Keyhole Cervical Foraminotomy Minimally Invasive Cervical Laminoforaminotomy Posterior Cervical Day Surgery: Foraminotomy/Microdiscectomy or Decompression

1. Posterior Cervical Foraminotomy
Mohamed Mohi Eldin
Professor of Neurosurgery
Cairo University
Egypt

2. Nomenclature
(Keyhole Cervical Foraminotomy)
(Minimally Invasive Cervical
Laminoforaminotomy)
(Posterior Cervical Day Surgery:
Foraminotomy/Microdisectomy or
Decompression)

3. Foraminal Nerve Root Compression
(3 Ds)
• Degenerative Changes
– bone spurs
– foraminal stenosis.
• Disc Collapse
– excessive strain
– stress in the neck area.
• Disc Prolapse

4. Cervical foraminotomy is a
decompression surgical procedure
• Widening of the neural foramen,
• Relieving pressure over spinal nerves at
foramen.

5. Traditional Posterior cervical
foraminotomy
• Larger incision
• More muscle trauma,
• Unnecessary bleeding
• Scarring
• Neck pain
• Limited motion ability
(early phase of recovery)
• Delay of hospital
discharge
• Slower return to work

6. Posterior cervical foraminotomy
• A minimally-invasive procedure
– Enlarge the neural foramen
– Remove any piece of disc which is pushing on the
nerve.
• Foraminotomy alone can alleviate symptoms
without a discectomy

7. Posterior cervical foraminotomy
The whole disc is not removed,
just the fragment pressing nerve root.
A fusion is not performed,
Typically do not require a neck collar after the surgery.

8. The basic steps of Procedure
• Prone position under general anesthesia
• An X-ray is used,
• Small incision,
• Muscles retracted,
• Surgical microscope,
• Remove bone spurs, thickened ligaments and disc fragments
• Removal of the bones and tissues around the neural foramen
• Finally, closure in layers

9. Patient Position

10. Using fluoroscopy is vital
The first step is to insert a spinal needle 1.0-1.5 cm
from the midline

11. Skin incision
• Through subcutaneous tissue at puncture location.
• Incision length and the tubular retractor width must
be the same.
incision of 2-4 cm
ENDOSCOPIC
MICROSCOPIC

12. METRx tubular retractor system
Consists of muscle dilators and retractors,
Uses a series of dilators to split muscle,
decreases tissue trauma, avoiding excess bleeding.
Muscles return to their original state easily after surgery

13. Dilator over Guidewire
Fascia penetrated (1st dilator) in twisting motion
Guidewire removed
Dilator moved forward lamina
Subsequent dilators on top of one another
Tubular retractor is inserted over dilators

14. A clear operative field
All soft tissue should be removed (cautery)
A clear view of bone

15. Lateral fluoroscopy
for correct instrument placement
Ligamentum flavum separated from lamina (curette)

16. A small hemi-laminotomy and
foraminotomy
• A small window is made on one side of a spinous process, at
the junction of the lamina and facet joint,
• To allow visualization of the involved root,
• Using a high speed drill and microinstruments.

19. The nerve root
• Ligamentum flavum removed from foramina,
• Nerve root identified,
• Foramen enlarged (Foraminotomy)
• Nerve root is retracted (dissector or retractor)
• Disc herniation can be seen.

20. Pediculotomy Adjunct to
Posterior cervical foraminotomy
If excessive nerve root manipulation is necessary or
foraminal volume limited,
With the nerve root protected,
superomedial aspect of inferior pedicle is resected using the
same 3-mm diamond bit.

21. Before Dealing with the disc
Lateral fluoroscopy
ensure correct level and opposite disc space.

22. Dealing with the disc
Nerve root gently elevated
Disc bulge is palpated, incised
Typically a tiny piece of disc is removed
The whole disc is not removed
Nerve root carefully decompressed

23. Multi-Level Posterior Cervical
Foraminotomy
• The total surgery time is approximately 2
hours, depending on the number of spinal
levels involved.

24. Closure in layers
Hemostasis.
Irrigation containing antibiotics
Gelfoam with methylprednisolone over root
Fascia closed with 1-2 strong sutures
Skin closed (dissolving sutures) leaving minimal
scar and requiring no bandage

26. Postoperative Medications
NSAID, Muscle relaxants

27. Benefits of MI Foraminotomy
Results comparable with open-foraminotomy,
Little or no postoperative pain,
No need for postoperative pain medications
Quick recovery & early discharge (3-6 hours)

28. General Risks & Complications
(similar to those for a any other spinal operation)
Complications related to anesthesia
Conditions such as thrombophlebitis
Infection, Persistent pain

29. The Risk
• Root or cord injury (1-2%)
• Recurrent disc protrusion (small number)
– At same side and level
– At different levels
– The opposite side.
• Still future likelihood to get neck pain.

30. Post-Operative Care
• Physical therapy
• Avoid bending & twisting of neck (1-2 weeks)
• Avoid heavy lifting (3-4 weeks).
• Brace not required (only a soft collar in early
postoperative period)
• Wound area can be left open to air with small
surgical tapes. It should be kept clean and dry.

31. Expectations in uncomplicated cases
• Good/excellent relief of arm pain (80-90%)
• Pins and needles usually improve immediately
• Numbness is slow to recovery
• Weakness may take 6-12 weeks to normalize

32. Outcome
Significant, rapid pain improvement
Return to light work 1-2 weeks
Return to heavy activities in 1-2 months

33. Other Points
Posterior cervical foraminotomy is excellent for
patient with arm symptoms secondary to a
cervical disc protrusion
avoiding implantation of foreign devices and
spinal fusion.
Not all patients are suitable for this operation,
but those who are generally do very well.

35. THANK YOU