Background <p>Anterior cervical discectomy and fusion (ACDF) is a procedure commonly performed for cervical radiculopathy or myelopathy. No consensus exists regarding the necessity of radiographs in the postoperative period to review for possible complication. The aim of this study was to assess the role of routine radiographs following one- and two-level ACDF with a primary focus to determine if they would alter the treatment course.</p> Methods <p>The authors conducted a single-surgeon, multi-institution randomized controlled study of adult patients who underwent one- or two-level ACDF between June 2019 and January 2023. Group 1 underwent lateral cervical radiographs two weeks and three months postoperatively; Group 2 underwent radiograph only when clinically indicated. Demographics, radiographic data, and post-treatment outcomes at a minimum follow-up of three months are reported.</p> Results <p>Two hundred surgeries on 200 patients involving 298 intervertebral disc levels were included. One hundred five patients were randomized to Group 1 and 95 were randomized to Group 2. The majority of patients had no complaints two weeks (72.4% in Group 1 and 80.0% in Group 2) and three months (93.3% in Group 1 and 91.6% in Group 2) postoperatively. Only one asymptomatic patient, with known osteoporosis, had a finding on radiograph that prompted a change in treatment course with addition of a cervical collar.</p> Conclusion <p>Our findings suggest that patients with osteoporosis may be considered for routine radiographs postoperatively, regardless of clinical presentation. However, outside this population, we recommend the use of radiographs be guided by symptomatology rather than as standard procedure.</p>