Background: Treatment modalities for degenerative cervical spine disease are widely debated and refined as new surgical techniques are developed. The current case series compares two common cervical spine procedures, anterior cervical discectomy and fusion (ACDF) and minimally invasive posterior keyhole foraminotomy (MIPKF). The decision making process of the two surgical approaches is discussed, and the long term outcomes are presented. Methods: A retrospective chart review of surgical patients having either an ACDF or MIPKF with an extensive chart review. Over 570 patient charts were identified and reviewed between 1994 and 2011. After exclusion, a total of 268 patients were identified in the ACDF group, and 112 patients were identified in the MIPKF group. Primary outcome measurement was the need for any reoperation, whether at the same level or adjacent levels due to recurrence of disease or adjacent level disease. Results: An average follow-up of 11.8 (±3.0) years in the ACDF group and 6.4 (±4.4) years in the MIPKF group was determined over a 17 year period. There was a reoperation rate of 2.6% in the ACDF group and 2.7% in the MIPKF group during the 17 year time period. Conclusion: ACDF has been demonstrated to be an effective surgical procedure in treating degenerative spine disease in patients with radiculopathy and/or myelopathy. However, in a population with isolated radiculopathy and radiological imaging confirming an anterolateral disc or osteophyte complex, the MIPKF can provide similar results without the associated risks that accompany an anterior cervical spine fusion.