Patients with severe posterior longitudinal ligament ossification in OPLL have significant postoperative recovery of their symptoms by surgical removal of the ossification in its entirety via the anterior approach with the dura intact. Posterior surgery is generally recommended for OPLL canal occupancy rates above 50%, and posterior surgery is relatively less risky. However, for symptomatic recovery, it is clear that the anterior approach is theoretically better for direct removal of the compression material, but it requires a higher surgical technique, and the risk of dural rupture, cerebrospinal fluid leakage, and worsening of neurological symptoms is significantly higher, and should be chosen carefully.