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Article
MINIMALLY INVASIVE POSTERIOR CERVICAL
FORAMINOTOMY: MICROSCOPIC TUBULAR
ASSISTED (WITH TECHNICAL TIPS)
Mohamed M. Mohi Eldin, MD1, Ahmed Salah Aldin Hassan, MD1, Wael Mohamed Nazim, MD2,
Mohamed shaban, MD2, Maged Ahmed Hamed Elgebaly3 and Mohammad Baraka, MD1.
1
Department of Neurosurgery, Faculty of Medicine, Cairo University, Egypt.
2
Department of Neurosurgery, Faculty of Medicine, Beni-Suef University, Egypt.
3
Neurosurgery Specialist, Faculty of Medicine, Beni-Suef University, Egypt.
*Corresponding author E-mail: mmohi63@yahoo.com

ABSTRACT: Study design: A prospective case series study.

Purpose: The main aim of this study is to report the technical tips of minimally invasive posterior cervical
foraminotomy using a tubular system.
Overview of Literature: There are clear advantages of performing a posterior cervical foraminotomy,
particularly in patients with cervical radiculopathy as it also allows better access to eccentrically located
disc fragments. Additionally, pseudarthrosis, graft subsidence, and kyphosis can be eliminated when a
posterior foraminotomy is performed. Minimal invasive foraminotomy raised the favorability of surgeons
for posterior approach which was decreasing in recent years due to morbidity associated with muscle
dissection in the traditional technique. Tubular assisted Microscopic Technique may sometime be
confusing intraoperatively due to small parameter of the channel so proper anatomy should be known.
Methods: Prospective preoperative and operative and postoperative data of 20 patients who underwent
minimally invasive microscopic tubular assisted posterior cervical foraminotomy for treatment of cervical
disc herniation; operative technique with some postoperative pitfalls are discussed.
Results: 70% of patients were males with median age 49.5 years, single or multiple and most common
level Was C5-6. The mean skin incision length was short (2.5-4) cm rang, with little amount of blood loss
(20- 270) cc rang, and short time post-operative hospital stay (1-2) days range. Considering postoperative
neck pain and post-operative brachialgia according to Odom’s criteria; 11 cases (55%) had excellent
outcome, 7 patients (35%) had good with total success rate (90%) and 2 patients (10%) had fair outcome.
Postoperative complication reported in only 2 (10%) patients in form of intraoperative Dural tear with no
postoperative CSF leak.
Conclusion: Microscopic assisted tubular posterior cervical foraminotomy provided satisfied results
considering skin incision length, intraoperative blood loss, post-operative hospital stay and post-operative
neck pain and brachialgia.
Key words: Cervical disc herniation, Microscopic Tubular assisted, Posterior cervical foraminotomy
(PCF), Minimally invasive approach

INTRODUCTION
Cervical radiculopathy is pain in the anatomical distribution of a single cervical nerve root with or without
sensorimotor impairment of the same nerve root. Radiculopathy is usually due to a soft lateral disc or
spondylosis with foraminal compromise caused either a calcified disc, osteophyte, or both [1]. The
management of cervical radiculopathy is a controversial area in spine surgery, although most patients are
thought to achieve resolution of symptoms with conservative management [2].
Recent studies provided evidence that surgical intervention may improve functional outcome when
compared with conservative management [2]. When surgical intervention is indicated, the posterior cervical
foraminotomy (PCD) with or without extrusion of disc fragment is a traditional surgical technique with
successful outcomes in patients with radicular pain due to a laterally located herniated disc [3]. The posterior
cervical approach was popularized by Spurling, Scoville and Frykholm [4, 5].
There are clear advantages of performing a posterior cervical foraminotomy, particularly in patients with
cervical radiculopathy such as we can operate c2-3 level which is difficult to be operated by anterior
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approach, it also allows better access to eccentrically located disc fragments, additionally, pseudarthrosis,
graft subsidence, and kyphosis can be eliminated when a posterior foraminotomy is performed [6].
Minimal invasive foraminotomy raised the favorability of surgeons for posterior approach which was
decreasing in recent years due to Morbidity associated with muscle dissection in the traditional technique.
Tubular assisted Microscopic Technique may sometime be confusing intraoperatively due to small
parameter of the channel so proper anatomy should be known.
The aim of this study is evaluating the technical steps of minimally invasive posterior cervical
foraminotomy as a treatment approach of managing cervical disc herniation and assessing operative time,
blood loss, complications and post-operative muscle spasm and pain relieve.

METHODS
Patients
a- Patient selection:
The recruited patients were selected after clinical & radiological features that suggested cervical
radiculopathy as a result of single level cervical disc lesion and not responding to conservative measures
more than 6 weeks with no previous cervical spine surgery. We excluded patients with cervical myelopathy
or patients with images showing central deformity. The study design was approved by the Neurosurgery
Department faculty of medicine, and all patients gave informed consent before being enrolled into the
study.

b-Study design:
case series of prospective collected patients.

c- Patient study population:

This study was done on patients selected from Cairo university hospital outpatient clinic from March 2018
till October 2019.
Twenty patients were operated upon by minimally invasive posterior cervical foraminotomy after fulfilling
the inclusion and exclusion criteria. The inclusion criteria were; unilateral cervical radiculopathy not
responding to conservative treatment for more than 6 weeks, with MRI cervical spine, XRAY AP-lateral
studies confirming unilateral posterolateral disc herniation or osteophyte or focal lateral thickening of the
ligamentum flavum corresponding to the clinical symptom, and without previous cervical spine surgery.

Preoperative clinical and radiological evaluation

All patients subjected to complete history taking and full neurological examination including motor and
sensory deficit followed by visual analogue scale (VAS) for pain assessment, then, routine laboratory
investigation including; complete blood picture (CBC) others esp. coagulation and radiological assessment
by both X-ray and MRI (figure1).

Fig. (1): Preoperative MRI C5-6 disc fragment Surgical technique

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All the patients were operated upon under general anesthesia with the tidal volume is kept at a minimum to
reduce bleeding from the epidural venous plexus in prone position which is used to reduce epidural venous
bleeding and facilitate a clear view of the nerve root, thereby minimizing injury to the nerve (figure 2).

Fig. (2): intraoperative positioning and Tubular system

The cervical spine is maintained in a neutral position, allowing the posterior cervical fascia to be slightly
loose. Exaggerated cervical extension narrows the foramina, whereas excessive flexion tightens the
posterior cervical fascia, making muscle retraction difficult and necessitating a longer incision.
Single dose of Broad spectrum third generation cephalosporin was given 30 mins before skin incision,
Para-median skin incision about 3-4 cm was done, then using dilator system and working channel, we used
intraoperative fluoroscopy to determine the correct level. We used microscope to do Foraminotomy.
We removed the lateral edge of the superior, inferior hemi-laminae using kerrison 1, medial third of
superior and inferior facets by drilling from medial to lateral parallel to the nerve root. We used sharp
dissection for ligamentum falvum with proper coagulation using gel foam and cottonoid of the venous
plexus. Blunt-tipped nerve hook is inserted anterior to the spinal canal dura, and gently swept superiorly
over the disc space, and then laterally, exploring any disc protrusion in the anterior aspect of the lateral
canal and neural foramen. The axilla of the nerve root is elevated rostrally by a nerve hook to expose the
PLL covering the extruded disc. In soft discs, the thin layer of the PLL is incised and the extruded
fragments are retrieved by use of the nerve hook(figure3).

Fig. (3): Extruded disc fragment.

No need to open PLL and key hole foraminotomy is enough for decompression in case of osteophyte
compression. Proper hemostasis and closure were done. Closure in layers without insertion of a drain.

Intra- and postoperative evaluation and follow up

Intra- operative assessment of blood loss, skin incision and operation time were recorded. Moreover, after
operation follow up for 6 months’ interval to evaluate length of stay in hospital, some complication as

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infection or hemiparesis, neck pain and spasm evaluation by VAS score, radiological assessment using x-
ray and CT in all cases and MRI(figure4).

Fig. (4): post-operative CT showing lt c5-6 foraminotomy.

in some cases with brachialgia post-operative and final outcome as regarding Odom's criteria for functional
outcome [7].

Statistical analysis
Continuous variables were presented in the form of mean value and standard deviation, the categorical
variables were presented in the form of numbers and percentages.

RESULTS
Patient's characteristics
The mean age of patients was 48 years; most of them were male (70%) and near half of cases
suffered from C5,6 disc prolapsed (40%), with average VAS score of pain in neck and arm about
(2-6) and (5-9) respectively (Table 1).
Table (1): Patients characteristics
Continues data represented as (mean± SD) and range, while categorical data as number
and percentage (%)
Factors Total (n=20)
Mean± SD Range
Age 48.4 ±7.2 (32-58)
Sex N %
Female 6 30
Male 14 70
Affected level N %
C3,4 1 5
C4,5 5 25
C5,6 8 40
C6,7 5 25
C5,6,7 1 5
VAS score Mean± SD Range
Neck 3.8 ±1.2 (2-6)
Arm 7.5 ±1.1 (5-9)
N: number, SD: stander deviation

Intraoperative Outcomes:
The mean length of skin incision was 3 cm with rang about (2.5-4) cm, the operation time averaged from
(80-180) mint and the amount of blood lost during the operation ranged from (20-270) cc (Table 2).

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Table (2): Inter-operative finding

Continues data represented as (mean± SD) and rang.
Factors Total (n=20)
(Mean± SD) Range
Skin incision(cm) 3.3 ±0.54 (2.5-4)
Length of operation (mints) 112.2±25.1 (80-180)
Blood loss (cc) 132.5 ±71.6 (20-270)
N: number, SD: stander deviation

Postoperative outcomes and consequence

The length of stay in hospital in all patients ranged from (1- 2) days and almost all cases (90%) had no
complication; only 2 patients Dural tear. Regarding the Odom's criteria of functional outcome, more than
half of cases had excellent outcome (55%), opposite to 2 cases with fair outcome (Table 3).

Table (3): Post-operative outcome

Continues data represented as (mean± SD) and range, while categorical data as number
and percentage (%)
Factors Total (n=20)
Mean± SD Range
Length of stay (day) 1.4 ±0.5 (1-2)
Complications N %
No 18 90
Dural tear 2 10
Odoms criteria N %
Fair 2 10
Good 7 35
Excellent 11 55
N: number, SD: stander deviation

On comparing the pain in neck and arm using VAS score before the operation and 3 months post-operative;
a significant statistical decrease after operation was reported, P < 0.001 for both (Table 4).

Table (4): VAS score difference after operation

Continues data represented as (mean± SD)
VAS score Pre-operative Post-operative P$
Mean± SD Mean± SD
Neck 3.8 ±1.2 2.3 ±1.1 < 0.001
Arm 7.5 ±1.1 2.4 ±0.9 < 0.001
$: Independent t-test, P considered significant if < 0.05.

DISCUSSION:
Degenerative cervical spine disorders will affect up to two-thirds of the population in their lifetime. While
often benign and episodic in nature, cervical disorders may become debilitating resulting in severe pain and
possibly neurological sequelae. Surgical treatment including anterior cervical discectomy with fusion and
posterior cervical foraminotomy has been effective treatments of many cervical disorders [8]. There are
clear advantages of performing posterior cervical foraminotomy, particularly in patients with cervical
radiculopathy. Posterior decompression allows better access to eccentrically located disc fragments while
obviating the need for retraction on the esophagus and laryngeal nerve, which can result in postoperative
dysphagia and hoarseness following anterior approaches. Additionally, pseudarthrosis, graft subsidence,
and kyphosis, which are well-reported complications of ACDF, can be eliminated when posterior cervical
foraminotomy is performed [9]. In the current study, the age of patients ranged between (32-58) years; most
of them were males (70%) which is in consistence with other published studies about posterior cervical
foraminotomy.

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Regarding the pain, almost all cases had neck pain and brachialgia with VAS score range from (2-6) and
(5-9) in neck and arm respectively that in agreement with Agrillo et al., [10] as he reported neck pain and
brachialgia in 80% and 60% respectively, while in Adamson study, [11] the symptoms were found in 52% of
cases.
Technically, the mean skin incision length in our series was 3.3 cm. skin incisions using minimal access
techniques are shorter than those used in open techniques. Skin incisions reported with tubular systems
ranged around the same length 3.2 cm [12].
The mean operative time in our study was initially longer than other studies and this is probably due to that
posterior cervical foraminotomy technique is not widely used and it needs to be mastered. Thus with
advancement of the learning curve operative times dropped from 120 minutes to 92 minutes.
Mean blood loss was 132 ml which was better than the average in open approach reported by Winder et al.,
was 233 ml. We utilized prone position to avoid possible complications of the sitting position in agreement
with Kim and Kim., [12], with comparable outcomes with other studies which preferred sitting position [13,
14].

In our experience we used a free hand Tubular system which is different from the standard tubular system
that is fixed to the operating table and we used electrocautery to expose the bony anatomy with no
complication. The free tube retractor was not posing extra difficulties due to unwanted slips or moves
during surgery and thus we can assure that there is not definite need for a table mounted retractor in the
cervical region.
We have performed all our foraminotomies successfully microscopically, some authors however, have
described using the micro endoscope in performing posterior cervical foraminotomy in a study conducted
on 100 patients with cervical disc disease; he noted the reduced need for postoperative analgesics and rapid
return of the patients to their full activities due to very limited postoperative pain in most cases. Moreover,
he stated that; the use of endoscope preserves the tissues and prevents the disruption of ligaments and
muscle splitting. However, the long learning curve was an obstacle in his approach [11].
The hospital stay was short; just about 1-2 days which was significantly shorter than kim and kim, who
reported average 6.7 days in open group, with less post-operative neck pain which was much higher in open
group 31% as reported by Winder et al., [15].
Considering the visual analogue score for pain (VAS); patient satisfaction with improvement of their
brachialgia was significant, P < 0.001. with 55% and 35% had excellent and good outcomes respectively on
Odom’s criteria of outcome assessment., outcome which were in harmony with most published data [16, 17].
Finally, regarding the post-operative complications are much less compared to anterior approaches, the
present series reported Dural tear in only 2 cases with no post-operative CSF leak. Furthermore, Clarke et
al., stated that the overall spectrum of posterior approach-related complications is much more limited than
the anterior approach and it includes: nerve root injury, Dural tearing, spinal cord injury and same-segment
and adjacent-segment disease [18].

LIMITATIONS:
The number of patients so this study need to be done on larger scale.
Short follow up period.
Post-operative analgesia wasn’t included in our study.

CONCLUSION:
Posterior cervical foraminotomy is an option in treatment of unilateral posterolateral cervical disc disease
with good results especially microscopic assisted tubular posterior cervical foraminotomy approach, which
showed short skin incision, short operative length, minimal intra-operative blood loss, short time of hospital
stay and post-operative reduction of neck pain and we recommend further evaluation of that approach.

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