Cervical Foraminotomy

What is a cervical discectomy?

This operation is done to remove a part of the disc that is pressing on a nerve and causing arm pain. Sometimes this is done from the back of the neck (cervical foraminotomy) and sometimes from the front (anterior cervical discectomy and fusion). The choice depends mostly on the anatomy of the disc prolapse. If the disc is mostly out to the side, away from the spinal cord, it can be removed from behind and no fusion is required.

If the disc is more central, it needs to be removed from in front. This also involves a fusion as all of the disc is removed.

A cervical foraminotomy is also indicated for treatment of foraminal stenosis (narrowing of the hole through which the nerve leaves the spinal canal).

This narrowing usually occurs because of degeneration in the small joints on either side of the foramen (blue arrows). As these become arthritic, they enlarge and encroach on the foramen.

How is cervical foraminotomy done?

You will be admitted on the morning of surgery and the operation will be done under general anaesthetic. You will be placed flat on your stomach on the operating table with your head fixed in a special headrest which is like a clamp with 3 small pins which grip the skull and prevent the head from moving. An x-ray is taken to mark the correct level and then a small three centimetre incision is made in the midline of the back of the neck. The muscle is stripped off the bone on the side of the disc prolapse and a small, tube-like retractor is inserted. The rest of the operation is done through this tube using an operating microscope and small instruments. A small area of bone, shown in black, is drilled away over the nerve (dotted red line).

With bony foraminal stenosis this is all that needs to be done, but if there is a disc prolapse this is removed.

The nerve is identified and gently retracted away from the disc prolapse. A grasping instrument is used to pull out the fragments of disc that have prolapsed out of the disc space and the nerve is decompressed. Once the disc has been cleared an analgesic (Fentanyl) and sometimes a steroid (Celestone) are injected into the space around the nerves and the retractor is removed and the wound closed. A dissolving stitch is used under the skin so that no stitches need to be removed later.

What to expect post-operatively

In most cases you will notice an immediate improvement in your arm pain. Any weakness or numbness is likely to improve gradually and may take a few months. Numbness is usually the last thing to get better and depending on how much damage has been done to the nerve by the pressure from the disc prolapse it may never go away completely.

Postoperatively you will be able to lie in any position that you find comfortable and the physiotherapist will get you up out of bed the following morning. Most people are able to go home after three or four days. You will have some neck muscle pain and spasm and aching across the shoulders which will gradually improve. The length of time that you need to take off work will depend on what you do. If you work in a sedentary occupation and are able to return on reduced hours with no lifting or work above your shoulders, you will probably only need three or four weeks off work. On the other hand if you work in a heavy manual job you may need up to three months off work. In most cases it is best to avoid any lifting for six weeks and then to gradually increase activities over the following six weeks. The physiotherapist will give you a booklet explaining what exercises to do. You will be given an appointment to see me in my rooms in 4 to 6 weeks.

Are there risks involved?

There are risks involved with anything in life and surgery is no different. Some of these risks are common to most or all operations and some are specific to the particular procedure.

The following are the most common or most serious complications. Other problems may occur rarely and it is impossible to list every one of them. Just try to list all of the possible things that could happen on your drive to work-a car crash is obvious; an aeroplane crashing onto the road in front of you is also possible but extremely unlikely and would not normally be considered common enough to affect your decision to drive. If there is anything in particular that you are concerned about, please ask me.

General risks of any operation

Anaesthetic complications such as heart attack, drug allergy or even death are possible but very rare.

Blood clots in the leg (DVT) or lung (pulmonary embolus) may occur unexpectedly but are very uncommon in otherwise healthy people.

Infections such as pneumonia, wound infection or urinary tract infection may occur after any operation.

Bleeding may occur especially in people taking aspirin. It is therefore recommended to cease aspirin (also called Cartia or Disprin) two weeks before elective surgery.

Specific complications

The aim of the operation is to relieve arm pain due to pressure on a nerve. Neck pain is usually due to the fact that the disc is damaged and this will not be helped by surgery. If most of your pain is neck pain rather than arm pain surgery would not normally be recommended.

Arm pain is relieved or significantly improved in approximately 90% of cases. In up to 10% of patients surgery may fail to relieve the arm pain for unknown reasons. Arm pain may return at a later date due to scarring but this is less common in the neck than in the lumbar spine.

Damage to the nerve root causing numbness or weakness in the arm is possible but uncommon.

Damage to the cervical spinal cord is very rare but at the worst has the potential to cause quadriplegia (numbness and weakness in all four limbs).

Wound infection is uncommon and would normally be treated with antibiotics.

Bleeding is rare except in people with bleeding disorders.

As the entire disc is not removed there is a small risk of recurrent disc prolapse.

Coming into hospital for surgery

These days, most operations are done on the same day as admission. You will need to come to the hospital admissions area at the notified time. If you have not already sent in the hospital admission forms, bring them with you.
You will need to fast for 6 hours which means nothing to eat or drink after the time notified.

You will usually be able to take your normal tablets but medications that affect your bleeding will usually be stopped preoperatively. Aspirin, (also called Disprin or Cartia),and Plavix (also called clopidogrel) should be stopped for two weeks if possible before an elective operation. Fish oil should be stopped for a week. Anti-inflammatories should be stopped for 48 hours. Warfarin will need to be discussed with me and your GP.

Make sure you bring your Xrays as these will be essential for most operations. If you cannot find them please let me know early so that they can be repeated if necessary.

If you would like to have a private room that should be indicated on the hospital admission forms. There are only a finite number of single rooms and sometimes it will not be possible to go straight into one, but if you indicate your preference every effort will be made to move you into a private room as soon as possible. (I do not have any say in this except in cases of medical need eg infections).

I will see you in hospital before you go to the operating room and the anaesthetist will also see you preoperatively and will want to know about your general health and any medications you are on. Please bring your usual tablets with you.