Anterior Cervical Discectomy and Fusion Achieves Outcomes Comparable to Laminoplasty in Patients With Spinal Cord-Canal Mismatch

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To compare the clinical and radiographic outcomes of anterior cervical discectomy and fusion (ACDF) and laminoplasty in patients with cervical myelopathy complicated by spinal cord-canal mismatch (SCCM). SUMMARY OF BACKGROUND DATA: SCCM, defined by a high spinal cord occupation ratio (SCOR), represents a congenital or developmental stenosis that may complicate surgical decision-making. Although laminoplasty provides indirect posterior decompression, ACDF offers direct ventral decompression and correction of local alignment. Comparative evidence in patients with SCCM-related myelopathy remains limited. METHODS: A retrospective review was conducted of 323 patients who underwent ACDF and 244 who underwent laminoplasty between 2014 and 2020. Patients with SCOR ≥0.7 on magnetic resonance imaging and a minimum 2-year follow-up were included. Clinical outcomes included the Japanese Orthopaedic Association (JOA) score, recovery rate, and Visual Analog Scale (VAS) for neck and arm pain. Radiographic parameters (C2-C7 sagittal vertical axis, cervical lordosis) and incidence of adjacent segment degeneration (ASD) were analyzed. RESULTS: Thirty-nine ACDF and 22 laminoplasty patients met the inclusion criteria. Baseline demographics were comparable, except for a higher prevalence of hypertension and more operated levels in the laminoplasty group. Both procedures significantly improved JOA scores with no difference in recovery rate (P=0.901). Neck and arm pain improved significantly after ACDF but not after laminoplasty, although between-group differences were not significant. Radiographic parameters were similar at follow-up. Symptomatic ASD occurred in 20.5% of patients with ACDF and in none after laminoplasty (P=0.079). Neither SCOR nor surgical approach independently predicted neurological recovery. CONCLUSIONS: ACDF and laminoplasty achieved comparable neurological recovery in SCCM-related myelopathy. Laminoplasty may reduce ASD risk, whereas ACDF yields comparable outcomes when decompression is sufficient. SCCM alone should not contraindicate anterior surgery; approach selection should consider alignment, pathology, and symptoms. LEVEL OF EVIDENCE: Level IV.