Systematic review and meta-analysis.To compare the effectiveness and safety between the anterior and posterior approach, and identify the more effective surgical approach for treating ossification of the posterior longitudinal ligament (OPLL) in the cervical spine.This meta-analysis searched three electronic databases (PubMed, Embase, Cochrane library), including 17 randomized and non-randomized controlled studies published since 2000-2023 that compared the effectiveness and safety of anterior and posterior surgical approaches for the treatment of ossification of the posterior longitudinal ligament. Japanese Orthopaedic Association (JOA) scores, functional recovery rates, excellent and good outcomes of the surgical approaches, Visual Analogue Scale (VAS), C2-C7 angle cobb and complication were analyzed. RevMan 5.3 was utilized for data analysis.This study suggested that there were no statistically differences between the anterior group and posterior group in terms of preoperative JOA score [WMD=0.23, 95% CI, (-0.22, 0.67), P=0.32], preoperative VAS [WMD=0.03, 95% CI, (-0.24, 0.30)], postoperative VAS [WMD=-0.16, 95% CI, (-0.47, 0.15) P=0.97] function recovery rate of patients with canal narrowing ratio less than 50-60% [WMD=-1.54, 95% CI, (-4.46, 1.38), P=0.30]. The anterior group showed higher postoperative JOA score [WMD=0.99, 95% CI, (036,1.63) P<0.05], post C2-C7 angle cobb [WMD=2.62, 95% CI, (0.36, 4.87), P=0.02] as well as function recovery rate (regardless of canal narrowing ratio) [WMD=16.05, 95% CI, (14.08, 18.03), P<0.05], especially a significant higher function recovery rate of patients with canal narrowing ratio greater than 50-60% [WMD=19.32, 95% CI, (17.25, 21.40), P<0.05]. There was a significant difference between anterior group and posterior group in complication. [OR=0.12, 95% CI, (0.01, 0.24), P<0.05].Based on the study's finding, The study suggested that when the conservative treatment for OPLL is unsatisfied, the surgical approach of entering through the anterior approach is a better choice. Nevertheless, it is still necessary to consider the specific situation of the patient. One of the next research directions is how to reduce the complications of anterior surgery.Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.