Abstract
To the Editor,
We read with great interest the systematic review and meta-analysis by Karthikeyan et al. 1 comparing laminoplasty (LP) and laminectomy with fusion (LF) for degenerative cervical myelopathy (DCM). Their effort to synthesize cost and patient-centered outcomes across multiple U.S. cohorts represents a valuable contribution to value-based spine care. The authors should be commended for addressing return-to-work, pain reduction, and cost domains often overlooked in prior meta-analyses.
Several aspects, however, merit clarification. The greater postoperative pain improvement after LF (mean difference 1.60; 95% CI 0.36-2.84) likely reflects indication bias, since fusion is typically reserved for patients with kyphosis, instability, or severe axial pain. Without adjustment for baseline deformity or preoperative VAS, pooled estimates may conflate indication with treatment effect. 2 Moreover, the substantial heterogeneity in cost reporting (I2 = 95%) underscores inconsistent definitions—some studies analyzed implant costs alone, others total hospitalization—which complicates interpretation. A standardized health-economic framework, such as that recommended for surgical evaluations, is needed to ensure comparability. 3 In addition, pooling “last-follow-up” pain data from 6 to 48 months may mask temporal differences in recovery trajectories between LP and LF. 4
Another limitation is the omission of validated functional and quality-of-life metrics, including the modified Japanese Orthopedic Association (mJOA) score, Neck Disability Index, and EuroQol-5D. Integration of these metrics is essential for interpreting pain and cost findings in the broader context of neurologic recovery. 5 Furthermore, sparse and heterogeneous reporting of postoperative opioid use and return-to-work outcomes precluded quantitative synthesis, restricting conclusions about long-term, patient-centered recovery.
Future research should employ prospective, multicenter designs with standardized definitions for cost, pain, and functional outcomes, coupled with longitudinal follow-up to distinguish early from sustained effects. Such methodological rigor will clarify comparative value between LP and LF and strengthen evidence-based surgical decision-making in DCM.
