Objective <p>The anterior approach for cervical ossification of posterior longitudinal ligament (OPLL) excision can improve long-term neurofunctional recovery by providing direct spinal cord decompression. The objective of the present study was to compare the clinical outcomes and complications between accurate anterior cervical ossified posterior longitudinal ligament en bloc resection (ACOE) versus piecemeal resection (ACOP) using propensity score-matching analysis.</p> Methods <p>Included in this study were 189 OPLL patients (65 female) who underwent anterior cervical surgery, with a mean age of 54.85 years. Of them, 105 patients (39 female) with a mean age of 55.69 years underwent ACOE, and the remaining 84 patients (26 female) with a mean age of 53.80 underwent ACOP. Of the 189 patients, 70 patients (37%) had a canal occupying ratio (COR) ≥ 50%, and therefore the patient data were stratified by COR with 50%. The clinical outcomes were compared between the two groups during a at least 27-month follow-up period.</p> Results <p>The mean final follow-up JOA score in ACOE group was higher than that in ACOP group. The JOA recovery rate of patients with COR ≥ 50% was higher in ACOE group. The mean operative time and intraoperative blood loss were both lower in ACOE group. However, postoperative complications were not significantly different between the two groups.</p> Conclusion <p>This study demonstrated that the ACOE technique gained higher JOA recovery rates and better neurological recovery than ACOP for OPLL patients with COR ≥ 50%. In addition, ACOE offered a shorter operative time and less intraoperative blood loss as compared with ACOP. Therefore, the postoperative complications were not more common between two groups.</p>