Long-Term Comparative Outcomes of ACDF, Cervical Disc Arthroplasty, and Posterior Cervical Foraminotomy for Single-Level Cervical Radiculopathy: A Propensity-Matched Analysis

Study Design Retrospective cohort study. Objective The incidence of cervical radiculopathy is expected to increase by over 30% by 2050. ACDF, CDA, and PCF are established surgical options, each with distinct risk-benefit profiles. The objective of the present investigation is to compare long-term outcomes and complications among anterior cervical discectomy and fusion (ACDF), cervical disc arthroplasty (CDA), and posterior cervical foraminotomy (PCF). Methods A retrospective analysis was conducted using TriNetX. Adult patients undergoing single-level ACDF, CDA, or PCF for cervical radiculopathy were identified. 1:1 propensity matching was performed. Outcomes included perioperative complications, reoperation rates, and new cervical pathology at 30 days, 90 days, 6 months, 1 year, 2 years, and 5 years. Statistical significance was set at p<0.05. Results Matched cohorts included ACDF vs. PCF (N=2,659), ACDF vs. CDA (N=3,749), and CDA vs. PCF (N=2,143). PCF demonstrated significantly higher reoperation rates at all timepoints compared to both ACDF and CDA in pairwise comparisons, (5-year: PCF 9.5 vs. ACDF 4.4%; PCF 10.0% vs. CDA 2.8%, p<0.001). ACDF patients demonstrated increased reoperation rates at 5 years (CDA 3.2% vs. ACDF 4.5%, p=0.01). ACDF was associated with higher early emergency department visits and ICU admissions compared to CDA. Conclusions PCF was associated with higher rates of subsequent cervical reoperation compared with ACDF and CDA in the matched cohorts. Differences in early postoperative complications and healthcare utilization were also observed between procedures. These findings should be interpreted in the context of differences in surgical indications and unmeasured clinical and radiographic factors that may influence procedure selection.