Spinemathema podcast · Episode 10 · About 9 minutes · October 2026

Episodes are narrated using an AI model of Mr Sadek’s own voice, from scripts he has written and approved.

Read the full article with references: Keyhole Surgery From the Back or Fusion From the Front? The FACET Trial

Transcript

Hello and welcome to the Spinemathema podcast. I’m Ahmed Sadek, a neurosurgeon, and in this episode I want to talk about a landmark trial called FACET. It asked a question that matters to a lot of people with a trapped nerve in the neck. If you need an operation, should it be done from the front of the neck or from the back?

Let me start with the problem. Cervical radiculopathy is the medical name for pain, pins and needles, numbness or weakness running down the arm because a nerve is being pinched as it leaves the neck. Usually that’s caused by a bulging disc or by bony spurs, which doctors call osteophytes. When the symptoms don’t settle and an operation is needed, there are two common choices.

The first is called anterior cervical discectomy and fusion, which most surgeons shorten to A C D F. The surgeon makes a small cut at the front of the neck, removes the disc and puts a spacer in its place, so that the two bones fuse together.

The second is called posterior cervical foraminotomy. That’s done from the back of the neck. The surgeon removes a small amount of bone to widen the hole that the nerve passes through. There’s no fusion and no implant left behind.

The researchers behind FACET pointed out that the operation from the back avoids important structures at the front of the neck, like the gullet, the carotid artery and the nerve to the voice box. It also doesn’t need expensive implants. Even so, surgeons have tended to prefer the front approach. And before this trial, the evidence comparing the two came mostly from studies looking back at past patients, plus one small, low quality randomised trial.

So here’s how FACET worked. It ran in nine hospitals in the Netherlands, between twenty sixteen and twenty twenty. It included adults aged eighteen to eighty with arm pain from one nerve, on one side, at one level of the neck, who needed surgery. People with neck pain alone, without pain going into the arm, couldn’t take part.

Three hundred and eighty nine people were assessed, and two hundred and sixty five were randomly allocated. One hundred and thirty two were assigned to the operation from the back, and one hundred and thirty three to the operation from the front. Their average age was fifty one, and half were women. In the front operation, the surgeons used a cage or bone cement in the disc space, but no plate. Nobody wore a neck collar afterwards.

This was what’s called a noninferiority trial. Instead of asking which operation is better, it asked whether the operation from the back was no worse than the front operation by more than a set margin, which here was ten per cent.

There were two main measures at one year. The first was a simple rating of the overall result, called the Odom criteria. That was collected by telephone by an interviewer who didn’t know which operation the patient had had. The second was arm pain, scored from nought to one hundred.

So what did they find? At one year, eighty eight per cent of people after the operation from the back had a good or excellent result, compared with seventy six per cent after the front operation. That met the test for noninferiority. In other words, the back operation was not worse.

Arm pain fell a lot in both groups. After the back operation, the average went from about sixty two down to about nineteen. After the front operation, it went from about sixty down to about sixteen. Arm pain at one year passed the noninferiority test. The size of the drop in arm pain only just missed it, by less than two points on a hundred point scale, and the authors felt that was too small to matter clinically. Neck pain, disability, quality of life, work ability and satisfaction were all similar.

The side effects were different, though. Swallowing difficulty and hoarseness were more common after the front operation. In the first year, six people had swallowing difficulty or a feeling of a lump in the throat after the front operation, compared with one after the back operation, and in one person it hadn’t gone away by a year. Wound infections, on the other hand, were more common after the operation from the back. And persistent arm pain that didn’t need another operation was recorded in eight people after the back operation, compared with two after the front.

The team then published two year results in twenty twenty four. Data were available for ninety seven per cent of patients. Using a statistical model, about eighty one per cent had a good or excellent result after the back operation, and seventy four per cent after the front operation. Again, the back operation met the noninferiority test, and now both arm pain measures did too.

By two years, nine people had needed another operation after the back approach, and seven after the front approach. That’s about eight per cent and six per cent, and the difference wasn’t statistically significant. All nine repeat operations after the back approach were done from the front. Recurrent arm pain without another operation was also more common after the back approach.

Now, no trial is perfect, so here are the limitations. Patients and surgeons obviously knew which operation had been done, although the main rating was collected by someone who didn’t. The trial recruited fewer people than planned, partly because of the COVID nineteen pandemic. Twenty five people didn’t have their allocated operation, most often because their symptoms improved on their own. The ten per cent margin was chosen by the investigators, because there isn’t an agreed figure. Some surgeons had strong preferences, mostly for the front operation, which may have affected who was enrolled. And the front operation was done without a plate, which the authors say is common in Europe but differs from countries such as the United States.

I also want to be clear about who this applies to. FACET only included people with one trapped nerve on one side at one level. It doesn’t tell us about pressure on the spinal cord itself, called myelopathy, or about neck pain alone, or about problems at several levels.

So what does this mean for you? If you have arm pain from a single trapped nerve in the neck and an operation is being considered, FACET suggests that both operations give similar results for most people over two years. The choice can be guided by what your scan shows, by what matters to you, and by the different side effects. The front operation involves fusing two bones, and carries a risk of swallowing problems and hoarseness. The back operation avoids fusion and implants, but in a minority of people the arm pain came back, and some needed a second operation.

Remember too that FACET compared two operations in people who already needed surgery. It doesn’t tell us whether surgery is better than non-surgical care like physiotherapy. Some people do get better without an operation. In FACET itself, eleven of the twenty five people who didn’t have their allocated operation had improved before surgery.

One last thing. If you notice clumsy hands, unsteady walking or new bladder problems, please tell your doctor promptly, because those can be signs of pressure on the spinal cord, which is a different condition from the one studied here.

Thank you for listening. This podcast is general information and not a substitute for advice about your own situation, so please speak to your own doctor or specialist. You’ll find the full article, the diagrams and the references at spinemathema dot com. And if you found this useful, please subscribe to the Spinemathema channel on YouTube.

This podcast is general information and is not a substitute for advice about your own situation. Please speak to your GP or specialist.