggest that LP-A may offer more favorable neurological outcomes in appropriately selected high-risk cases.