Study DesignRetrospective cohort study.ObjectivesSevere neck pain has traditionally been considered a relative contraindication for cervical disc replacement (CDR) due to risk of persistent neck pain from the remaining mobile segment. However, recent studies suggest potential for neck pain improvement with CDR. This study aimed to compare postoperative improvements in neck pain and disability between patients undergoing anterior cervical discectomy and fusion (ACDF) and CDR.MethodsPredominant neck pain was defined as neck pain equal to or greater than arm pain preoperatively (visual analog scale [VAS]) and neck disability index (NDI) > 20. Patients with predominant neck pain who underwent 1- or 2-level ACDF or CDR for radiculopathy between 2017 and 2023 were included. Patient-reported outcomes (NDI, VAS) were assessed up to 1 year postoperatively. Inverse probability of treatment weighting (IPTW) was used to control for confounders. Linear mixed-effect models were applied to compare postoperative outcomes.ResultsA total of 179 patients (105 ACDF, 74 CDR) were included. Both groups showed significant improvement in NDI and VAS neck scores from baseline to 1 year (NDI: β = -1.81, < .001; VAS neck: β = -.26, < .001). After IPTW, no significant differences were found between ACDF and CDR across all PROMs up to 1 year (NDI: β = -0.44, = .09; VAS neck: β = -.07, = .10).ConclusionCDR was associated with postoperative improvements in neck pain and disability comparable to those observed with ACDF in patients with predominant neck pain and radiculopathy. These findings suggest that CDR may be a reasonable treatment option for selected patients.