Laminoplasty Versus Laminectomy and Fusion in the Treatment of Degenerative Cervical Myelopathy: A Systematic Review and Meta-Analysis of Cost and Patient-Centered Outcomes in the United States

Abstract

Study design

Systematic review and meta-analysis.

Objective

This systematic review and meta-analysis compared cervical laminoplasty (LP) with laminectomy and fusion (LF) for the treatment of degenerative cervical myelopathy (DCM), focusing on healthcare costs and patient-centered outcomes.

Methods

A systematic review of EMBASE and Medline (inception to September 2024) identified studies comparing LP and LF for multilevel DCM. Outcomes included return-to-work (RTW), direct treatment costs, and changes in pain and opioid use. Meta-analyses were performed using random-effects models to estimate pooled mean differences (MD) between treatment arms and mean per treatment for study outcomes. Study quality was assessed with the Newcastle-Ottawa Scale.

Results

Twelve retrospective cohort studies (7581 patients; LP: 1,848, LF: 5733) met inclusion criteria. After appraising the included studies, we determined that 25% were of high quality, 67% were of moderate quality, and 8% were of low quality. LF had higher treatment costs ($74,772.8 USD, 95% CI $29,503.72-$120,041.88) than LP ($52,109.07 USD, 95% CI $12,234.14-$91,985.43), with an MD of −$21,620.69 USD (95% CI −$35,215 to −$8025.53, I² = 95%). LF led to greater pain reduction (MD in VAS = 1.60, 95% CI 0.36-2.84, I² = 63%). Opioid use was inconsistently reported, preventing meta-analysis. One study found higher RTW rates at 12 months for LP (88.9%) vs LF (64.3%).

Conclusion

LF incurred greater costs but provided superior pain relief. Significant heterogeneity and limited high-quality evidence highlight the need for further research on cost-effectiveness and patient-centered outcomes.

Keywords

degenerative cervical myelopathy laminoplasty laminectomy and fusion systematic review meta-analysis

Introduction

Degenerative cervical myelopathy (DCM) is the most common cause of spinal cord dysfunction in adults.¹ DCM often leads to progressive neurological impairment, significantly impacting patients’ quality of life, functional capacity, and ability to engage in daily activities, including employment.² Surgical intervention is the primary treatment for DCM, and aims to alleviate spinal cord compression in order to halt disease progression and promote recovery.^1,3 A recent randomized controlled trial (RCT) comparing ventral and dorsal approaches for management of DCM concluded similar improvement in physical functioning at 1-year follow-up.⁴ Notably, the ventral group experienced a higher complication rate, highlighting the need to closely examine commonly used dorsal approaches, such as cervical laminoplasty (LP) and laminectomy and fusion (LF).^5,6

Cervical laminoplasty is a motion-preserving procedure that decompresses the spinal cord by expanding the spinal canal while maintaining the native biomechanics of the cervical spine. This approach is often chosen where there is no significant cervical deformity, as it avoids the need for fusion and thus preserves cervical range of motion. However, laminoplasty is typically reserved for patients with minimal or no axial neck pain, as it does not address spondylotic neck pain and may be contraindicated in those with significant preoperative axial symptoms.⁷ Postoperative axial pain is thought to result from degenerative discs and sponydylotic uncovertebral and zygapophyseal joints, which may remain symptomatic after motion-preserving procedures.⁸ In contrast, laminectomy with fusion (LF) involves the removal of the lamina to achieve decompression, followed by stabilization of the affected spinal levels using instrumentation and bone grafts. LF is generally favored in cases with cervical kyphosis, instability, or multilevel involvement where treatment can induce iatrogenic instability. However, the risk of adjacent segment disease following fusion remains an important consideration.^3,5,6

While both LP and LF are widely used, there is a lack of consensus with regards to which procedure offers superior outcomes across various clinical parameters. Numerous studies have examined the effects of these techniques on a range of outcomes, including the modified Japanese Orthopedic Association (mJOA) score, Neck Disability Index (NDI), SF-36, as well as complications, and radiographic parameters such as cervical alignment.^5,6,9-12 Despite the wealth of literature on LP vs LF, there is a need for a comprehensive synthesis of evidence to guide clinical decision-making, particularly in evaluating the patient-centered outcomes of return-to-work (RTW), postoperative opioid use, and treatment costs.

This systematic review and meta-analysis will aim to synthesize the existing evidence on the primary outcomes of RTW, postoperative opioid use, and treatment costs in patients undergoing LP vs LF for DCM. In addition, we will compare each approach with respect to postoperative pain as measured by the Visual Analog Scale (VAS), given its relationship to analgesic requirements, to provide a comprehensive comparison of these 2 surgical techniques. By conducting this review, we hope to generate evidence that informs surgical decision-making, optimizes patient-centered care, and supports cost-effective treatment strategies in managing degenerative cervical myelopathy.

Methods

Study Design

This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.¹³ The study protocol was pre-registered in a systematic review database (PROSPERO ID CRD42024605897).

Search Strategy and Study Eligibility

Original studies were retrieved from EMBASE and Medline from the earliest available date to September 2024 using the search strategy outlined in supplemental Table 1. Reference lists of retrieved studies were screened to identify additional articles meeting inclusion criteria that were not captured in primary database search. We included all English language studies involving adult human subjects (age ≥18 years) comparing LP and LF for multilevel degenerative cervical myelopathy reporting on at least one of the following outcomes: return-to-work, pain, opioid use, and treatment cost. Studies containing anterior surgery cohorts were included if the LP and LF cohort analyses were reported independently. Studies involving laminectomy alone, laminoplasty with selective instrumented fusion, or combined anterior-posterior surgical approaches were excluded. Studies involving patients with oncologic, traumatic, or infectious pathologies were excluded. Case series with less than 5 patients, cadaver studies, or studies involving non-human subjects were excluded. In addition, reviews, commentaries, editorials and conference proceedings were excluded. Abstracts were reviewed based on study criteria, with data subsequently summarized from relevant full text using Microsoft Excel version 16. Studies for which only the abstract was available were excluded. For meta-analyses, studies were excluded if they did not report return-to-work in the proportion of patients, total index hospital cost in dollar value, baseline and postoperative pain scores as measured by the Visual Analog Scale (VAS), and total postoperative opioid use in morphine milligram equivalents (MME).

Data Collection

Initial title and abstract screening were performed by a single reviewer (VK). Full-text reviews were conducted independently by 2 reviewers (VK and HS), with discrepancies resolved through consensus. Publication variables collected included first author, year of publication, study design, and location. Baseline characteristics collected included sample size, age, sex, and preoperative pain scores. Postoperative variables collected included treatment cost, proportion of patients returning to work, postoperative opioid use, postoperative pain scores as measured by VAS, and follow-up period.

Bias and Certainty of Evidence Assessment

The methodological quality of the included studies was assessed using the Newcastle-Ottawa scale (NOS) for observational studies.¹⁴

Study Outcomes

Study outcomes assessed included postoperative opioid use (morphine milligram equivalents and proportion in %), return-to-work (proportion in %), treatment costs in US dollars (USD), and pain scores (VAS). Cost data was adjusted to January 2024 USD using the medical component of the consumer price index.¹⁵ Studies reporting total direct costs associated with an index hospital stay for LP and LF were pooled for analysis to calculate the average cost for each surgical treatment and the mean difference (LP vs LF). For studies reporting pain outcomes, baseline VAS and postoperative VAS scores at last follow-up were extracted. We then calculated change in VAS scores within each treatment arm across the included studies. This was then used within the pooled analysis to calculate the average change in VAS for each surgical treatment and the mean difference in change in VAS (LP vs LF).

Data Synthesis and Statistical Analyses

All statistical and meta-analyses were performed using R version 4.4.1 with the meta library package. An a priori significance level of P = .05 was used for two-tailed tests. Descriptive statistics were reported as mean and standard deviation for continuous variables and count with proportions for categorical variables. Pooled estimates for patient-level characteristic (age and sex) were calculated by treatment group (Table 2).

Studies included in meta-analyses were those that reported treatment cost (total index hospital in USD) and pain (VAS). Return-to-work and opioid use were not considered for meta-analyses due to an insufficient number of studies and inconsistent reporting across studies, respectively. For studies that did not report standard deviations directly, we estimated standard deviation using reported 95% confidence intervals, quartiles, or ranges where available, as described in the Cochrane Handbook.^16,17

Random-effects meta-analysis was performed to account for heterogeneity across studies. To compare treatment groups, pooled mean differences with 95% CIs between LP and LF for continuous outcomes were calculated and visualized on forest plots. The pooled estimates of the mean for outcomes was calculated with 95% CIs. Heterogeneity across studies was evaluated with Cochran’s Q and I² statistics, with P ≤ .10 or I² > 50% considered significant heterogeneity.¹⁸

Results

Overview of Studies and Patients

Our search identified 462 studies, of which 12 met our eligibility criteria (Supplemental Figure 1).^19-30 Table 1 summarizes the findings from our systematic review of included studies. All 12 studies were retrospective cohort studies comparing LP and LF. Of these, 6 studies were eligible for meta-analysis.^{23,24,26-28,30}

Table 1.

Summary of Findings From Systematic Review for Outcomes After LP and LF

Author & year	Country	Design	Surgical technique	Sample size	Age, mean (SD); baseline characteristics	% male	Outcomes^a	FU, months	ROB
Chua et al, 2024	US	RC (multi-center)	LP	277	64.5 (11.3)	55.2	Total facility cost in cost units: 1003.8 (308.8)	NR	Moderate
Chua et al, 2024	US	RC (multi-center)	LF	229	67.4 (11.)	56.3	Total facility cost in cost units: 1600 (498.8)	NR	Moderate
Miranda et al, 2024	US	RC (multi-center)	LP	12	56.3 (9)	41.6	RTW at 12-month FU: 88.9%	12	Low
Miranda et al, 2024	US	RC (multi-center)	LF	29	60.3 (5.8)	69.0	RTW at 12-month FU: 64.3%	12	Low
Lightsey IV et al, 2023	US	RC (multi-center)	LP	138	64.8 (10.57)	60.1	Inpatient opioid use in MME: 260 (26)	NR	Moderate
Lightsey IV et al, 2023	US	RC (multi-center)	LF	108	66.4 (10.39)	53.7	Inpatient opioid use in MME: 312 (26)	NR	Moderate
Shankar et al, 2024	US	RC (single center)	LP	79	62.0 (11.2)	78.4	Opioid use at 6-month follow-up: 5.1%	6	Moderate
		RC (single center)	LF	185	62.2 (12.1)	65.9	Opioid use at 6-month follow-up: 15.7%	6
		RC (multi-center)	LP	210	54.4 (6.9)	66.7	Prescribed 6-month opioid supply: 6.7%; opioid use past 6 month postoperatively: 6.7%	6
		RC (multi-center)	LF	1606	54.4 (7.3)	55.9	Prescribed 6-month opioid supply: 11.0%; opioid use past 6 month postoperatively: 10.4%	6
Bakr et al, 2023	US	RC (single center)	LP	76	60.5 (12); VAS 4.7 (2.9)	64.4	Opioid use at 3-month FU: 17.1%; opioid use at 1-year FU: 10.5%; MME/day preop (median and IQR): 30 (20-52); MME/day postop (median and IQR): 30 (19-57); VAS at 24-month FU: 3.8 (3.1)	14	Low
Bakr et al, 2023	US	RC (single center)	LF	59	65.5 (9); VAS 5.6 (3.0)	42.3	Opioid use at 3-month FU: 23.7%; opioid use at 1-year FU: 8.5%; MME/day preop (median and IQR): 44 (23-60); MME/Day postop (median and IQR): 23 (17-40); VAS at 24-month FU 3.6 (2.9)	15	Low
Jain et al, 2022	US	RC (multi-center)	LP	551	56 (6.7)	70.4	Total index surgery median cost in USD, (IQR): 41 550.38 (26 299.19-66 113.80)	24	Moderate
Jain et al, 2022	US	RC (multi-center)	LF	352	57 (5.9)	56.8	Total index surgery median cost (IQR): 73 236.08 (50 595.09-107937.92)	24	Moderate
Goh et al, 2020	US	RC (multi-center)	LP	108	65.6 (10.3)	NR	Implant cost: 2384.39 (768.86); Supply cost: 1033.78 (458.80); total cost: 3418.17 (937.54)	NR	Moderate
Goh et al, 2020	US	RC (multi-center)	LF	142	65.6 (10.3)	NR	Implant cost: 7418.31(1705.34); Supply cost: 930.41 (565.85); LF total cost: 8348.71 (1899.93)	NR	Moderate
Warren et al, 2013	US	RC (single center)	LP	55	63 (13)	70.9	Total cost: 25 904.09 (7214.41); total operating room-related cost: 11 713.37; total perioperative-related cost: 11 026.84	NR	Moderate
Warren et al, 2013	US	RC (single center)	LF	26	60 (9)	57.7	Total cost: 54 649.25 (14 850.96); Total operating room-related cost: 32 522.53; total perioperative-related cost: 19 503.29	NR	Moderate
Highsmith et al, 2011	US	RC (single center)	LP	30	61 (9.25) VAS: 3.2 (2.8)	NR	Total hardware cost: 5882.00; VAS 3.4 (2.6)	42	High
Highsmith et al, 2011	US	RC (single center)	LF	26	58 (9.75) VAS: 5.8 (3.2)	NR	Total hardware cost: 16 805.71; VAS 3.0 (2.3)	41	High
Adogwa et al, 2014	US	RC (multi-center)	LP	258	59 (11)	69.0	Total index hospital cost: 38 166.68 (33 619.52)	38	Low
Adogwa et al, 2014	US	RC (multi-center)	LF	2927	58 (11)	55.1	Total index hospital cost: 51 830.09 (45 568.06)	48	Low
Heller et al, 2001	US	RC (single center)	LP	13	56 (11.25);	NR	Narcotic use at most recent follow-up: 7.7%	26	Moderate
Heller et al, 2001	US	RC (single center)	LF	13	55 (9.75);	NR	Narcotic use at most recent follow-up: 7.7%	26	Moderate
Blizzard et al, 2017	US	RC (single center)	LP	41	57.8 (10.7); VAS 4.25 (3.51)	65.9	Total median cost (IQR): 133 902.35 (69 494.44-133 588.65); VAS 3.56 (3.1)	19	Moderate
Blizzard et al, 2017	US	RC (single center)	LF	31	59.0 (9.79); VAS 4.71 (2.9)	74.1	Total median cost (IQR): 163 409.36 (153 655.39-180 062.22); VAS 3.18 (3.13)	18	Moderate

Abbreviations: FU = follow-up; ROB = risk of bias; RC = retrospective cohort; LP = laminoplasty; LF = laminectomy and fusion; SD = standard deviation; IQR = interquartile range; NR = not reported; MME = morphine milligram equivalents; RTW = return-to-work; VAS = visual analogue scale.

^aValues are presented as mean (SD) for continuous variables, count (%) for categorical variables, and cost data is reported in USD ($), unless otherwise stated.

From the included studies, there were a total of 7581 patients with DCM, of whom 1848 (24.3%) were treated with laminoplasty and 5733 (75.6%) were treated with LF. Baseline demographics were found to be similar (Table 2). The mean age for patients treated with LP was 60.2 years (95% CI 58.1-62.4) and 60.8 years (95% CI 58.4-63.2) for the LF group, with the proportion of male patients at 65.9% (95% CI 64.9-67.0) in the LP cohort and 64.0% (95% CI 63.2-64.7) in the LF group. Follow-up periods varied across studies, ranging from 6 to 48 months. Overall, there were few studies examining all outcomes: return-to-work (n = 1), cost (n = 7) opioid use (n = 4), and pain (n = 3).

Table 2.

Pooled Baseline Summary Statistics for Patients Treated With LP and LF From a Meta-Analysis of Baseline Characteristics From Individual Studies

Characteristic	LP (1848, 12 studies)				LF (5733 pts, 12 studies)
	No. of Pts (studies)	PE (95%CI)	Heterogeneity		No. of Pts (studies)	PE (95%CI)	Heterogeneity
	No. of Pts (studies)	PE (95%CI)	I², %	P value	No. of Pts (studies)	PE (95%CI)	I², %	P value
Age, yrs	1848 (12)	60.2 (58.1-62.4)	95	<.001	5733 (12)	60.8 (58.4-63.2)	99	<.001
Sex, % male	1697 (9)	65.9(64.9-67.0)	71	<.001	5552 (9)	64.0 (63.2-64.7)	69	<.001

Abbreviations: PE = pooled estimate, CI = confidence interval.

Pooled Estimate for Cost in LP and LF

Seven studies reported on cost outcomes.^{19,23-26,28,30} Of these, 2 were excluded from the meta-analysis due to reporting in a non-currency metric (cost-units) and for only reporting implant costs.^19,25 The meta-analysis of treatment costs included 5 studies that reported total hospital index costs associated with either treatment. Among the 5 studies, the total index hospital cost averaged $52,109.7 USD (95% CI $12,234 to $91,985.43 USD) for LP and $74,772.8 USD (95% CI $29,503.72 to $120,041.88 USD) for LF. Both pooled estimates showed significant heterogeneity (I² = 100%; P < .01), suggesting substantial variability in cost outcomes for both treatments across the included studies (Table 3).

Table 3.

Pooled Estimates of Cost and VAS From the Meta-Analyses of Outcomes From Individual Studies

Outcome	Pooled Estimate (95% CI)	Number of studies	Heterogeneity
Outcome	Pooled Estimate (95% CI)	Number of studies	I² %	P value
LP cost (total index hospital cost in USD)	Mean cost: 52 109.7 (12 234.14, 91 985.43)	5	100	<.01
LF cost (total index hospital cost in USD)	Mean cost: 74 772.8 (29 503.72, 120 041.88)	5	100	<.01
Cost difference, LP – LF (total index hospital cost in USD)	Mean difference: −21 620.69 (−35 215.86, −8025.53)	5	95%	<.01
LP pain (change in VAS from preoperative to postoperative)	Mean VAS change: −0.52 (−1.18, 0.14)	3	41	.187
LF pain (change in VAS from preoperative to postoperative)	Mean VAS change: −2.08 (−2.66, −1.49)	3	99	<.01
Pain difference, LP – LF (change in VAS from preoperative to postoperative)	Mean difference: 1.60 (0.36, 2.84)	3	63	.07

The random-effects model demonstrated a significant difference in treatment cost between LP and LF (mean difference = −$21,620.69 USD; 95% CI −$35,215.86 to −$8025.53 USD) (Figure 1). We found significant heterogeneity in cost reporting across studies (I² = 95%, P < .01).

Figure 1.

Forest Plot of Studies Showing Mean Difference in Total Index Hospital Cost after LP vs LF

Pooled Estimate for Pain in LP and LF

Three studies were included in the meta-analysis comparing changes in VAS between patients undergoing LP and LF.^23,27,30 When examining the mean change in VAS after surgery across studies, the LP group showed a smaller reduction in pain from baseline to postoperative assessment, with a mean change in VAS of −0.52 (95% CI −1.18 to 0.14), indicating no significant change postoperatively relative to baseline. In contrast, the LF demonstrated a larger reduction in pain, with a mean change of −2.08 (95% CI −2.66 to −1.49) postoperatively. The heterogeneity assessment for mean VAS change was low for the LP group (I² = 41%, P = .187) but high for the LF group (I² = 99%, P < .01), suggesting greater variability in LF pain outcomes across included studies (Table 3).

The meta-analyses of LP vs LF, with respect to magnitude of change in VAS from baseline to postoperative assessment, revealed a significant mean difference in VAS score between the 2 surgical approaches. The pooled mean difference was 1.60 (95% CI 0.36 to 2.84), suggesting that the LF group experienced a larger reduction in VAS scores compared to the LP group (Figure 2). There was significant heterogeneity among the included studies (I² = 63%, P = .07).

Figure 2.

Forest Plot of Studies Showing Mean Difference in Change in VAS after LP vs LF

Postoperative Opioid Use

Four studies reported outcomes for patient opioid use following LP and LF.^21-23,29 Due to variability in the reporting of opioid use outcomes across the studies, with 1 study reporting total inpatient opioid use in MME and 3 reporting the proportion of patients using opioids at varying follow-up intervals, a meta-analysis was not feasible. However, the extracted data provide relevant insights into opioid utilization patterns following LP and LF. Lightsey IV et al reported total inpatient opioid use, with the LF group requiring a higher opioid dose of 312 MME compared to 260 MME in the LP group (P = .03). Shankar et al examined opioid use at different time points within a single-surgeon cohort, demonstrating that the LF group had higher 6-month opioid use of 15.7% compared to 5.1% in the LP group (P = .02). This study also examined national cohort data, reporting 6-month opioid use of 10.4% in the LF group compared to 6.7% in the LP group (P = .09).

Bakr et al reported opioid use rates of 23.7% at 3 months and 8.5% at 1 year in the LF group, compared to 17.1% at 3 months and 10.5% at 1 year in the LP group (3-month P = .340, 1-year P = .689). This group also reported lower inpatient postoperative opioid consumption for the LF group (23 MME/day) compared to the LP group (30 MME/day), though this difference was not statistically significant (P = 1.00). Heller et al reported equal rates of narcotic use (7.7%) at the latest follow-up in both groups. Overall, there was considerable heterogeneity in reported opioid use postoperatively due to small sample sizes, variability in reporting methods, and differences in follow-up periods.

Return-to-Work

Only 1 study comparing LP and LF reported on return-to-work (RTW) rates at various time points, including 1, 3, 6, and 12 months postoperatively. At the 12-month follow-up, 88.9% of the LP cohort had returned to work compared to 64.3% of those who underwent LF.²⁰

Quality Assessment of Studies Comparing LP and LF

All twelve included observational studies were evaluated using the Newcastle-Ottawa Scale (NOS), with only 3, 25%, categorized as high-quality studies. The remaining studies were rated as moderate (N = 8, 67 %) and low quality (N = 1, 8%) due to several factors, including inadequate follow-up and lack of cohort comparability (Supplemental Table 2).

Discussion

This systematic review and meta-analysis provides important insights into the comparative effectiveness of LP vs LF for the treatment of DCM. Through the analysis of 12 retrospective studies encompassing 7581 patients, we found significant differences in treatment costs and postoperative pain outcomes between the 2 procedures while identifying important knowledge gaps in return-to-work outcomes and postoperative opioid use patterns.

We found a substantial difference in treatment costs between the 2 procedures, with LF associated with a higher average total hospital index cost $74,772.8 USD (95% CI $29,503.72 to $120,041.88 USD, I² = 100%) compared to $52,109.07 USD (95% CI $12,234.14 to $91,985.43 USD, I² = 100%) for LP. The pooled mean difference between LP and LF (MD = −$21,620.69 USD; 95% CI −$35,215 to −$8025.53 USD, I² = 95%) reinforces the significant cost difference associated with these 2 treatments. This cost differential likely reflects several factors, including the additional instrumentation required for fusion, longer operative times, and potentially extended hospital stays associated with LF. These differences in treatment costs have important implications in the context of value-based care. Prior studies have demonstrated that the lower cost associated with LP does not compromise safety or effectiveness. In fact, patients undergoing LP have been shown to experience shorter hospital length of stays, fewer complications, and reduced rates of unplanned reoperations, highlighting the potential of LP to serve as a cost-effective strategy in appropriately selected patients.^23,31 Conversely, in those with more significant cervical deformity, instability, or significant preoperative axial neck pain, LF may offer improved postoperative pain symptoms and structural correction.³² From a health system perspective, these comparative cost insights can support more nuanced surgical decision-making, guide institutional resource allocation, and inform the development of reimbursement policies that align with patient complexity and expected value of care. Overall, these estimates provide valuable reference points for healthcare systems and payers, though the high heterogeneity observed suggests that costs vary considerably across different healthcare settings and geographic regions.

Our analysis of pain outcomes revealed that LF was associated with a greater reduction in pain, from baseline to postoperative assessment, compared to LP (MD of change in VAS = 1.60, LP vs LF; 95% CI 0.36 to 2.84, I² = 63%). One possible explanation is that patients undergoing LF may have higher baseline axial neck pain, reflected in greater preoperative VAS scores, thereby allowing for greater absolute improvement post-operatively. While this differs from previous meta-analyses that reported no significant differences between the 2 treatments,^{5,6,9,11,12,33} our finding should be interpreted with caution given our smaller sample of included studies (n = 3). The limited number of studies in our analysis increases the risk of sampling error and reduces the precision of our effect estimate.

The examination of postoperative opioid use patterns, while limited by heterogeneous reporting methods, suggests a complex relationship between surgical approach and analgesic requirements. Some studies indicated higher early and late postoperative opioid requirements with LF,^21,22 while others showed comparable or lower usage patterns.^23,29 This variability underscores the need for standardized reporting of opioid outcomes in future prospective studies, particularly given the current emphasis on opioid stewardship in surgical practice.

The paucity of data on return-to-work outcomes represents a significant gap in the current literature. The single study reporting these outcomes suggested superior return-to-work rates with LP at 12 months (88.9% vs 64.3% for LF).²⁰ While this finding is intriguing and potentially related to the motion-preserving nature of LP, the limited data prevents firm conclusions about the relative impact of these procedures on occupational outcomes.

Limitations

This meta-analysis had several important limitations. Notably, since only studies that reported costs in USD were included in the pooled analysis, the generalizability of our findings is limited beyond the United States. Overall, there was a general lack of high-quality studies reporting on outcomes of interest, particularly on return-to-work and opioid use. All included studies were retrospective in design, with no prospective cohort or RCTs comparing LP and LF. There was significant heterogeneity amongst included studies, particularly in follow-up periods across studies, contributing to inconsistent outcomes. For example, all 3 studies reporting on postoperative VAS scores had different time points for assessment, corresponding to different follow-up intervals. A few studies had relatively small sample sizes (n < 15) within treatment arms, which can further affect the precision of effect estimates. Lastly, there was significant variability in outcome reporting across studies. For example, some studies examining cost reported total costs associated with the index surgery, while others reported on specific cost components such as implants. Similarly, studies examining postoperative opioid use varied, with some reporting inpatient opioid needs in MME and others focusing on the proportion of patients using opioids at different follow-up intervals.

Conclusion

In this systematic review and meta-analysis, we found some evidence demonstrating that in patients with multilevel DCM, there is a higher treatment cost but greater improvement in postoperative pain associated with LF compared to LP. However, due to significant heterogeneity of the included studies, these findings should be cautiously interpreted and warrant future prospective RCTs comparing these 2 treatments using standardized outcome measures.

Supplemental Material

Supplemental Material - Laminoplasty Versus Laminectomy and Fusion in the Treatment of Degenerative Cervical Myelopathy: A Systematic Review and Meta-Analysis of Cost and Patient-Centered Outcomes in the United States

Supplemental Material for Laminoplasty Versus Laminectomy and Fusion in the Treatment of Degenerative Cervical Myelopathy: A Systematic Review and Meta-Analysis of Cost and Patient-Centered Outcomes in the United States by Vishwathsen Karthikeyan, Husain Shakil, Christopher S. Lozano, Armaan K. Malhotra, Uzondu F. Agochukwu, Ankit I. Mehta, C. Rory Goodwin, Nathan Evaniew, Paul A. Koljonen, Allan R. Martin, James D. Guest, Kurpad SN, Jefferson R. Wilson, and Aditya Vedantam in Global Spine Journal

Footnotes

ORCID iDs

Vishwathsen Karthikeyan

Christopher S. Lozano

Armaan K. Malhotra

Ankit I. Mehta

C. Rory Goodwin

Paul A. Koljonen

Jefferson R. Wilson

Aditya Vedantam

Author Contributions

VK, HS, JRW, AV contributed to the conception and design of the study. Data collection and analysis were performed by VK and HS. VK drafted the manuscript. All authors provided critical revisions. Study supervision was provided by AV.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This supplement was organized and financially supported by AO Spine through the AO Spine Knowledge Forum Spinal Cord Injury, a focused group of international spine experts, and AO Spine North America. AO Spine is a clinical division of the AO Foundation, which is an independent medically-guided not-for-profit organization based in Davos, Switzerland

Data Availability Statement

Data supporting the findings of this study are available from the corresponding author upon request.*

Supplemental Material

Supplemental material for this article is available online.

References

Badhiwala

Ahuja

Akbar

, et al. Degenerative cervical myelopathy — update and future directions. Nat Rev Neurol. 2020;16(2):108-124. doi:10.1038/s41582-019-0303-0

Wilson

Tetreault

Kim

, et al. State of the art in degenerative cervical myelopathy: an update on current clinical evidence. Neurosurgery. 2017;80(3S):S33-S45. doi:10.1093/neuros/nyw083

Fehlings

Tetreault

Riew

, et al. A clinical practice guideline for the management of patients with degenerative cervical myelopathy: recommendations for patients with mild, moderate, and severe disease and nonmyelopathic patients with evidence of cord compression. Glob Spine J. 2017;7(3_suppl):70S-83S. doi:10.1177/2192568217701914

Ghogawala

Terrin

Dunbar

, et al. Effect of ventral vs dorsal spinal surgery on patient-reported physical functioning in patients with cervical spondylotic myelopathy: a randomized clinical trial. JAMA. 2021;325(10):942-951. doi:10.1001/jama.2021.1233

Liu

Yang

Huo

Wang

Yang

Ding

. Laminoplasty versus laminectomy and fusion for multilevel cervical compressive myelopathy: a meta-analysis. Medicine (Baltim). 2016;95(23):e3588. doi:10.1097/MD.0000000000003588

Phan

Scherman

Leung

Virk

Mobbs

. Laminectomy and fusion vs laminoplasty for multi-level cervical myelopathy: a systematic review and meta-analysis. Eur Spine J. 2017;26(1):94-103. doi:10.1007/s00586-016-4671-5

Weinberg

Rhee

. Cervical laminoplasty: indication, technique, complications. J Spine Surg. 2020;6(1):290-301. doi:10.21037/jss.2020.01.05

Pinter

Mikula

Reed

, et al.

Is severe neck pain a contraindication to performing laminoplasty in patients with cervical spondylotic myelopathy?

Clin Spine Surg. 2023;36(3):127-133. doi:10.1097/BSD.0000000000001444

Wang

Wen

Zhang

Wang

. Laminoplasty versus laminectomy with fusion for treatment of multilevel cervical compressive myelopathy: an updated meta-analysis. Postgrad Med J. 2022;98(1163):680-688. doi:10.1136/postgradmedj-2020-139667

10.

Yoon

Hashimoto

Raich

Shaffrey

Rhee

Riew

. Outcomes after laminoplasty compared with laminectomy and fusion in patients with cervical myelopathy: a systematic review. Spine. 2013;38:S183-S194. doi:10.1097/BRS.0b013e3182a7eb7c

11.

Yuan

Wei

Gan

Cao

Luo

. Comparison of laminectomy and fusion vs laminoplasty in the treatment of multilevel cervical spondylotic myelopathy: a meta-analysis. Medicine (Baltim). 2019;98(13):e14971. doi:10.1097/MD.0000000000014971

12.

Zhao

Ren

, et al. Comparison of laminoplasty vs. laminectomy for cervical spondylotic myelopathy: a systematic review and meta-analysis. Front Surg. 2022;8:790593. doi:10.3389/fsurg.2021.790593

13.

Page

McKenzie

Bossuyt

, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. doi:10.1136/bmj.n71

14.

Ottawa hospital research institute. https://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. Accessed October 28, 2024.

15.

CPI inflation calculator. https://data.bls.gov/cgi-bin/cpicalc.pl. Accessed October 31, 2024.

16.

Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range | BMC Medical Research Methodology | Full Text. doi:10.1186/1471-2288-14-135. Accessed October 28, 2024.

17.

Cochrane handbook for systematic reviews of interventions. https://training.cochrane.org/handbook/archive/v6.4. Accessed October 28, 2024.

18.

Higgins

JPT

Thompson

Deeks

Altman

. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414):557-560. doi:10.1136/bmj.327.7414.557

19.

Chua

Lim

Hershman

Fogel

Tobert

. Cervical laminoplasty versus laminectomy and fusion: a comprehensive time-driven activity-based cost analysis. Spine. 2024;49:1555-1560. doi:10.1097/BRS.0000000000005150

20.

Miranda

Whitmore

Kanter

, et al. Patients may return to work sooner after laminoplasty: occupational outcomes of the cervical spondylotic myelopathy surgical trial. Neurosurgery. 2025;96:131-141. doi:10.1227/neu.0000000000003048

21.

Lightsey

Georgakas

Lindsey

, et al. Inpatient opioid use varies by construct length among laminoplasty versus laminectomy and fusion patients. N Am Spine Soc J. 2023;16:100229. doi:10.1016/j.xnsj.2023.100229

22.

Shankar

Kim

Bienstock

, et al. Postoperative opioid use and prescribing patterns among patients undergoing cervical laminectomy with instrumented fusion versus cervical laminoplasty with reconstruction. Glob Spine J. 2024;14(2):561-567. doi:10.1177/21925682221116825

23.

Bakr

Soufi

Jones

, et al. Laminoplasty versus laminectomy with fusion for treating multilevel degenerative cervical myelopathy. N Am Spine Soc J. 2023;15:100232. doi:10.1016/j.xnsj.2023.100232

24.

Jain

Sharma

Wang

Ugiliweneza

Drazin

Boakye

. Simulated bundled payments for 4 common surgical approaches to treat degenerative cervical myelopathy: a consideration to break the clinical equipoise. Clin Spine Surg. 2022;35(8):E636-E642. doi:10.1097/BSD.0000000000001315

25.

Goh

Striano

Lopez

, et al. Laminoplasty versus laminectomy and fusion for cervical spondylotic myelopathy: a cost analysis. Spine J. 2020;20(11):1770-1775. doi:10.1016/j.spinee.2020.07.012

26.

Warren

Ricart-Hoffiz

Andres

, et al. Retrospective cost analysis of cervical laminectomy and fusion versus cervical laminoplasty in the treatment of cervical spondylotic myelopathy. Int J Spine Surg. 2013;7(1):e72-e80. doi:10.1016/j.ijsp.2013.04.001

27.

Highsmith

Dhall

Haid

Rodts

Mummaneni

. Treatment of cervical stenotic myelopathy: a cost and outcome comparison of laminoplasty versus laminectomy and lateral mass fusion: clinical article. J Neurosurg Spine. 2011;14(5):619-625. doi:10.3171/2011.1.SPINE10206

28.

Adogwa

Huang

Hazzard

, et al. Outcomes after cervical laminectomy with instrumented fusion versus expansile laminoplasty: a propensity matched study of 3185 patients. J Clin Neurosci. 2015;22(3):549-553. doi:10.1016/j.jocn.2014.10.001

29.

Heller

Edwards

Murakami

Rodts

. Laminoplasty versus laminectomy and fusion for multilevel cervical myelopathy: an independent matched cohort analysis. Spine. 2001;26(12):1330-1336. doi:10.1097/00007632-200106150-00013

30.

Blizzard

Caputo

Sheets

, et al. Laminoplasty versus laminectomy with fusion for the treatment of spondylotic cervical myelopathy: short-term follow-up. Eur Spine J. 2017;26(1):85-93. doi:10.1007/s00586-016-4746-3

31.

McDonald

Hershman

Hogan

, et al. Cervical laminoplasty versus posterior laminectomy and fusion: trends in utilization and evaluation of complication and revision surgery rates. J Am Acad Orthop Surg. 2022;30:858. https://journals.lww.com/jaaos/abstract/2022/09010/cervical_laminoplasty_versus_posterior_laminectomy.6.aspx. Accessed June 3, 2025.

32.

Park

Lee

. Choosing the right treatment for degenerative cervical myelopathy. J Clin Orthop Trauma. 2025;66:103014. doi:10.1016/j.jcot.2025.103014

33.

Daher

Nassar

McDonald

Balmaceno-Criss

Diebo

Daniels

. Laminoplasty versus laminectomy and posterior fusion for cervical myelopathy: a meta-analysis of radiographic and clinical outcomes. Spine. 2024;49(18):1311-1321. doi:10.1097/BRS.0000000000005041

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