This is a review of the retrospective cohort study by Park et al published in The Spine Journal, in which the authors compared anterior cervical discectomy and fusion (ACDF) and posterior cervical foraminotomy (PCF) specifically in patients with cervical radiculopathy and vertically narrow foramina. This is a clinically important study because most ACDF vs PCF comparisons treat cervical radiculopathy as a relatively uniform entity, whereas this paper focuses on a specific anatomic subgroup that may behave differently.

The authors included 77 patients total – 44 ACDF and 33 PCF – all with at least one foramen measuring <6 mm and at least 2 years of follow-up. Baseline demographics and preoperative clinical scores were similar, although the PCF group had more levels treated on average (2.6 vs 1.8), which is an important point when interpreting results. The study assessed both patient-reported outcomes (neck pain VAS, arm pain VAS, NDI, and MCID) and radiographic parameters (FH, C2-C7 SVA, lordosis, and ROM), which strengthens the paper because it links a mechanical/anatomic rationale to clinical outcomes.

The central finding was straightforward and clinically intuitive: ACDF restored foraminal height, while PCF did not. That radiographic difference appears to have mattered over time. Both groups improved early, but from 3 months to 2 years, neck and arm pain scores worsened in the PCF group and remained stable in the ACDF group. By 2 years, neck and arm pain were significantly worse in the PCF cohort. This pattern supports the authors’ argument that in a vertically narrow foramen, posterior decompression may not be enough to provide durable relief because it does not address the vertical component of stenosis.

Another useful part of the study is the revision analysis. The overall revision rate did not significantly differ between groups, but the reason for revision did. In the ACDF group, revisions were for hematoma evacuation or adjacent segment disease. In the PCF group, all revisions were due to recurrent radiculopathy at the index level, and all required revision ACDF. That distinction is highly relevant for counseling. Even if the total revision percentages are not statistically different, the pattern of failure appears meaningfully different in this anatomic subset.

One of the paper’s strengths is that it proposes a practical selection factor, FH, rather than only comparing procedures broadly. This is very much in line with how surgeons actually make decisions. The study also provides a plausible mechanistic explanation: PCF enlarges the foramen in the anteroposterior direction but does not restore vertical height, whereas ACDF can restore FH through interbody distraction and may also reduce future recurrence risk by eliminating motion at the treated level.

The study also fits into the current literature in an interesting way. Prior randomized and comparative studies have often shown PCF to be non-inferior to ACDF for cervical radiculopathy overall. Park et al do not necessarily contradict that literature – rather, they suggest that anatomy matters, and that vertically narrow foramina may represent a subgroup in which ACDF has an advantage. That is a useful contribution, especially as PCF (including minimally invasive approaches) continues to gain popularity.

There are several limitations worth emphasizing. This is a retrospective single-center study with a modest sample size. The groups were not randomized, and approach selection followed institutional practice patterns, which introduces selection bias. The PCF group had more operated levels, which could independently affect outcomes. The PCF cases were all open PCF, so the results may not generalize to modern minimally invasive or endoscopic PCF techniques. In addition, although pain VAS differences at 2 years were significant, MCID achievement rates were not significantly different, which tempers how strongly the clinical superiority argument should be stated. The FH measurement methodology (sagittal CT rather than oblique reconstructions) is practical but may introduce measurement imprecision.

Overall, Park et al provide a thoughtful and clinically actionable study suggesting that foraminal height should be considered when choosing between ACDF and PCF for cervical radiculopathy. In patients with vertically narrow foramina (FH <6 mm), ACDF appears to offer more durable foraminal restoration and better long-term pain outcomes, while PCF may carry a greater risk of recurrent index-level radiculopathy.