Cervical Foraminotomy

July 25, 2017 by Dr. Shim0
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Hi my name is Dr. John Shim and I want to discuss cervical foraminotomy. By now you have already tried non-surgical treatments and have decided to move forward with surgery. Cervical foraminotomy surgery is awkward because your pain pattern and physical examination matches the findings on your diagnostic studies. Forminotomy means enlarging the space for the exiting nerve. Let me show you a typical cervical MRI with narrowing of the space for the nerve. This is the sagittal view. It's a side view of your neck. For most patients there are some normal disc levels but the offending narrowing will be identified near the space or foramen where the nerves exit from the spinal cord. The narrowing is usually caused by a combination of bone spurring and/or disk herniation. The axial view or the cross-sectional view will provide another angle to visualize the encroachment on the nerve. Depending on the location of the bone spur or disc herniation sometimes a cervical foraminotomy approach may require too much spinal cord manipulation. In that scenario another surgical approach may have much less risks for the surgeon. There are many nuances that need to be considered. Experience helps when planning the operation. Still the exposure is relatively the same for the average-sized patient a less than 1.5 inch incision is made over the intended surgical site. Care is taken to preserve the large neck ligaments called the ligamentum nuchae. Muscle tissues are retracted away from the bony and ligament covering over the spinal canal. Magnification is used to obtain better visualization of the anatomy. Tools such as bur, carecen rasures and micro curettes are used to remove the bony covering. The narrowing is opened. The foramen is then opened to remove pressure off the nerve. Bone spurs are shaved and if needed disc material is gently removed and taken away from the nerve and spinal cord. The wounds are then closed . Most patients now have the procedure performed on an outpatient basis. Greater than 90% of the properly selected patients have improvement of their symptoms. Most will return back to all their activities within a few months. This is Dr. John Shim and I hope this video helped you understand the cervical foraminotomy surgery. Thank you

What is Cervical Foraminotomy?

In my prior blogs,  we discussed cervical radiculopathy,  or in simple terms,  a pinched nerve in the neck.  Usually,  there is associated pain, numbness and tingling corresponding to the distribution of the pinched nerves functions.  As we discussed before,  these nerves can have a distribution of sensation called dermatomes, as well as corresponding associated reflexes, and set groups of muscles.

Causes of the pinching of the nerve are usually from disk herniations,  and bone spurs.  Unfortunately,  but rarely,  it can be caused my more serious problems such as fractures, infections and tumors.  In general, however,  most episodes of cervical radiculopathy usually resolve with non-surgical means.  But for a certain percentage of patients,  surgery will become the only treatment that will give relief.

Cervical Foraminotomy is one of the options that can provide surgical relief in that patient population.

In the most simple explanation,  Cervical Foraminotomy means removing the bone spurs that cause the pinching of the nerve.  The incision is made from the back of the neck, and the bone spurs from the arthritic facet joints are partially removed.

Cervical Foraminotomy can also be combined with removing of a disc herniation that is located in an accessible location in the spine.  The surgical judgement call involves  determining which cervical disc herniations can be approached through the opening created by the cervical foraminotomy.  If the disc herniation is located too far to the middle of the spine,  it requires retraction on the spinal cord to properly remove the disk fragment.  The key is to minimize any pressure on the spinal cord during removal of the disc.  If the location of the disc necessitates excessive spinal cord retraction to retrieve the disk,  the better approach may be to remove the disc from the front.  That procedure is the Anterior Cervical Discectomy and Fusion surgery.

Sometimes,  even with posterior Cervical Foraminotomy,  there remains residual bone spurs, but with improvement of the space for the nerve,  there is still favorable reduction of the pain.

While performing Cervical Foraminotomy,  the surgeon must assess the facet joints of the neck to see if there is stability of the joint.  If the joint is not stable, and allows excessive motion,  this can also lead to nerve pinching.  Also,  if certain instances,  more bone than orginally planned must be removed,  with a high risk of developing instability.  In those scenarios,  a Posterior Cervical Fusion may also be performed at the time of the surgery, or at a later staged time.

For properly selected patients,  with isolated nerve entrapment from posterior bone spurs,  Cervical Foraminotomy is an excellent option.

 

Citations

  • Mai HT, Chun DS, Schneider AD, Hecht AC, Maroon JC, Hsu WK. The Difference in Clinical Outcomes After Anterior Cervical Fusion, Disk Replacement, and Foraminotomy in Professional Athletes. Clin Spine Surg. 2017 Jul 17; PubMed PMID: 28719454
  • Peto I, Scheiwe C, Kogias E, Hubbe U. Minimally Invasive Posterior Cervical Foraminotomy: Freiburg Experience With 34 Patients. Clin Spine Surg. 2017 Feb 23; PubMed PMID: 28234772

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Last modified: September 21, 2017