| Procedures: Cervical Posterior Foraminotomy |
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Technical Considerations Posterior Foraminotomy involves partial resection of the facet joint (foramen roof) to achieve nerve root decompression. Studies have shown that there is an increased risk of instability if more than 50% of the facet joint is removed. [1] Literature Review Featured References Posterior Foraminotomy is a well established operation. An historical perspective is contained in the table below.[2-9]
The keyhole foraminotomy (posterior foraminotomy) describes the small aperture created for the nerve. A particular study reviewed 84 consecutive patients, 96% had preoperative arm pain from a compressed cervical nerve root and 59% had weakness in a muscle group supplied by those individual nerves. The patients were reviewed at 6.1 years as an average after the operation to evaluate the results. The results: 93 excellent, 5% good, 2% fair but 100% obtained relief of their preoperative arm pain. [10] The duration of symptoms and relationships to results is an important consideration. A particular study examined prognostic factors (what determines the result of the operation) for posterolateral formaminotomy. [9]
Different types of pathology can compress the cervical (neck) spinal nerve. Different articles in the literature provide some clue to the nature of results with posterior foraminotomy as the operation addresses the different causes of nerve compression. In one series of 36 patients, with arm pain and arm weakness before surgery, all patients had a disc fragment underneath the nerve causing the symptoms. 100% had pain relief, 100% had strength return, 88% sensation to the arm returned. [6] Bone Spurs as a cause of nerve root compression caused arm pain and 50% of patients had neurological findings on physical exam. 95.5% improved with posterior foraminotomy reviewed at 8 months after surgery. 6.7% required further surgery for return of symptoms. [11] Perhaps one study summarized the issue of multiple causes of nerve root compression the best: soft disc herniation, bone spurs, and combinations of soft disc herniation and bone spurs. 92% returned to work after surgery and 93% had recovery from arm weakness and 82% sensory recovery. [5] A single nerve root may be compressed or multiple nerve roots. For multiple level posterolateral foraminotomy, arm pain was relieved, but weakness of the arm commonly persisted and decreased sensation in the arm persisted compared to single level problems. [7] Potential Advantage The advantage of posterior foraminotomy is the ease of exposure of the intended goal of surgery, the cervical nerve root, and no fusion of the motion segment is required. Potential Disadvantage The nerve root cannot be retracted with ease, thus limiting exposure of the floor of the canal. Judgment of nerve root freedom requires experience. Complications Potential complications of surgery involve the anatomic approach, the actual procedure, and the closure. Other complications are medical complications, anaesthesia complications and longer term complications in the post-operative period. Injury to the neurological structures include spinal cord injury, nerve root injury, dural tear. Bone injuries include facet joint destruction and instability. Vascular injury could involve the vertebral artery. Wound problems include drainage, wound breakdown, and bleeding. Author’s Comment Posterolateral Foraminotomy is a viable option for cervical (neck) spinal nerve decompression. The value of this operation is the avoidance of an anterior approach and the structures in the front of the neck, and avoidance of a fusion procedure recommended in some anterior operations. Posterolateral foraminotomy performed microscopically but especially microendoscopically can be an outpatient operation. References 1. Zdeblick, T.A., et al., Cervical stability after foraminotomy. A biomechanical in vitro analysis. J Bone Joint Surg [Am], 1992. 74(1): p. 22-7. 2. Henderson, C.M., et al., Posterior-lateral foraminotomy as an exclusive operative technique for cervical radiculopathy: a review of 846 consecutively operated cases. Neurosurgery, 1983. 13(5): p. 504-12. 3. Williams, R.W., Microcervical foraminotomy. A surgical alternative for intractable radicular pain. Spine, 1983. 8(7): p. 708-16. 4. Dillin, W., et al., Cervical radiculopathy. A review. Spine, 1986. 11(10): p. 988-91. 5. Krupp, W., H. Schattke, and R. Muke, Clinical results of the foraminotomy as described by Frykholm for the treatment of lateral cervical disc herniation. Acta Neurochir (Wien), 1990. 107(1-2): p. 22-9. 6. Aldrich, F., Posterolateral microdisectomy for cervical monoradiculopathy caused by posterolateral soft cervical disc sequestration [see comments]. J Neurosurg, 1990. 72(3): p. 370-7. 7. Zeidman, S.M. and T.B. Ducker, Posterior cervical laminoforaminotomy for radiculopathy: review of 172 cases. Neurosurgery, 1993. 33(3): p. 356-62. 8. Davis, R.A., A long-term outcome study of 170 surgically treated patients with compressive cervical radiculopathy. Surg Neurol, 1996. 46(6): p. 523-30; discussion 530-3. 9. Woertgen, C., et al., Prognostic factors of posterior cervical disc surgery: a prospective, consecutive study of 54 patients. Neurosurgery, 1997. 40(4): p. 724-8; discussion 728-9. 10. Silveri, C.P., et al., Cervical disk disease and the keyhole foraminotomy: proven efficacy at extended long-term follow up. Orthopedics, 1997. 20(8): p. 687-92. 11. Kumar, G.R., R.S. Maurice-Williams, and R. Bradford, Cervical foraminotomy: an effective treatment for cervical spondylotic radiculopathy. Br J Neurosurg, 1998. 12(6): p. 563-8. 12. An, H.S., et al., Spinal disorders at the cervicothoracic junction. Spine, 1994. 19(22): p. 2557-64. 13. Baba, H., et al., Laminoplasty with foraminotomy for coexisting cervical myelopathy and unilateral radiculopathy: a preliminary report. Spine, 1996. 21(2): p. 196-202. 14. Baba, H., et al., Laminoplasty following anterior cervical fusion for spondylotic myeloradiculopathy. Int Orthop, 1994. 18(1): p. 1-5. 15. Burke, T.G. and A. Caputy, Microendoscopic posterior cervical foraminotomy: a cadaveric model and clinical application for cervical radiculopathy. J Neurosurg, 2000. 93(1 Suppl): p. 126-9. 16. Chesnut, R.M., J.J. Abitbol, and S.R. Garfin, Surgical management of cervical radiculopathy. Indication, techniques, and results. Orthop Clin North Am, 1992. 23(3): p. 461-74. 17. Debois, V., et al., Soft cervical disc herniation. Influence of cervical spinal canal measurements on development of neurologic symptoms. Spine, 1999. 24(19): p. 1996-2002. 18. Ducker, T.B. and S.M. Zeidman, The posterior operative approach for cervical radiculopathy. Neurosurg Clin N Am, 1993. 4(1): p. 61-74. 19. Ebraheim, N.A., et al., The projection of the cervical disc and uncinate process on the posterior aspect of the cervical spine. Surg Neurol, 1999. 51(4): p. 363-7. 20. Fager, C.A., Posterolateral approach to ruptured median and paramedian cervical disk. Surg Neurol, 1983. 20(6): p. 443-52. 21. Grieve, J.P., et al., Results of posterior cervical foraminotomy for treatment of cervical spondylitic radiculopathy. Br J Neurosurg, 2000. 14(1): p. 40-3. 22. Grundy, P.L., T.J. Germon, and S.S. Gill, Transpedicular approaches to cervical uncovertebral osteophytes causing radiculopathy. J Neurosurg, 2000. 93(1 Suppl): p. 21-7. 23. Heiskari, M., Comparative retrospective study of patients operated for cervical disc herniation and spondylosis. Ann Clin Res, 1986. 18(Suppl 47): p. 57-63. 24. Herkowitz, H.N., L.T. Kurz, and D.P. Overholt, Surgical management of cervical soft disc herniation. A comparison between the anterior and posterior approach. Spine, 1990. 15(10): p. 1026-30. 25. Koshu, K., T. Tominaga, and T. Yoshimoto, Spinous process-splitting laminoplasty with an extended foraminotomy for cervical myelopathy. Neurosurgery, 1995. 37(3): p. 430-4; discussion 434-5. 26. Rock, J.P. and J.I. Ausman, The use of the operating microscope for cervical foraminotomy. Spine, 1991. 16(12): p. 1381-3. 27. Roh, S.W., et al., Endoscopic foraminotomy using MED system in cadaveric specimens. Spine, 2000. 25(2): p. 260-4. 28. Snow, R.B. and H. Weiner, Cervical laminectomy and foraminotomy as surgical treatment of cervical spondylosis: a follow-up study with analysis of failures. J Spinal Disord, 1993. 6(3): p. 245-50; discussion 250-1. 29. Tan, L.C., Medial cervical facetectomy for radiculopathy due to foraminal stenosis: 71 personal consecutive cases. J Clin Neurosci, 1999. 6(3): p. 207-211 [Record as supplied by publisher]. 30. Tanaka, N., et al., The anatomic relation among the nerve roots, intervertebral foramina, and intervertebral discs of the cervical spine. Spine, 2000. 25(3): p. 286-91. 31. Ullman, J.S., M.B. Camins, and K.D. Post, Complications of cervical disk surgery. Mt Sinai J Med, 1994. 61(3): p. 276-9. 32. Wirth, F.P., et al., Cervical discectomy. A prospective analysis of three operative techniques. Surg Neurol, 2000. 53(4): p. 340-6; discussion 346-8. 33. Woertgen, C., et al., Long term outcome after cervical foraminotomy [In Process Citation]. J Clin Neurosci, 2000. 7(4): p. 312-5 [MEDLINE record in process]. 34. Zeidman, S.M., T.B. Ducker, and J. Raycroft, Trends and complications in cervical spine surgery: 1989-1993. J Spinal Disord, 1997. 10(6): p. 523-6. |