Abstract

BackgroundCervical foraminotomy (CF) and anterior cervical discectomy and fusion (ACDF) are both used to treat 1–2 level cervical radiculopathy. We evaluated demographic and Patient-Reported Outcomes Measurement Information System (PROMIS) to match cohorts and compare the safety/efficacy of performing CF versus ACDF for 1–2 level unilateral radiculopathy.

MethodsThis was a retrospective review of 64 patients with similar clinical and radiological data that underwent 1–2 level unilateral CF versus ACDF for cervical radiculopathy. Variables studied included operative revision rates, adverse events, surgical costs, postoperative imaging, PROMIS scores, numeric pain scores, incidence of dysphagia, frequency of vocal cord paralysis, and postoperative neurological status.

ResultsWe found no clinical or radiological differences between patients undergoing ACDF versus CF for unilateral 1–2 level cervical radiculopathy. Surgical differences were observed; ACDF patients demonstrated a 6.25% revision rate versus 0% for CF patients, 40% of ACDF patients reported mild dysphagia versus 0% for CF, 3% undergoing ACDF exhibited vocal cord paralysis versus 0% for CF, and ACDF incurred high implant costs (i.e., $1,836.37 and $2,773.44 for one- and two-level ACDFs) versus 0% for CF warranting no implants.

ConclusionPatients undergoing CF versus ACDF for 1–2 level unilateral cervical radiculopathy required 3.70 fewer postoperative X-rays, 40 min less operative time, and 10.95-h shorter lengths of hospital stay (P

Keywords: Anterior cervical discectomy and fusion, Cervical radiculopathy, Patient reported outcomes, Posterior cervical foraminotomy, Posterior keyhole foraminotomy

INTRODUCTION

Patient-Reported Outcomes Measurement Information System (PROMIS) is a National Institutes of Health (NIH) sponsored tool that utilizes standardized questionnaires to measure patient-based outcomes (i.e., pain, function, and depression).[ 7 , 6 ] We utilized PROMIS scores to compare/assess demographic, radiological, and surgical outcomes following cervical foraminotomy (CF) versus anterior cervical discectomy and fusion (ACDF). We are aware of the added unique risks of ACDF documented in the literature versus CF (i.e., vascular or esophageal injury, dysphagia, recurrent laryngeal nerve paralysis, and adjacent segment disease).[ 5 , 9 , 10 ]

MATERIALS AND METHODS

Study design and setting

This is an IRB-approved retrospective cohort study of outcomes for 32 ACDF (CPT 22551) versus 32 CF (CPT 63020) patients matched by demographic and clinical characteristics [2015–2021; Table 1 ]. Multiple inclusion and exclusion criteria were used to select patients for this study [ Figure 1 ]. A major shortcoming of the study design was a patient selection for ACDF versus CF based on the surgeon or patient preferences. Major variables assessed included reoperations, adverse events, changes in numeric pain scores, preoperative and postoperative visits, surgery duration, hospital/implant costs, length of hospital stay, postoperative motor status, dysphagia, vocal cord paralysis, PROMIS outcomes, and other covariates [ Table 1 ].

Table 1:

Preoperative patient demographics.

Figure 1:

The exclusion criteria displaying which patients were included in the analysis. ACDF: Anterior cervical discectomy and fusion, PCF: Posterior cervical foraminotomy

RESULTS

Adverse events

For ACDFs performed over 6.15 years, two patients required revisions (i.e., 1 for pseudoarthrosis and the other for recurrent axial pain), 13 had mild dysphagia, and there was one case of vocal cord paralysis but no infections. A 5.99-year record review following CF showed no patients required operative revisions, and there were no adverse events (i.e., no dysphagia, no vocal cord paralysis, and no infections).

PROMIS evaluations

Ten weeks postoperatively, 89%/85% of ACDF and 50%/50% of CF patients reported improvement versus their preoperative PROMIS function/pain status [ Table 2 ]. Notably, 51% of ACDF and 37% of CF patients achieved minimum clinically important difference (MCID) for physical function, and 67% and 36%, respectively, achieved MCID for pain, but ACDF patients reported 4.44 greater PROMIS pain interference (PI) t-score values [ Appendix 1 and Table 3 ]. Further, 63% of ACDF versus 56% of CF patients reported complete pain resolution, 34% versus 47% reported full return of strength, and 47% versus 56% reported resolution of neurological symptoms [ Table 4 ]. However, there were no significant differences between the two groups in average improvement for PROMIS Physical Function (PF), DE t-scores, and time to achieve MCID for PF, PI, or DE PROMIS scores [ Appendices 1 and 2 ].

Table 2:

Unadjusted PROMIS counts and improvements above preoperative levels.

Table 3:

Postoperative regression for achieving MCID measured by PROMIS function (PF), pain (PI), and depression (DE) scores.

Table 4:

Unadjusted postoperative results for resolution of pain, weakness, and paresthesia.

Symptom resolution

Sixty-three percentages of ACDF versus 56% of CF patients reported complete pain resolution, 34% versus 47% reported full return of strength, and 47% versus 56% reported resolution of neurological symptoms [ Table 4 ].

Lower hospital costs, operating room time, and length of stay for CF versus ACDF

The average implant cost for one-level ACDF was $1,836.37, and for two-level ACDF was $2,773.44; CF incurred no implant costs [ Table 5 ]. Additional benefits of CF operations included statistically less operating time (137 vs. 177 min) and a shorter length of stay [22.7 vs. 33.7 h; Table 5 ].

Table 5:

Hospital costs and postoperative imaging.

Fewer postoperative radiographs for CF versus ACDF patients

CF patients required fewer postoperative cervical radiographs (i.e., average 0.4) versus ACDF patients [i.e., average 4.10; Table 5 ]. Three cervical CTs were performed for CF versus 5 for ACDF patients, while MR scans were performed in 7 CF versus 10 ACDF patients, respectively [ Table 5 ]. The frequency of adjacent segment degeneration was 44% for 2.23 years after CF versus a slightly higher 50% for ACDF patients, followed by an average of 1.88 years.[ 4 ]

DISCUSSION

Although ACDF is more commonly performed to treat cervical radiculopathy without myelopathy, CF appears to provide comparable results but with fewer adverse events/morbidity and costs.[ 10 ] Although we found that ACDF patients had greater likelihood of achieving MCID measured with PROMIS PI, they required a 6.25% revision rate versus 0% for CF, more postoperative X-rays (i.e., 4.1 vs. 0.4 studies), longer operations, longer lengths of hospital stay, high implant costs versus 0% for CF, a 41% risk of dysphagia versus 0% for CF, and a 3% risk of vocal cord paralysis versus 0% for CF.[ 8 , 12 ]

ACDF and CF revision rates range between 5% and 10%[ 1 - 3 , 9 , 11 , 12 ], with large retrospective studies often reporting fewer revisions for ACDF[ 5 ], while randomized trials show lower CF reoperation rates.[ 10 ] Baseline cohort health differences could explain this variation as studies with low CF revisions, including our study, document low comorbidities, and studies favoring ACDF report high comorbidities. Differences in reoperation rates may also be attributable to more surgeons performing ACDF in medically complex patients, given its familiarity and popularity, whereas few may be adequately trained in or technically adept at performing CF.

CONCLUSION

Advantages for CF versus ACDF for one- or two-level unilateral cervical radiculopathy included 3.70 fewer postoperative X-rays, 40 min less operative time, a 10.95-h shorter length of hospital stay, a 0% reoperation rate versus 6.5% for ACDF, no implant costs, no postoperative dysphagia (41% for ACDF), and no vocal cord paralysis (3% for ACDF).

Ethical approval

The research/study was approved by the Institutional Review Board at the University of Rochester research subjects review board (RSRB), number STUDY00000982, approved the study dated March 02, 2023.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

Supplementary material available on

https://dx.doi.org/10.25259/SNI_1017_2024

Disclaimer

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.

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