Anterior Cervical Discectomy and Fusion Provides Better Outcome Compared to Posterior Cervical Foraminotomy When Foramen is Vertically Narrow.

Abstract

Posterior cervical foraminotomy (PCF) cannot widen the neural foramen vertically, whereas anterior cervical discectomy and fusion (ACDF) could increase foraminal height (FH) by distracting the disc space. To compare the clinical and radiographic outcomes between ACDF and PCF in patients with cervical radiculopathy and vertically narrow foramina (FH <6 mm). Retrospective cohort study. Patients who underwent single- or multi-level ACDF (n=44) or PCF (n=33) between 2015 and 2022 and had at least one neural foramen with FH <6 mm were retrospectively analyzed. Clinical outcomes included visual analog scale (VAS) scores for neck and arm pain and the Neck Disability Index (NDI), assessed preoperatively and at 3 months and 2 years postoperatively. Radiographic parameters included FH, C2-C7 sagittal vertical axis, and cervical range of motion. Revision surgery rates and causes were also evaluated. Between-group comparisons of continuous variables were conducted using Student's t-test, whereas categorical variables were analyzed using the chi-squared test. Paired t-tests were used to compare repeated measures over time. Intra-observer reliability of radiographic measurements was assessed using intraclass correlation coefficients. Preoperative demographics and clinical scores were comparable between the groups. Postoperative FH significantly increased only in the ACDF group (p<0.001) and was significantly greater than that in the PCF group at both 3 months and 2 years (p<0.001). Neck and arm pain VAS scores significantly worsened in the PCF group between 3 months and 2 years postoperatively (p=0.003 and p=0.003, respectively) but remained stable in the ACDF group. At 2 years, the VAS scores for neck and arm pain were significantly worse in the PCF group (p=0.004 and p=0.036, respectively). Although the overall revision rates did not significantly differ (ACDF 6.8% vs. PCF 12.1%, p=0.161), all PCF revisions were owing to recurrence of radiculopathy at the index level (p=0.030), whereas ACDF revisions were unrelated to index-level pathology. In patients with vertically narrow foramina (FH <6 mm), ACDF provides superior long-term pain relief and better restoration of FH than PCF. In this subset of patients, PCF may be associated with an increased risk of symptomatic recurrence at the index level. FH should be considered when selecting a surgical approach for cervical radiculopathy.