Posterior Cervical Endoscopic Foraminotomy & Discectomy

A posterior cervical foraminotomy enlarges the tunnel where the nerve leaves the neck. Often, alongside the narrowing, there is a herniated disc fragment pressing on the nerve, and the same posterior keyhole approach can be used to remove it — a combined foraminotomy and discectomy. Working from behind, the nerve is identified and freed, and a soft fragment beneath or beside it is lifted out under magnified vision, all without removing the whole disc or fusing the segment. For a soft, laterally placed disc trapping a nerve, this is an elegant, motion-preserving solution.

The limitation of the standard posterior approach has always been reaching pathology that sits directly in front of the nerves and the cord — a hard, calcified disc, a bone spur from the uncovertebral joint, or a fragment that extends towards the centre. To reach these from behind would traditionally mean retracting the nerve or the cord out of the way, which in the neck is dangerous. This is exactly the problem the partial pediculotomy and partial vertebrotomy technique was developed to solve.

This is the advanced refinement, and it is a genuinely clever solution. Rather than pulling the nerve aside to reach pathology in front of it, the technique creates space by removing a small, controlled amount of bone — the inner third of the pedicle, and a little of the vertebral body in front of the cord — to open a working corridor beneath and in front of the nerve. Through that corridor, a hard disc fragment or an uncovertebral bone spur can be reached and removed, and the fragment delivered forward into the space created, without retracting the neural structures at all. The stability of the segment is preserved because only a small, defined amount of bone is taken. It extends what can be achieved from behind to include the harder, more central pathology that would otherwise have required an operation from the front.

I am candid that this is one of the most demanding techniques in spinal surgery, and it belongs firmly in experienced, subspecialised hands. Drilling precisely around the pedicle and the vertebral body, immediately next to the spinal cord and the vertebral artery, and correctly identifying the nerve and its separate sensory and motor branches before any disc is removed, leave a very small margin for error. Confirming the exact level is critical, because the levels are close together and wrong-level surgery is a recognised risk. This is exactly the kind of frontier technique I have trained in and written about, and I apply it selectively, to the right patient, with meticulous planning — never as a routine.

The evidence supports the combined and advanced posterior endoscopic approaches. The foundational randomised trial by Ruetten and colleagues established posterior full-endoscopic cervical surgery as an effective, fusion-avoiding alternative to the anterior approach. The partial pediculotomy, partial vertebrotomy technique was described and refined by Kim and colleagues, whose published series and a comparative study against anterior cervical decompression and fusion report that it can address foraminal and harder, more central cervical pathology from behind, without neural retraction and while preserving segmental stability, with outcomes comparable to fusion. Technical reports also describe posterior full-endoscopic discectomy for migrated and difficult cervical disc herniations. This is the literature I draw on in offering these techniques to carefully selected patients.

Because the approach is a keyhole from behind that avoids a fusion, recovery is generally quick — many people go home the same day or the next, with the arm pain often settling early, the neck's movement preserved, and none of the swallowing precautions that follow a front-of-neck operation. Where the more advanced technique has been used for harder pathology, recovery follows the same pattern, guided closely by the team. Numbness and long-standing weakness may take longer to recover and do not always resolve fully. 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)
• —Kim HS, et al. Safe route for cervical approach: partial pediculotomy, partial vertebrotomy for posterior endoscopic cervical foraminotomy and discectomy. (PMID 32438007)
• —Kim HS, et al. Anterior cervical decompression and fusion versus PPPV posterior endoscopic cervical decompression for foraminal pathology: comparative study. Medicina 2023. (PMID 37512034 / PMC10383634)
• —Song Z, et al. Posterior endoscopic cervical decompression versus ACDF for single-level radiculopathy: mid-term results. (PMID 36823701)
• —Zhang C, et al. Posterior endoscopic cervical decompression: review and technical note. (PMID 32746520)
• —Ahn Y, et al. Circumferential decompression technique of posterior endoscopic cervical foraminotomy. (PMID 35111847 / PMC8803431)
• —Wu PH, Kim HS, et al. Posterior full-endoscopic cervical discectomy for highly migrated cervical disc herniation: technical note. (PMID 36422713)