DrDillin.com: Spine Procedures

Procedures: Cervical Posterior Foraminotomy

Keywords
Cervical Foraminotomy
Posterior Cervical Foraminotomy
Posterior Cervical Discectomy
Microcervical Posterior Foraminotomy
Laminoforaminotomy
Microendoscopic Cervical Foraminotomy

Definition
Posterior Cervical Foraminotomy is an operation designed to decompress a single cervical nerve root or multiple cervical nerve roots from a posterior approach (back of the neck). This operation is an alternative to operations designed to accomplish the same goal from an anterior approach (through the throat).

Indications
This operation is indicated for the relief of arm pain, arm numbness, and/or arm weakness from pressure on a single cervical nerve root or multiple nerve roots.
The table below illustrates the findings associated with a single nerve root.

Click to enlarge images.

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Root	Sensory	Motor	Reflex
C4	Top of Shoulder	None	None
C5	Outside of Shoulder	Shoulder Abduction	None
C6	Thumb and Index Finger	Elbow Flexion Wrist Extension	Biceps
C7	Middle Finger, occasionally IndexFinger	Elbow Extension Wrist Flexion	Triceps
C8	Little Finger and occasionally Ring Finger	Hand Intrinsics	None

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]

Year	# Patients	Follow-up	Success	Authors
1983	846	2.8 years	96%	Henderson
1982	235		96%	Williams
1986	50	1-7 years	96%	Simeone
1990	230	3.5 years	92%	Krupp
1990	36	2 years	100%	Aldrich
1993	172	<2 years	97%	Zeidman
1996	170	15 years	86%	Davis
1997	54	1 year	94%	Woertgen

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]

Finding	Better Results	Porrer Results
Symptom Duration	58 days	243 days
Neck and Shoulder Pain	46%	85%
Duration of Sensory Loss	65 days	158 days
Duration of Arm Weakness	46 days	168 days
Surgical Finding of stenosis commpressing the nerve root	8%	46%
Surgical Finding of disc herniation commpressing the nerve root	40%	15%

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.