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Objective <p>To estimate the comparative effectiveness of posterior cervical foraminotomy (PCF) versus anterior cervical discectomy with fusion (ACDF) for single-level cervical radiculopathy in Chinese hospitals, using the target trial emulation framework guided by the FACET randomized trial protocol.</p> Design <p>Target trial emulation using retrospective electronic health record data with propensity score matching and doubly robust estimation. FACET noninferiority margins served as clinical benchmarks for interpretation.</p> Setting <p>Two Tertiary A teaching hospitals in China, January 2020 to October 2024.</p> Participants <p>1876 eligible adults (890 PCF, 986 ACDF). Propensity score matching yielded 743 pairs (<i>n</i> = 1486).</p> Main Outcome Measures <p>Co-primary outcomes: Odom procedural success and visual analogue scale arm pain at 1 year. Secondary outcomes: neck pain, reoperation, complications, and length of stay. Approximately 43% of primary outcomes were missing; results are hypothesis-generating.</p> Results <p>After matching, covariate balance was adequate (15/17 standardized mean differences &lt; 0.10). Odom success was 82.5% for PCF versus 74.9% for ACDF (risk difference, + 7.7% points; 95% CI, 2.1 to 13.2). Mean arm pain was 23.2 versus 25.6&#xa0;mm (difference, − 2.4&#xa0;mm; 95% CI, − 4.8 to − 0.0), a difference well below the minimal clinically important difference and therefore not clinically meaningful. Both estimates fell within the FACET noninferiority benchmarks. Complications were lower for PCF (3.4% vs. 10.5%; <i>P</i> &lt; 0.001), driven by ACDF-specific dysphagia (7.8%). Subgroup analysis showed a significant interaction by pathology type (<i>P</i> = 0.01); this finding is exploratory and hypothesis-generating. Results were robust across seven sensitivity analyses including doubly robust estimation and tipping-point analysis.</p> Conclusions <p>PCF and ACDF produced broadly comparable clinical outcomes at 1 year, with PCF showing fewer perioperative complications. The treatment effect varied by pathology type. Because follow-up was limited to 1 year, longer-term durability outcomes such as adjacent-segment disease, pseudarthrosis, and recurrent radiculopathy could not be assessed. These hypothesis-generating findings support further prospective investigation of PCF as a potential alternative to ACDF in selected Chinese patients.</p>

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Comparative effectiveness of posterior cervical foraminotomy versus anterior cervical discectomy with fusion for single-level cervical radiculopathy: a target trial emulation study

  • 期刊论文

  • 发表日期：

    2026年7月17日

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  • Cheng Zhao,
  • Weiguo Len,
  • Gang Hu,
  • Yun Shen,
  • Shengdi Lu,
  • Meng Wu

摘要

Objective

To estimate the comparative effectiveness of posterior cervical foraminotomy (PCF) versus anterior cervical discectomy with fusion (ACDF) for single-level cervical radiculopathy in Chinese hospitals, using the target trial emulation framework guided by the FACET randomized trial protocol.

Design

Target trial emulation using retrospective electronic health record data with propensity score matching and doubly robust estimation. FACET noninferiority margins served as clinical benchmarks for interpretation.

Setting

Two Tertiary A teaching hospitals in China, January 2020 to October 2024.

Participants

1876 eligible adults (890 PCF, 986 ACDF). Propensity score matching yielded 743 pairs (n = 1486).

Main Outcome Measures

Co-primary outcomes: Odom procedural success and visual analogue scale arm pain at 1 year. Secondary outcomes: neck pain, reoperation, complications, and length of stay. Approximately 43% of primary outcomes were missing; results are hypothesis-generating.

Results

After matching, covariate balance was adequate (15/17 standardized mean differences < 0.10). Odom success was 82.5% for PCF versus 74.9% for ACDF (risk difference, + 7.7% points; 95% CI, 2.1 to 13.2). Mean arm pain was 23.2 versus 25.6 mm (difference, − 2.4 mm; 95% CI, − 4.8 to − 0.0), a difference well below the minimal clinically important difference and therefore not clinically meaningful. Both estimates fell within the FACET noninferiority benchmarks. Complications were lower for PCF (3.4% vs. 10.5%; P < 0.001), driven by ACDF-specific dysphagia (7.8%). Subgroup analysis showed a significant interaction by pathology type (P = 0.01); this finding is exploratory and hypothesis-generating. Results were robust across seven sensitivity analyses including doubly robust estimation and tipping-point analysis.

Conclusions

PCF and ACDF produced broadly comparable clinical outcomes at 1 year, with PCF showing fewer perioperative complications. The treatment effect varied by pathology type. Because follow-up was limited to 1 year, longer-term durability outcomes such as adjacent-segment disease, pseudarthrosis, and recurrent radiculopathy could not be assessed. These hypothesis-generating findings support further prospective investigation of PCF as a potential alternative to ACDF in selected Chinese patients.