Posterior Cervical Endoscopic Foraminotomy (PCEF)

In the neck, each nerve leaves the spine through a bony tunnel — the foramen — on its way to the arm. Wear and tear can narrow this tunnel: bone spurs from the facet joint or the uncovertebral joint, a bulging or herniated disc, and loss of disc height all crowd the exiting nerve. The result is arm pain, pins and needles, numbness or weakness following the path of that nerve — brachialgia. Many cases settle with time and non-operative care; when they do not, surgery to free the nerve is offered.

This is the heart of why I favour the endoscopic approach, and it matters a great deal to patients. The traditional operation — anterior cervical discectomy and fusion, or ACDF — approaches from the front and removes the whole disc, replacing it with a cage and fusing the segment. It is an excellent operation with a long track record, but it carries specific downsides: it stiffens the segment permanently, it can accelerate wear at the neighbouring levels over time (adjacent segment disease), and the front-of-neck approach carries a risk of swallowing problems and, occasionally, hoarseness. The posterior cervical endoscopic foraminotomy avoids all of this. It reaches the trapped nerve directly from behind and enlarges the tunnel to free it — without removing the disc, without a cage, and without a fusion — so the neck keeps moving and the neighbouring levels are not loaded by a stiff segment. For a nerve trapped by posterior or foraminal pathology, that is a compelling advantage.

The patient is positioned prone, and under x-ray guidance the endoscope is docked onto the facet joint at the correct level through an incision under a centimetre long. Working under continuous saline irrigation and magnified vision, a fine diamond burr is used to thin the edge of the lamina and the medial part of the facet joint until the junction with the nerve's tunnel is reached. The ligament is removed, the edge of the superior facet trimmed as needed, and the exiting nerve exposed and freed. A soft disc fragment beneath the nerve can be removed through the same approach; gentle upward lift of the nerve may reveal a sequestered fragment to be lifted out. Great care is taken to identify the nerve — which often has separate sensory and motor branches running together — and to avoid passing instruments too far forward, protecting the nearby vertebral artery. Decompression is confirmed when the nerve lies free and pulses under irrigation.

I set out this detail because cervical endoscopic surgery is genuinely advanced work and I treat it with the respect it deserves. Working with a fine drill in the neck, close to the spinal cord and the vertebral artery, demands precise instrument control and a confident three-dimensional understanding of the anatomy. Confirming the correct level, identifying the nerve and its branches before any disc is touched, and knowing exactly how much bone to remove to free the nerve while preserving the facet and the stability of the segment are judgements built through subspecialty training and experience. These are precisely the skills I have concentrated my practice and my writing on.

The evidence for posterior cervical endoscopic foraminotomy is strong. A landmark randomised controlled trial by Ruetten and colleagues compared the full-endoscopic posterior foraminotomy with the anterior approach and found equivalent relief of arm pain, with the endoscopic operation avoiding a fusion and its associated risks. Systematic reviews and meta-analyses comparing posterior cervical foraminotomy with ACDF report comparable clinical outcomes for single-level radiculopathy, with the posterior approach preserving motion and avoiding the swallowing risks and, over the longer term, the adjacent-segment problems associated with fusion. Studies of neck movement after the procedure confirm that motion at the operated level is largely preserved. This body of evidence is exactly why I offer it as a motion-preserving alternative to fusion in suitable patients.

Because the operation is a keyhole from behind that spares the muscles and avoids a fusion, recovery is usually quick — many people go home the same day or the next, with a small dressing, and notice the arm pain settling early. The neck keeps its movement, and there is no need for the eating or swallowing precautions that follow a front-of-neck operation. Numbness and long-standing weakness may take longer to recover and do not always resolve fully. Activity is built back up over the following weeks, and the neck is followed up over the longer term.

• —Ruetten S, et al. Full-endoscopic cervical posterior foraminotomy for lateral disc herniations: prospective randomized controlled study. (PMID 18427313)
• —Sahai N, et al. ACDF versus posterior cervical foraminotomy for cervical radiculopathy: systematic review. (PMID 28032703)
• —Wang H, et al. Minimally invasive posterior cervical foraminotomy versus anterior cervical fusion and arthroplasty: systematic review and meta-analysis. (PMID 39036750)
• —Xie Y, et al. Microscopic ACDF versus posterior endoscopic cervical keyhole foraminotomy: systematic review and meta-analysis. (PMID 35344521 / PMC9949523)
• —Deng Y, et al. Percutaneous endoscopic cervical foraminotomy for cervical radiculopathy: systematic review and meta-analysis. (PMID 33157922)
• —Kim J, et al. Cervical kinematic change after posterior full-endoscopic cervical foraminotomy. (PMID 36809260 / PMC9942978)
• —Clark JG, et al. Same-segment and adjacent-segment disease after posterior cervical foraminotomy. (PMID 17233284)