Minimally Invasive Posterior

Cervical Foraminotomy
and Discectomy
Syareza Manefo

Departemen Ilmu Bedah Saraf

Faculty of Medicine – Universitas Padjajaran
Bandung - 2022
 Introduction
Cervical Radiculopathy
Defined as a syndrome of pain and/or sensorimotor deficits due to compression of a
cervical nerve root

Etiology of the syndrome :

Cervical disc
Spondylosis Instability Trauma Tumors
disease

The Resident’s Guide to Spine Surgery. Springer Publishing

 Introduction
Typical symptoms :
Arm pain
typically in
a Neck pain Numbness Weakness
dermatomal
distribution

Management Modality :

Most patients (75–90%) with cervical radiculopathy will have symptomatic improvement with conservative,
nonoperative management, which includes :
● Physical therapy
● Cervical traction
● Epidural steroid injections.

The Resident’s Guide to Spine Surgery. Springer Publishing

 Introduction
However, when patients either fail conservative management or begin to experience progressive
neurologic deficits, surgical intervention is warranted

The two most common

procedures :

Anterior cervical
Posterior cervical
discectomy and fusion
foraminotomy (PCF)
(ACDF)

The Resident’s Guide to Spine Surgery. Springer Publishing

 History of Procedure

In 2001, Adamson
This procedure
Using minimally described the MIS
became the
invasive lumbar PCF endoscopic
preferred Over the following
PCF was first discectomy as a technique and
technique in the decades, the
described by model, the results in his first
treatment of anterior approach
Spurling and minimally invasive 100 consecutive
herniated cervical became much
Scoville and technique for PCF patients, showing
discs until Smith more commonly
Frykholm was first described 97% of patients
and Robinson used.
in cadaver studies with good or
introduced the
in 1998 excellent
anterior approach
outcome

The Resident’s Guide to Spine Surgery. Springer Publishing

 Indications
Patients with a lateral soft disc herniation or foraminal stenosis causing nerve root compression
and subsequent progressive or intractable radiculopathy

Relative contraindications to ACDF :

Previous History of History of May influence
surgery radiation infection the decision to
perform PCF

Absolute contraindications to ACDF :

Patients with
Diffuse spondylotic
Primary axial neck Central disc Bilateral radicular evidence of cervical
disease causing
pain herniation symptoms. spine instability or
central stenosis
deformity

The Resident’s Guide to Spine Surgery. Springer Publishing

 Indications :
Potential Complications :

Tracheal or esophageal Injury to the carotid or

Injury to the jugular vein
injury vertebral arteries

Subsequent adjacent
segment disease as
Injury to the recurrent Stress on adjacent
well as pseudarthrosis,
laryngeal nerve spinal levels
graft subsidence and
kyphosis

The Resident’s Guide to Spine Surgery. Springer Publishing

 Surgical Technique
Pre-operative Steps :

Neuromonitoring
with somatosensory
Induction of general Mayfield head
evoked potentials
endotracheal holder is affixed to Electromyography
(SSEPs) to monitor
anesthesia the patient’s head
integrity of the
spinal cord

Positioning :

The procedure can then be performed in either of two positions: prone or sitting

The Resident’s Guide to Spine Surgery. Springer Publishing

 Surgical Technique
Prone Position :
For positioning into the prone position, the
patient is carefully turned onto the open Jackson
table with C-flex head positioning system (Allen
Medical). The arms are then tucked at the
patient’s side

Advantages :
● Decreased risk of intraoperative hypotension
and air embolism

Disadvantages :
Patients are positioned prone with their heads
● Risk of venous air embolism and intraoperative
secured in a radiolucent Mayfield head holder.
hypotension

The Resident’s Guide to Spine Surgery. Springer Publishing

 Surgical Technique
Sitting Position :

● Sitting position is performed when using the endoscope.

● Potential advantages of the sitting position include decreased operative time and blood loss
compared to prone position.
● Disadvantages include risk of venous air embolism and intraoperative hypotension

The Resident’s Guide to Spine Surgery. Springer Publishing

 Anatomy :

The Resident’s Guide to Spine Surgery. Springer Publishing

 Surgical Technique
Regardless of positioning,
Once the appropriate level is
fluoroscopy is then brought into the
marked, the patient is then prepped
field for lateral x-ray to localize the
and draped in the standard fashion.
appropriate level.
After soft tissue removal and bony
visualization, a curved currete is
used to define the anatomy of the
lamino-facet complex and remove
ligamentum flavum from the
underside of the lamina.
The Resident’s Guide to Spine Surgery. Springer Publishing
Under fluoroscopic guidance,
sequential dilators from a tubular
A 2 cm incision is then made
retractor system are passed and the
approximately 1.5  cm lateral from
final tubular retractor system
midline, extending through the
(between 16 and 21 mm) is held in
fascial layer.
place with the attachment secured
to the operative table.
Soft tissues are then removed from
the operative field using Bovie
electrocautery and pituitary The microscope or endoscope is
rongeurs, moving cautiously, in then brought into the field.
order to avoid penetrating through
the interlaminar space.
 Surgical Technique

The retractor is locked into the

correct position using an arm that
attaches to the side of the bed.

The Resident’s Guide to Spine Surgery. Springer Publishing

 Surgical Technique

(A) Initial localization of the C3-C4 facet docking site with fluoroscopy allows (B) a small incision to be planned that is
only slightly larger than the size of the desired tube to be used.

The Resident’s Guide to Spine Surgery. Springer Publishing

 Surgical Technique
1 or 2 mm Kerrison punch is
then utilized to perform the Epidural bleeding from the nerve
laminotomy and the procedure root venous plexus is to be
The ligamentum flavum can then
extends laterally to perform the expected during this portion of
be removed to visualize the dura
foraminotomy. Often, a high- the procedure. It can be
and proximal nerve root.
speed drill will need to be controlled with Gelfoam and
utilized for appropriate bony cotton patties.
removal.

Once the nerve root is

To facilitate removal of disc or
visualized, a 45-degree-angled
osteophyte and minimize nerve In the case of soft disc
nerve hook is used to palpate
root retraction, approximately herniation, once identified, the
the neural foramen to assess if
2 mm of the superior medial posterior longitudinal ligament
decompression is adequate and
portion of the rostral pedicle can can be incised with a #11 blade.
to identify any disc fragments or
be drilled.
osteophytes.

The Resident’s Guide to Spine Surgery. Springer Publishing

 Surgical Technique

Initial exposure for foraminotomy and discectomy Visualization of disc herniation through tube

The Resident’s Guide to Spine Surgery. Springer Publishing

 Surgical Technique
Once satisfactory nerve root
decompression has been
In the case of osteophyte, a down-
Fragments can then be mobilized achieved, the wound is then
angled curette can be used to
using a micro nerve hook and copiously irrigated with antibiotic-
reduce them or break them apart
removed using a pituitary rongeur. soaked saline, hemostasis is
to facilitate their removal.
achieved, and the tube retractor
system is removed from the field.

A 2-cm incision with The fascial, subcutaneous, and

minimal muscle skin layers are then closed with
absorbable sutures, and a skin
dissection allows a glue is used as the final layer
quick recovery

The Resident’s Guide to Spine Surgery. Springer Publishing

 Literature Review
● Overall  PCF is an effective procedure

● The literature reports good-excellent relief of radiculopathy symptoms in 85–100% of patients.

● Several studies have shown statistically significant improvements in Neck Disability Index, Visual
Analog Scale for Neck, and Visual Analog Scale for Arm scores at both 1- and 2-year follow-up

Minimally invasive posterior cervical foraminotomy has been shown to be a viable

alternative to anterior cervical discectomy and fusion in a select patient population,
notably those with a lateral soft disc herniation or foraminal stenosis

The Resident’s Guide to Spine Surgery. Springer Publishing

 Literature Review

In a retrospective review of patients undergoing ACDF or PCF at a single

institution between 2005 and 2011, Lubelski et al. reported that both procedures
have a statistically equivalent 2-year reoperation rate

Another retrospective review by Ruetten et al. comparing ACDF vs PCF in

unilateral single-level radiculopathy in posterolateral or foraminal disc herniation
showed no significant difference between the groups in terms of the overall
outcome, complication rate, or revision rate

The Resident’s Guide to Spine Surgery. Springer Publishing

Thank You