Spine Journal - 2026-04-01 - Journal Article; Comparative Study
Reevaluating the 50% facetectomy threshold in posterior cervical foraminotomy: a comparative clinical and radiographic analysis.
Choi JU, Hwang CJ, Cho JH, Park S, Lee HR, Lee DH
Topics
Key Takeaway
Facet resection ≥50% during posterior cervical foraminotomy produced equivalent VAS and NDI improvements to <50% resection at 2 years, though bone bridge formation was significantly higher (66.7% vs 26.3%, p=0.002).
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Summary
This study asked whether facet resection ≥50% during PCF compromises clinical outcomes or radiographic stability compared to <50% resection. Eighty-five patients were divided into Group O (≥50%, n=58) and Group C (<50%, n=27), with outcomes assessed via VAS, NDI, JOA, and radiographic parameters at 6 months and 2 years. Both groups achieved equivalent PROM improvements; segmental gliding and interspinous distance were modestly reduced in the ≥50% group, and bone bridge formation was significantly more frequent (66.7% vs 26.3%), but no frank instability was observed.
Key Limitation
Retrospective design at a single center with no standardized intraoperative measurement of resection percentage introduces significant classification error between groups.
Original Abstract
BACKGROUND CONTEXT
Posterior cervical foraminotomy (PCF) is a motion-preserving procedure for cervical radiculopathy. Traditional guidelines recommend limiting facet resection to less than 50% to preserve spinal stability, a threshold derived from cadaveric biomechanical studies. However, the clinical relevance of this limit has not been fully validated.
PURPOSE
To evaluate whether facet joint resection exceeding 50% during PCF adversely affects clinical outcomes or radiographic stability.
STUDY DESIGN/SETTING
Retrospective cohort study conducted at a single tertiary referral center.
PATIENT SAMPLE
A total of 85 patients (204 operated levels) who underwent PCF between 2005 and 2023 were included. Patients were categorized into ≥50% resection (Group O, n=58) and <50% resection (Group C, n=27).
OUTCOME MEASURES
Clinical outcomes were assessed using self-report instruments, including the Visual Analog Scale (VAS) for neck and arm pain, the Neck Disability Index (NDI), and the Japanese Orthopaedic Association (JOA) score. Physiologic parameters were evaluated on radiographs and included C2-C7 Cobb angle, sagittal vertical axis, segmental range of motion (ROM), gliding distance, interspinous distance, disc height, bone bridge formation, and the presence of foraminal restenosis. Functional outcomes were not applicable in this cohort.
METHODS
Clinical and radiographic data were assessed preoperatively and at 6 months and 2 years postoperatively. Segment-level analyses were performed using linear mixed-effects models to account for clustering within patients and to evaluate the association between the extent of resection and radiographic changes.
RESULTS
Both groups demonstrated significant postoperative improvement in VAS and NDI scores without inter-group differences at any time point. Spinal alignment and global motion parameters remained comparable during follow-up. Bone bridge formation was more frequent in the ≥50% resection group (66.7% vs 26.3%, p=.002). At the segmental level, greater resection was significantly associated with modest reductions in gliding (B = -0.016, p=.004) and interspinous distance (B = -0.108, p<.001) at 2 years, without evidence of instability.
CONCLUSIONS
Facet resection exceeding 50% during PCF did not compromise clinical outcomes or radiographic stability at 2 years, suggesting similar short-term performance to limited resection. Minor radiographic changes such as accelerated bone bridge formation, were observed, warranting further prospective evaluation of long-term stability. These preliminary findings suggest that surgeons may prioritize complete neural decompression over strict adherence to the 50% threshold when anatomically necessary.