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This is a retrospective observational single-center study.To compare anterior decompression and fusion (ADF) and laminoplasty (LAMP) for the treatment of cervical spondylotic myelopathy (CSM) patients with large anterior compression in terms of clinical and radiologic outcomes.We have reported that insufficient posterior decompression could be often seen after laminoplasty for CSM patients with preoperative anterior clearance of the spinal cord, defined as an interval <4 mm between the preoperative the modified K-line and anterior structure of the spinal canal at most compressive segment on sagittal T1-weighted magnetic resonance imaging. Here we conduct a study comparing ADF and LAMP for the treatment of CSM patients with such a risk factor.Of the 221 consecutive CSM patients treated with either ADF or LAMP between 2008 and 2012 at our hospital, 79 patients in whom the interval was <4 mm with age ranged from 50 to 79 years were enrolled. Patients with myelopathy caused by single-level disk herniation, tumor or ossification of posterior longitudinal ligament, or patients with a history of cervical spine injury were excluded. The Japanese Orthopedic Association (JOA) scoring system for cervical myelopathy, recovery rate of the JOA score at the time of 2 years after surgery were investigated as clinical outcomes to compare these 2 groups.Demographics were almost similar between ADF and LAMP groups. The mean preoperative and postoperative JOA scores were 10.9 and 13.8 points for ADF group and 10.1 and 12.4 points for LAMP group, indicating that the recovery rate of JOA score was significantly greater in ADF group (49.6%) than that in LAMP group (38.2%; P=0.047). In LAMP group, spinal cord deformity was a significant predictive factor for unsatisfactory clinical outcome.ADF provided better surgical treatment for the patients with absence of preoperative anterior clearance of the spinal cord.