Microscopic Posterior Cervical Foraminotomy

Overview and Indications

Using innovative technology, a cervical decompression can now be accomplished using a small poke-hole incision with minimal tissue dissection and a faster recovery. A microscopic posterior cervical foraminotomy can both be performed in less time, with less tissue damage, and less pain than traditional open cervical spinal surgery.

A microscopic posterior cervical foraminotomy is performed for patients with a symptomatic cervical herniated nucleus pulposus with foraminal stenosis occurring at one or two levels of the spine. It is performed to remove the large, arthritic osteophyte(s) (bone spur) and a portion of the herniated disc(s) that are compressing the spinal nerves. A microscopic posterior cervical foraminotomy is favored for patients with a small or moderate herniated disc and foraminal stenosis at one or two levels, yet it is not recommended for patients with cervical kyphosis, severe neck pain, or large herniated discs.

Surgical Technique

The surgery is performed utilizing general anesthesia. A breathing tube (endotracheal tube) is placed and the patient breathes using a ventilator during the surgery. Preoperative intravenous antibiotics are given. Patients are positioned in the prone (lying on the stomach) position, generally using a special operating table/bed with special padding and supports. The surgical region (neck area) is cleansed with a special cleaning solution. Sterile drapes are placed, and the surgical team wears sterile surgical attire such as gowns and gloves to maintain a bacteria-free environment.

A 1-2 centimeter (depending on the number of levels) poke-hole incision is made on one side of the neck, directly over the involved spinal level(s). The fascia and muscle is gently divided using special cannulated retractors and sleeves. A partial laminectomy (removal of lamina portion of bone) and foraminotomy (removal of bone spurs near where the nerve comes through the hole of the spine bone) is performed using special biting and grasping instruments (such as a pituitary rongeur, kerrison rongeur, and curettes), an operating microscope, and x-ray guidance, allowing the nerves to return to their normal size and shape when the compressive lesions are removed. The nerve roots and neurologic structures are protected and carefully retracted, so that the bone spurs can be visualized and removed. Small dental-type instruments and biting/grasping instruments (such as a pituitary rongeur and kerrison rongeur) are used to remove the arthritic, hypertrophic (overgrown) bone spurs and ligamentum flavum. All surrounding areas are also checked to ensure no compressive spurs or disc fragments are remaining.

The wound area is usually washed out with sterile water containing antibiotics. The deep fascial layer and subcutaneous layers are closed with 1-2 strong sutures. The skin can usually be closed using special surgical glue, leaving a minimal scar and requiring no bandage.

The total surgery time is approximately 2 hours, depending on the number of spinal levels involved.

Post-Operative Care

Most patients are able to go home 1-2 days after surgery. Before patients go home, physical therapists and occupational therapists work with patients and instruct them on proper techniques of getting in and out of bed and walking independently. Patients are instructed to avoid excessive bending and twisting of the neck in the acute postoperative period (first 1-2 weeks). Patients can gradually begin to bend and twist their neck after 2-3 weeks as the pain subsides and the neck and back muscles get stronger. Patients are also instructed to avoid heavy lifting in the acute postoperative period (first 3-4 weeks).

Brace

Most patients are not required to wear a neck brace after surgery, however, most patients are issued a soft cervical collar. This reduces the stress on the neck area and helps decrease pain in the early postoperative period.

Wound Care

The wound area can be left open to air. No bandages are required. Small surgical tapes affixing the suture should be left in place. The area should be kept clean and dry.

Showering/Bathing

Patients can shower immediately after surgery, but should keep the incision area covered with a bandage and tape, and try to avoid the water from water hitting directly over the surgical area. After the shower, patients should remove the bandage, and dry off the surgical area. Patients should not take a bath until the wound has completely healed, which is usually around 2 weeks after surgery.

Driving

Patients may begin driving when the pain has decreased to a mild level, which usually is between 2-7 days after surgery. Patients should not drive while taking pain medicines (narcotics). When driving for the first time after surgery, patients should make it a short drive only and have someone come with them, in case the pain flares up and they need help driving back home. After patients feel comfortable with a short drive, they can begin driving longer distances alone.

Return to Work and Sports

Patients may return to light work duties as early as 1-2 weeks after surgery, depending on when the surgical pain has subsided. Patients may return to moderate level work and light recreational sports as early as 1 month after surgery, if the surgical pain has subsided and the neck strength has returned appropriately with physical therapy. Patients may return to heavy lifting and sports activities in 1-2 months if the surgical pain has subsided and the neck strength has returned appropriately with physical therapy.

Doctor's Visits and Follow-Up

Patients will return for a follow-up visit to see the doctor approximately 8-10 days after surgery. The incision will be inspected. There is one suture that will be removed. Medications will be refilled if necessary. Patients will be given a prescription to begin physical therapy for gentle neck exercises.

Results and Outcome Studies

The results of microscopic posterior cervical foraminotomy surgery in the treatment of symptomatic cervical herniated nucleus pulposus and foraminal stenosis are generally excellent. Numerous research studies in medical journals demonstrate greater than 84-95% good or excellent results. Most patients are noted to have a significant, rapid improvement of their radicular arm pain and return to many, if not all, of their normal daily and recreational activities.

Selected Bibliography

Anand N, Regan JJ, Bray RS. Posterior cervical foraminotomy: long-term results and functional outcome of a consecutive series of patients with minimum two-year follow-up. Spine J 2002;2:5-6.

Henderson CM, Hennessy RG, Shuey HM Jr, et al. Posterior-lateral foraminotomy as an exclusive operative technique for cervical radiculopathy: A review of 846 consecutively operated cases. Neurosurgery 1983; 13:504-12.

Khoo L, Cannestra A, Holly L, Shamie A, Wang J, Fessler R. A long-term clinical outcome analysis of minimally invasive cervical foraminotomy for the treatment of cervical radiculopathy. Spine J 2005;5:S161-2.

Khoo LT, Fessler RG. Minimally invasive posterior cervical microendoscopic foraminotomy. Spine J 2002:2:6.