Comparing Mid-Term Outcomes Between ACDF and Minimally Invasive Posterior Cervical Foraminotomy in the Treatment of Cervical Radiculopathy

Arash Emami, MD; Daniel Coban, MD; Stuart Changoor, MD; Conor Dunn, MD; Nikhil Sahai, MD; Kumar Sinha, MD; Ki Soo Hwang, MD; Michael Faloon, MD


Spine. 2022;47(4):324-330. 

In This Article

Abstract and Introduction


Study Design: Retrospective cohort study.

Objective: To compare minimally invasive posterior cervical foraminotomy (MI-PCF) and anterior cervical discectomy and fusion (ACDF) in the treatment of unilateral cervical radiculopathy.

Summary of Background Data: MI-PCF has been shown to be equally effective as ACDF in treating cervical radiculopathy due to foraminal stenosis and similar pathologies. Additionally, it has been hypothesized that preserving motion and avoiding fusion reduces risk for adjacent segment disease, but potentially increases risk for subsequent revision to an ACDF. With similar short-term outcomes and substantial advantages, MI-PCF may be an effective alternative to ACDF for addressing appropriate cervical pathology.

Methods: A retrospective review was performed to identify patients between 2009 and 2013 who underwent ACDF or MI-PCF with a minimum follow-up of 7 years. Demographic data was recorded. Revision rates and average time to revision between cohorts were compared. Clinical outcomes were assessed at each follow-up visit with Neck Disability Index and Visual Analog Scale for neck and Visual Analog Scale for arm pain scores. All complications were reviewed. Standard binomial and categorical comparative analysis were performed.

Results: A total of 251 consecutive patients were included (205 ACDF, 46 MI-PCF). Mean follow-ups for the ACDF and MI-PCF groups were 98.3 and 95.9 months, respectively. Complication rates were 2.9% and 2.2% for the ACDF and MI-PCF cohorts, respectively (P = 0.779). Revision rates were 7.8% for the ACDF cohort and 8.7% for the MI-PCF cohort (P = 0.840). Both cohorts experienced significant improvements in their clinical scores compared with their preoperative values. Final Visual Analog Scale for neck pain (ACDF: 2.6; MI-PCF: 1.6) and Visual Analog Scale for arm pain (ACDF: 1.1; MI-PCF: 0.4) scores differed significantly at final follow-up (P = < 0.001; P = < 0.001).

Conclusion: MI-PCF is a safe and effective alternative to ACDF in the treatment of cervical radiculopathy, demonstrating substantial benefit. After final follow-up, MI-PCF demonstrated superior improvements in Visual Analog Scale scores, without increased complication or revision rates.

Level of Evidence: 3


Cervical radiculopathy is a common source of impairment in the population and one of the most frequently encountered conditions addressed by spine surgeons.[1,2]

Bearing an annual incidence of approximately 83 per 100,000 people, the consequence of such pathology is the cause of significant burden from both an economic and healthcare systems standpoint.[3,4] Initially described by Smith and Robinson in 1958, anterior cervical discectomy and fusion (ACDF) has since become widely accepted as the standard treatment for cervical radiculopathy.[5,6] However, due to a number of disadvantages common to ACDF including the development of symptomatic adjacent segment disease (ASD), pseudarthrosis, loss of motion segments, and postoperative dysphagia, the use of novel minimally invasive approaches has become increasingly more favorable for treating cervical radiculopathy.[7,8]

Minimally invasive posterior cervical foraminotomy (MI-PCF) was initially described in cadaveric models by Roh et al in 2000 and first reported by Adamson in 2001 on 100 consecutive patients.[9–11] Compared with ACDF, studies have demonstrated notable advantages of MI-PCF including shortened hospital stay and quicker return to work, reduced blood loss, medication use, and cost.[12,13] Additionally, preserved range of motion due to the avoidance of fusion has been hypothesized to contribute to a lower risk of ASD and other complications leading to revision surgery in the long term.[8] However, recent studies with relatively short-term follow-up have demonstrated a comparable revision rate between MI-PCF and ACDF.[14,15]

MI-PCF may be an effective alternative approach to ACDF for addressing cervical radiculopathy in the population. Current existing studies have failed to confirm mid-term outcomes of the procedure compared with ACDF as there is a paucity of reports in the literature addressing the effectiveness of MI-PCF to the current standard of care. Therefore, the objective of this study was to compare MI-PCF to ACDF in the treatment of unilateral cervical radiculopathy by analyzing revision rates, average time to revision, complications, and patient-reported clinical outcome scores after mid-term follow-up.