Clinical Course
37 year old female with severe right arm pain, right arm numbness, and right arm weakness for 5 months. Her pain was 10 on a scale of 10. Conservative treaments included physical therapy, muscle relaxants, anti-inflammatory medications, and narcotics. She was unable to play a musical instrument due to numbness in the fingers and weakness in her arm. Her physical exam revealed pain in her arm with neck motion (lookin up and to the right), some pain relief in the arm when putting her right arm over her head, numbness in the index and middle fingers and weakness in her triceps muscle.

Diagnostic Tests
A Cervical MRI scan showed a herniated disc in the exit zone for the right C7 nerve root at C6-C7. CT-discogram revealed dye leaking out of the C6-C7 disc space under the right C7 nerve root and reproducing the patient's pain.

Decision
Surgery was chosen due to the duration of symptoms, the failure to respond to conservative treatment and the degree of disability. A posterior approach (from the back of the neck) was chosen because the patient sings professionally and did not want any potential risk from anterior cervical surgery (surgery through the front of the throat). A MicroEndoscopic Foraminotomy was chosen as the surgical procedure.

Surgical Treatment
The MicroEndoscopic Foraminotomy (M.E.F.) is a minimally invasive spine operation combining the use of flurosocopy (dynamic xray for localization) and endocopic visualization. The surgeon actually looks at the anatomy on television while performing the operation. The cervical foraminotomy for relief of arm pain and arm weakness is a well established operation. The operation was performed on an outpatient basis. The patient returned to her usual occupation in 3 weeks with complete resolution of her right arm pain, right arm weakness and right hand numbness.

Surgeon's Comment
This classic foraminal disc herniation produced pressure on the right C7 nerve root causing the patient's symptoms and disability. The value of the microendosocpic approach in this patient was avoiding any risk to the vocal cords in a singer by choosing an alternative approach. Although, the risk of vocal cord paralysis is small with anterior surgery, it is not zero. The location of the herniation was optimum for M.E.F. Her quick surgical recovery was due to the optimum response of the biologal factors causing pain to decompression and the nature of minimally invasive surgery.