Review Posterior longitudinal ligament resection or preservation in anterior cervical decompression surgery M.J. Avila, J. Skoch, K. Sattarov, S. Abbasi, A. Patel, C.M. Walter, A.A. Baaj ⇑ a Division of Neurosurgery, University of Arizona, Tucson, AZ 85724-5070, USA article info Article history: Received 6 November 2014 Accepted 5 January 2015 Available online xxxx Keywords: ACDF Anterior cervical Cervical vertebrae Discectomy Posterior longitudinal ligament abstract We reviewed the literature to determine differences in clinical outcomes for the removal or preservation of the posterior longitudinal ligament (PLL) in anterior cervical discectomy and fusion (ACDF). The out- comes are surgeon and case-dependent for both practices. A literature review was performed in PubMed from the years 1960 to 2014 to identify studies describing surgeries where the PLL was removed or preserved during ACDF. Searches were performed using Medical Subject Headings (MeSH) and refer- ences included in the reviewed articles were also considered. Additionally we searched recent articles that cited those from the original search. The search yielded 79 articles and 115 pertinent citations. These 194 articles were reviewed for specific discussions of PLL resection or preservation. Four articles containing 122 patients were included in the final analysis. In 69 patients the PLL was removed and in 53 the PLL was preserved. Both groups improved in clinical scores during follow up. One patient in the PLL removal group had a cerebrospinal fluid leak. MRI and correlative outcome data suggest that a non-ossified PLL itself does not contribute to significant cord compression. Postoperative MRI of patients with the PLL removed showed a larger spinal cord diameter. Resection of the PLL is safe and common in ACDF surgery but there does not appear to be a demonstrable clinical difference in patients where it is resected. The ultimate decision is likely surgeon and case-dependent. Randomized trials could further determine the importance of PLL removal in ACDF treated patients. Ó 2015 Elsevier Ltd. All rights reserved. 1. Introduction The anterior cervical discectomy and fusion (ACDF) technique is the most common procedure for the treatment of cervical myelo- radiculopathy. The technique was originally described by Cloward in 1958, [1] and since then has gained enormous success with relatively little modification in technique. More than one mil- lion cervical spine procedures were performed between 2002 and 2009 and of those, 80% were anterior cervical and fusion, [2] more than all the posterior approaches combined. Up to 95% of patients with preoperative weakness treated with an ACDF procedure experience some motor recovery after the surgery [3]. Additionally, economic studies have found that ACDF is a cost- effective procedure for treating patients with disc herniation that causes radiculopathy [4]. However, controversy still exists over the management (removal or preservation) of the posterior longitudinal ligament (PLL) in the ACDF approach [5]. There are risks and benefits for either option but the practice appears to be surgeon-dependent. Without clear guidelines on this important topic, we sought to per- form a comprehensive review to determine differences in out- comes and complications after ACDF surgery with or without PLL resection. To the best of our knowledge, this is the first review to address this important subject. 2. Methods A literature review was performed in September 2014 using the MEDLINE database via PubMed for English language articles pub- lished between the years 1960 and 2014. The search terms were derived from the Medical Subject Heading (MeSH) database. If not available, the term was searched as a free word and terms included posterior longitudinal ligament, anterior neck, cervical spine, cervical surgery, discectomy, and discectomy and fusion. A second search was performed adding the term ACDF, specifi- cally in addition to the terms above. Two experienced physicians (MJA and AAB) selected the articles for further review based on perceived relevance. After this, the chosen articles were reviewed by the authors. In an effort to expand on the known information http://dx.doi.org/10.1016/j.jocn.2015.01.021 0967-5868/Ó 2015 Elsevier Ltd. All rights reserved. ⇑ Corresponding author. Tel.: +1 520 626 2164; fax: +1 520 626 8313. E-mail address: abaaj@surgery.arizona.edu (A.A. Baaj). Journal of Clinical Neuroscience xxx (2015) xxx–xxx Contents lists available at ScienceDirect Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn Please cite this article in press as: Avila MJ et al. Posterior longitudinal ligament resection or preservation in anterior cervical decompression surgery. J Clin Neurosci (2015), http://dx.doi.org/10.1016/j.jocn.2015.01.021