Article Reviewed Bakr O, Soufi K, Jones Q, et al. Laminoplasty versus laminectomy with fusion for treating multilevel degenerative cervical myelopathy. N Am Spine Soc J. 2023;15:100232. Published 2023 May 30. doi:10.1016/j.xnsj.2023.100232 https://pubmed.ncbi.nlm.nih.gov/37416091/ Commentary The reviewed study by Bark et al is a retrospective review that assessed outcomes and costs associated with adult patients with degenerative cervical myelopathy (DCM) undergoing laminectomy with fusion (LF) versus laminoplasty (LP). This study is of interest as, in the United States, LP is not as commonly performed compared to LF and controversy exists as to which procedure is most optimal for DCM patients. Study patients were 18 years of age and older with a primary diagnosis of DCM who underwent multilevel (3 or more levels) LF or LP between January 1, 2014, and September 30, 2020. Patients were excluded if they had previous cervical spine surgery, or diagnoses of cancer, acute trauma, or infection. Clinical data was obtained via chart review and hospital costs were obtained from the hospital billing department. Radiographic measurements included C2-7 cervical lordosis angle, cervical sagittal vertical axis (cSVA) and T1 slope angle for patients who had 3 months or more of follow up. For the LF group, 59 patients were included (average age 65.5 years, 57.6% female); in the LP group, 76 (average age 60.5 years, 35.5% female). There were no significant differences between the groups with regards to body mass index, tobacco use, American Society of Anesthesiologists score, or diabetes status. The LF group had a significantly greater number of operative levels (average 6.9 vs 4.2) and greater number of levels decompressed (4.8 vs 4.2). There was a significant difference with regards to inclusion of C7 between the two groups with the LF group including C7 in 81% of patients compared to the LP group (31.6%). LP patients had significantly greater cervical lordosis at baseline compared with LF patients (11.8° vs 6.9°) but similar cSVA and T1 slope. In terms of hospital course, the operation time was longer in the LF group, but there was no difference in EBL or fluid replacement. LOS was shorter in the LP group by about 1 day. Wound infection/dehiscence was higher in the LF compared with LP group (13.6% vs 5.9%, RR of 5.15, p=0.021). The LF group also had a higher rate of unplanned return to OR within 30 days (11.9% vs 2.6%, p=0.041) and were more likely to visit the ED following a ground level fall within 24 months (11.9% vs 2.6%, p =0.041). No statistical differences were seen in other complications; however, 2 patients in the LF cohort sustained a dural tear compared to 0 patients in the LP group. Postoperative neck pain and utilization of opioids were similar. Patients with less than 3 months of follow up were excluded from radiographic analysis leaving 57 patients with average follow up of 12 months in the LF group and 75 patients with average follow up of 13.3 months in the LP group. Both groups lost similar lordosis with surgery with ultimate lordosis comparable for the two groups. sCVA were similar for the two groups. There was a significant decrease in T1 slope in the LP group (-4.4°) but this did not significantly change in the LF group (+0.2°). Postoperative C5 palsy was not statistically different between the groups (11.9% vs 6.6% but with p=0.284). In terms of costs, the LP cases incurred 18.6% and 34.5% lower fixed and variable hospital costs compared to LF cases (p = 0.03 and p < 0.001). One factor that is hard to control with such studies is patient selection. There were differences in patient characteristics, alignment, and number of levels treated between the groups. The authors do not discuss how patients were selected for each procedure. These variables may have contributed to treatment selection. With regards to surgical/hospital variables, the authors report a reduced length of stay and complications in the LP group. The higher rates of wound issues and unplanned return to the operating room are important, but notable that the rates seem high compared to expected. The authors also reported similar rates of postoperative neck pain, utilization of opioids and C5 palsy in both groups, despite previous studies suggesting a higher rate in patients who underwent LP. The overall costs of LP are reported to be lower than LF. Although postoperative pain was evaluated, other patient reported outcomes (PROs) and metrics such as return to work and degree of decompression were not assessed. Furthermore, although the average follow up period was over a year in both cohorts, the large standard deviation suggests that some patients had short follow up. The authors also excluded patients with follow up less than 3 months, but their radiographic measurements seemed to have been recorded at 6 to 10 weeks after patient discharge and no long-term radiographic measurements were included. Nevertheless, the study provides insight into the possible benefits of LP compared with LF for DCM patients with appropriate baseline cervical lordosis, and without spinal instability. These benefits include possible reduced patient morbidity with lower hospital costs, operation time, length of stay and complication rates. This study also highlights the need for prospective studies including high quality randomized controlled trials investigating not only clinical but also long-term radiographic outcomes of these procedures.