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Cervical posterior foraminotomy: how i do it

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Abstract

Background

Cervical pathologies are addressed through a variety of anterior and posterior approaches and minimally invasive procedures have been successfully applied during the last decades. Posterior cervical foraminotomy (PCF) should be proposed with isolated foraminal stenosis.

Method

We provide a step-by-step description of PCF through the use of tubular retractors. Its advantages and limitations were detailed.

Conclusion

PCF performed with tubular retractors represent a safe and efficient alternative to address an isolated level disease with unilateral radiculopathy. The risk of mechanical instability is limited when only the medial third of the facet is drilled. Patients present rapid functional recovery.

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References

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Acknowledgments

Paintings were made by an Elsevier artist under the creative influence of one of the authors (JBC).

Author information

Correspondence to Giulia Cossu.

Ethics declarations

Patient consent statement

The patient has consented to the submission of this “How I Do It” for submission to the journal.

Conflict of interest

The authors declare no conflict of interest.

Additional information

Key points

1. The anatomy of the vertebral artery should be carefully studied at preoperative imaging

2. The patient should be in a prone position with the head fixed in a Mayfield head holder.

3. 3D navigation may be used to plan the incision and the position of tubular retractors, as well as to define intraoperatively the extent of decompression. However, the procedure can also be safely performed under standard radioscopy control

4. The use of tubular retractors limits the dissection of the paraspinal musculature and thus the local pain. Also, the functional recovery is enhanced.

5. The use of a tubular retractor of 16 mm is generally enough to allow a good exposure and ensure a satisfying decompression

6. The microscopic view allows the correct identification of the different structures and the safe performance of the procedure

7. Only the medial third of the facet joint should be drilled to avoid postoperative long-term risks of mechanical instability

8. The copious venous bleeding secondary to the exposure of the epidural venous plexus may be easily managed with positional measures, local hemostatic material, and mechanical compression.

9. Once the dura and the concerned nerve root are visualized, the foraminotomy should be enlarged with Kerrison rongeurs, and the extent of the decompression should be checked with curettes or crochets

10. If a disc fragment is present, the root can be gently displaced medially and cranially to removed it with the aid of small rongeurs.

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This article is part of the Topical Collection on Spine - Other

Electronic supplementary material

A 22-year-old lady presented a history of left-sided pain radiating down the medial aspect of her left arm and a mild triceps weakness. Cervical magnetic resonance showed a left-sided C6–C7 disk herniation with secondary foraminal stenosis. PCF was performed, and the patient experiences a significant relief in her symptoms upon follow-up. No complication secondary to the procedure was noticed. (MP4 211,479 kb).

ESM 1

A 22-year-old lady presented a history of left-sided pain radiating down the medial aspect of her left arm and a mild triceps weakness. Cervical magnetic resonance showed a left-sided C6–C7 disk herniation with secondary foraminal stenosis. PCF was performed, and the patient experiences a significant relief in her symptoms upon follow-up. No complication secondary to the procedure was noticed. (MP4 211,479 kb).

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Cite this article

Cossu, G., Messerer, M. & Barges-Coll, J. Cervical posterior foraminotomy: how i do it. Acta Neurochir (2020). https://doi.org/10.1007/s00701-020-04221-z

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Keywords

  • MetrX
  • Minimally invasive spine surgery
  • Cervical spine
  • Foraminotomy
  • Tubular retractor