Dear Editor,We read with great interest the recent paper by Zhu et al. [1] ''Anterior approach versus posterior approach for the treatment of multilevel cervical spondylotic myelopathy: a systemic review and meta-analysis'' published online in European Spine Journal. In this article, the authors performed a meta-analysis to compare the clinical outcomes, complications, and surgical trauma between anterior and posterior approaches for the treatment of multilevel cervical spondylotic myelopathy (CSM), and did very well. While the question being asked is an important one, there are some methodological aspects of this study which give cause for concern.1. Authors searched only three electronic databases (MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials databases) for studies, compared anterior and posterior surgical approaches for the treatment of multilevel cervical spondylotic myelopathy. The small number of required papers would be an important limitation of the review. We suggest more electronic databases should be systematically searched. 2. The results of the meta-analysis further suggested that there were significant heterogeneities between studies in Fig. 4 (I 2 = 81 %) and Fig. 6 (I 2 = 53 %). Meanwhile, the studies were combined using the method of inverse variance (IV) with the assumptions of a fixedeffects model, rather than DerSimonian and Laird random-effects model. In our opinion, the studies should be combined by DerSimonian and Laird random-effects model [2], which considers both within-and between-study variations. 3. The authors never mention potential importance of publication bias in the limitations of their metaanalysis. We suggest that the publication bias is still needed to be assessed by visual examination of funnel plot and statistical tests (e.g., Egger's linear regression test or Begg's rank correlation test).We agree on the following conclusions of the authors: the anterior approach was associated with better postoperative neural function than the posterior approach in the treatment of multilevel CSM. There was no apparent difference in the neural function recovery rate. The complication and reoperation rates were significantly higher in the anterior group compared with the posterior group. The surgical trauma associated with corpectomy was significantly higher than that associated with laminoplasty/laminectomy. We believe that our remarks will contribute to more accurate elaboration of the results presented by Zhu et al.