Posterior foraminotomy versus anterior decompression and fusion in patients with cervical degenerative disc disease with radiculopathy: up to 5 years of outcome from the national Swedish Spine Register

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>The long-term efficacy of posterior foraminotomy compared with anterior cervical decompression and fusion (ACDF) for the treatment of degenerative disc disease with radiculopathy has not been previously investigated in a population-based cohort.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>All patients in the national Swedish Spine Register (Swespine) from January 1, 2006, until November 15, 2017, with cervical degenerative disc disease and radiculopathy were assessed. Using propensity score matching, patients treated with posterior foraminotomy were compared with those undergoing ACDF. The primary outcome measure was the Neck Disability Index (NDI), a patient-reported outcome score ranging from 0% to 100%, with higher scores indicating greater disability. A minimal clinically important difference was defined as &gt; 15%. Secondary outcomes were assessed with additional patient-reported outcome measures (PROMs).</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>A total of 4368 patients (2136/2232 women/men) met the inclusion criteria. Posterior foraminotomy was performed in 647 patients, and 3721 patients underwent ACDF. After meticulous propensity score matching, 570 patients with a mean age of 54 years remained in each group. Both groups had substantial decreases in their NDI scores; however, after 5 years, the difference was not significant (2.3%, 95% CI −4.1% to 8.4%; p = 0.48) between the groups. There were no significant differences between the groups in EQ-5D or visual analog scale (VAS) for neck and arm scores. The secondary surgeries on the index level due to restenosis were more frequent in the foraminotomy group (6/100 patients vs 1/100), but on the adjacent segments there was no difference between groups (2/100).</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>In patients with cervical degenerative disc disease and radiculopathy, both groups demonstrated clinical improvements at the 5-year follow-up that were comparable and did not achieve a clinically important difference from one another, even though the reoperation rate favored the ACDF group. This study design obtains population-based results, which are generalizable.</jats:p></jats:sec>

Transtubular Anterior Cervical Foraminotomy for the Treatment of Compressive Cervical Radiculopathy: Surgical Results and Complications in a Consecutive Series of Cases

“…In terms of reoperation rate at the index level, the overall reoperation rate in this study was comparable with that reported in the literature for ACDF and other ACF series [5,8,[11][12][13]15,16,21,22,29] whereas PCF was reported to have a higher reoperation rate than ACF [6,30].…”

Operative treatment of cervical radiculopathy: anterior cervical decompression and fusion compared with posterior foraminotomy: study protocol for a randomized controlled trial

“…Both methods seem to result in a high frequency of clinical success with low incidences of complications and reoperations according to retrospective data, but at different costs as no implants are utilized in PF [37]. In an observational registry study, we did not find any difference between the two methods in terms of clinical outcome, complications, and reoperations [34]. As there may be undetected selection bias and underreporting of complications in a registry study, the results need to be confirmed in studies with higher level of evidence.…”

“…We believe that PF may in the long term have unremitting degeneration issues and that the risk for restenosis will increase over time. The reason may be the partial facetectomy in a loadbearing joint, in which the degeneration will continue [34].…”

“…The incidence of ASD is 6.7% 10 years after one level of PF, with 3.2% requiring reoperation for ASD [33]. The preserved motion may lead to restenosis as the degeneration continues with the risk of secondary surgery on the index level [34]. PF will lead to clinical success in 64-96% with a reoperation incidence of 4-7% in retrospective cohort studies [22][23][24][25][26][27][28][29][30][31][32][35][36][37].…”

Fully endoscopic cervical spine surgery: What does the future hold?

“…Undoubtedly, ACDF procedures currently vastly outnumber the PCF of all types for cervical radiculopathy. In a recent study 7 published from the Swedish registry in 2020, of the total of 4368 procedures, only 647 were PCFs. Another study published from a north American cohort, had 4852 patients with PCF and 46147 patients in ACDF group.…”