The Advantages of Cervical Foraminotomy
I am assuming you have already had the discussion about the need for a neck surgery for a pinched nerve in the neck. Let us assume you have already failed the standard non-surgical treatments including time, medications, therapy and injections. Let us further assume certain diagnostic tests have isolated the pinched nerves to a specific location, and a specific nerve.
The decision now is to decide which surgery will give you relief. Right now, most of the recommendations are about either removing a disk, or bone spur, and then fusing those bones together. The rationale being that removal of the whole disk will improve the arm pain from the pinched nerve, but because so much of the disk is removed, the spine will become unstable, thus the spine fusion. The operation is a very common operation, with high success rates. It is an excellent option for the proper patient. A variation of this operation is the same approach to remove the disk/bone spur, but instead of a fusion, an artificial disk device is inserted. This also is an option in the properly selected group. There are nuanced requirements for patients to qualify. In my experience, that can also be a very successful option.
The least discussed option is the title of this blog. Posterior Cervical Foraminotomy. The research on this approach also demonstrates good success, and our experience also is of excellent relief in the properly selected patient. And that is the point. In all these scenarios, the proper selection is tantamount to a successful outcome.
Let’s Discuss the Pro’s and Con’s to the Posterior Cervical Foraminotomy:
1. It is not a fusion operation. There is no insertion of a bone graft, or an artificial disk device.
2. The incision is on the back of the neck. The dissection does not encounter vital structures such as the esophagus, trachea, carotid artery.
3. It can be done as an outpatient procedure.
4. Recovery is dependent on healing of the incision site. There is no need to protect the neck because of maturation of a fusion, or a risk of dislodging a disk replacement device.
5. Cost wise, the total cost of the procedure is limited to the surgery facility, the anesthesia staff, and the surgical fee. Typically, all three fee’s are less than compared to a fusion or an artificial disk device. The cost of the hardware for fusion, and certainly the artificial disk device, is a significant expense.
6. In the properly selected patient, the results are comparable to discectomy and fusion, or discectomy and artificial disk replacement.
7. If there is the need for addtional surgery in the future, it can be performed with minimal scarring, leaving all options available for the surgical team. The more invasive Anterior fusion or disk replacement surgeries will leave more scar formation, with the associated risks of injury secondary to scar dissection.
1. Not all pinched nerves are amenable to this approach. The goal is to remove the laterally located bone spur, or disk that is causing the pain. A more central (in the middle) disk, or spur means manipulation of the nerves, and potentially the spinal cord to approach the problem. The spinal cord manipulation is not advised, and most surgeons will recommend the anterior discectomy to avoid the manipulation.
2. Greater than two levels have decreased success rates. This is also true of any approach. But with this more minimalist approach, some will be willing to try to do more levels. Be aware the results will still be less likely to be successful with more levels.
3. Body habitus may make visualization difficult. Obese patients, and those with large shoulders may make it very difficult to visualize the appropriate level without more vigorous dissection, and opening techniques. It may not be an outpatient event. Also, depending on the potential visualization difficulties, some surgeons will advise further non surgical care, or referral to others.
4. Dissection of the neck muscles or ligaments (ligamentum nuchae) can be a very painful recovery, with muscle spasms. Understand that potential prior to surgery.
5. Dissection around the facet joint capsules can cause the development of spinal instability.
6. There is a rare but serious nerve problem called the C5 syndrome. The exact mechanism is not definitively known, but there can be a delayed development of weakness to the shoulder and arm muscles. Fortunately, the vast majority of these patients do recover, but it can occur. While it also occurs with Anterior fusion and replacement surgeries, there is a trend of more of these events with posterior procedures.
As in all surgeries, there are also the standard risks associated with any surgery.
Posterior Cervical Foraminotomy is an excellent option for the properly selected patient.
- Church EW, Halpern CH, Faught RW, Balmuri U, Attiah MA, Hayden S, Kerr M, Maloney-Wilensky E, Bynum J, Dante SJ, Welch WC, Simeone FA. Cervical laminoforaminotomy for radiculopathy: Symptomatic and functional outcomes in a large cohort with long-term follow-up. Surg Neurol Int. 2014;5(Suppl 15):S536-43. PubMed PMID: 25593773