1. Informed consent signed, preoperative labs normal, no Aspirin/Plavix/Coumadin/other anticoagulants for at least 2 weeks preoperatively
2. Appropriate intubation and sedation
3. Place the patient prone in neutral position with Mayfield head holder
4. Time out performed
5. Incision along posterior cervical spine midline
6. Subperiosteal dissection of muscles down to bone performed at appropriate level (see ▶Fig. 1.9)
7. X-ray/fluoroscopic confirmation with two people for appropriate level (see ▶Fig. 1.10)
8. Laminectomy and foraminotomy unilaterally or bilaterally, if needed, depending on diagnosis and indication for surgery (see ▶Fig. 1.11)
a. Use pituitary rongeur/Kerrison rongeur and high-speed drill
Fig. 1.9 Fluoroscopy reveals trajectory of tube for cervical decompression. Identify the facet joint before placing parallel to disk space at that level. (Source: Minimally invasive tubular posterior cervical decompressive techniques. In: Vaccaro A, Albert T, eds. Spine Surgery: Tricks of the Trade. 3rd ed. Thieme; 2016).
9. Once spinal cord and/or nerve roots are decompressed, obtain X-ray confirming appropriate levels decompressed
10. If stabilization is planned, then instrumentation and fusion can be performed
11. Muscle and skin closure with drain placed (if necessary)
Pitfalls
• Intraoperative CSF leak
• Blood clot (deep vein thrombosis, or more severe pulmonary embolism)
• Damage to spinal nerves and/or cord
• Postoperative weakness or numbness or continued pain
• Postoperative wound infection
• Continued symptoms postsurgically/unresolved symptoms with no improvement to quality of life
Prognosis
• Most patient are discharged home the same day for single level foraminotomy
• Typically, 4 to 6 weeks post operation most patients are able to return to normal day-to-day activities
• PT/OT can be performed as outpatient to regain strength
• Most patients do very well and are happy with the results
Fig. 1.10 Guide for patient selection considering between anterior cervical diskectomy and fusion (ACDF) and posterior foraminotomy (PF). Patients selected for PF will have mediolateral or lateral disk herniation and are without relevant osseous component. (Source: Scholz T, Geiger M, Mainz V, et al. Anterior cervical decompression and fusion or posterior foraminotomy for cervical radiculopathy: results of a single-center series. J Neurol Surg A Cent Eur Neurosurg 2018;79(03):211–217).
1.3 Tumor/Vascular
1.3.1 Cervical Tumor Resection (Vertebral Pathology)
Symptoms and Signs
• Incidental with symptoms (depending on size and location)
• Moderate/Severe numbness in upper extremities
Fig. 1.11 A spinal needle marks entrance site for a lower cervical (C6–C7) foraminotomy. It is recommended to enter the skin rostral to the foramen. (Source: Operative procedure. In: Wolfla C, Resnick D, eds. Neurosurgical Operative Atlas: Spine and Peripheral Nerves. 3rd ed. Thieme; 2016).
• Paresthesias in upper body extremities
• Neck pain and loss of mobility due to neck pain
• Radiating pain down the arms
• Pain in moving shoulders
• Muscle weakness in arms
• Inability to conduct fine motor skills with hands
Surgical Pathology
• Cervical spine benign/malignant tumor
Diagnostic Modalities
• CT of cervical spine with and without contrast to assess whether there is bony involvement of tumor
• MRI of cervical spine with and without contrast to assess if there is spinal cord, epidural space, or nerve root involvement of tumor
• PET scan of body to look for other foci of tumor
• CT of chest/abdomen/pelvis to rule out metastatic disease
Differential Diagnosis
• Metastatic tumor
– Breast, prostate, lung, renal cell
Fig. 1.12 (a–h) Higher cervical (C2) resection of giant cell tumor via endoscopic transnasal and transoral approaches. Radiology reveals the location of the tumor. Gross total tumor resection was achieved. (Source: Surgical technique. In: Stamm A, ed. Transnasal Endoscopic Skull Base and Brain Surgery: Surgical Anatomy and Its Applications. 2nd ed. Thieme; 2019).
• Primary tumor (see ▶Fig. 1.12)
– Schwannoma, myeloma, plasmacytoma, meningioma
Treatment Options
• Acute pain control with medications and pain management
• If asymptomatic or mildly symptomatic with neck pain/radiculopathy with
