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Study Design: A retrospective review of a prospective, randomized control Food and Drug Administration (FDA) investigational device exemption trial comparing anterior cervical discectomy and fusion (ACDF) with Bryan cervical disc arthroplasty., Objective: Determine the clinical significance of adjacent-level ossification disease (ALOD) on long-term functional outcomes after ACDF or arthroplasty., Summary of Background Data: ALOD occurs when the anterior longitudinal ligament and annulus adjacent to the index surgical level calcifies. As previously reported, ALOD happens more commonly after an arthrodesis than an arthroplasty. No investigation has previously examined 10-year clinical outcomes associated with ALOD., Materials and Methods: Forty patients were included in the 10-year follow-up. The index level was radiographically blinded and the cephalad-adjacent level was evaluated for ALOD. These scores underwent statistical analysis to compare the 2 surgical groups (ACDF and arthroplasty) for differences in the development of ALOD at a decade follow-up. Two investigational groups, on the basis of a high or low ALOD score, then proceeded through statistical analysis to compare the functional outcomes of patients in each group., Results: Statistical evaluation of ALOD findings in patients from each surgical group found a significantly higher rate of high-grade ALOD in patients who underwent cervical arthrodesis with plate fixation compared with cervical arthroplasty (68.2% vs. 11.1%, P=0.0003). Functional outcomes of patients were also assessed at the 10-year mark and outcomes in patients with either high-grade or low-grade ALOD were compared. When stratified by high versus low-grade ALOD, no significant difference was found for Neck Disability Index (NDI) (P=0.6431), VAS-arm (P=0.4497), or VAS-neck (P=0.8700) scores between groups., Conclusions: The present study suggests that there are no significant long-term functional outcome differences between patients with and without significant ALOD. Our findings suggest ALOD may be a radiographic finding that does not alter patient-reported outcomes., Level of Evidence: Level III-therapeutic.