Posterior Cervical Foraminotomy

Where a nerve root is compressed as it leaves the cervical spine — often by a bone spur or a disc fragment sitting to one side of the canal — the result is typically pain, tingling or weakness travelling down the arm in the pattern of that nerve. When this arm pain is the main problem, is clearly coming from one nerve on one side, and has not settled with non-operative treatment, decompressing that nerve from behind can be considered as an alternative to an anterior operation.

In a posterior cervical foraminotomy, the spine is reached from the back of the neck. A small amount of bone is carefully removed from the roof of the nerve's exit channel (the foramen), and any disc fragment or spur pressing on the nerve is taken away, freeing the nerve without disturbing the disc from the front and without a fusion. Increasingly this can be done through a small tubular or endoscopic approach that spreads rather than cuts the muscle, which can mean less tissue disruption and a quicker early recovery. These minimally invasive and endoscopic techniques are a particular area of interest and expertise, offered where they suit the individual problem.

This operation can be considered for cervical radiculopathy where the compression is to one side and coming largely from behind or from the side — the classic situation being a single nerve pinched by a lateral disc fragment or spur. It is attractive where preserving motion is valued and a fusion is best avoided. It is less suitable where compression is central, where the spinal cord is significantly involved, or where alignment problems mean an anterior operation or fusion would serve better. The choice is individualised.

The evidence increasingly supports posterior cervical foraminotomy as an effective alternative to ACDF for suitable one-sided nerve compression. A recent randomised non-inferiority study found that foraminotomy gave results comparable to ACDF for cervical radiculopathy, and systematic reviews of minimally invasive foraminotomy report good relief of arm pain while preserving motion and avoiding a fusion. The balanced view is that, for the right nerve-compression problem, this is a well-evidenced, motion-preserving option — with minimally invasive and endoscopic approaches offering the further advantages of smaller wounds and less muscle disruption in appropriate cases.

The operation is usually performed under general anaesthetic, and with minimally invasive techniques the wound is small and the early recovery often quick. Arm pain frequently eases soon after the nerve is freed. Because there is no fusion, movement is generally encouraged as comfort allows. As with any operation there are risks, which are discussed fully beforehand. Whether a posterior foraminotomy — and whether an open or endoscopic approach — is the best choice depends on the individual problem and is decided together.

• —Broekema AEH, et al. Posterior cervical foraminotomy versus ACDF for cervical radiculopathy: 2-year results of the FACET randomised non-inferiority study. J Bone Joint Surg Am 2024. (PMID 39047120)
• —Sahai N, et al. Minimally invasive posterior cervical foraminotomy as an alternative to ACDF for unilateral cervical radiculopathy: systematic review and meta-analysis. Spine 2019. (PMID 31343619)
• —Fang H, et al. Minimally invasive posterior cervical foraminotomy versus anterior cervical fusion and arthroplasty: updated systematic review and meta-analysis. Brain Spine 2024. (PMID 39036750)
• —Liu WJ, et al. Comparison of ACDF versus posterior cervical foraminotomy in cervical radiculopathy: a systematic review. Orthop Surg 2016. (PMID 28032703)