Case Studies Series: Cervical Foraminotomy
This patient was a 59-year-old when I initially met him. He presented with a 6-month history of left arm pain extending into the shoulder and upper arm. The pain did occasionally go down to his forearm. He had numbness around the left shoulder and mild weakness of the deltoid and biceps muscles. He had seen another spine surgeon who had recommended doing an anterior cervical discectomy and fusion between cervical 4 and 5 as well as between cervical 5 and 6 (ACDF of C4/5 and C5/6). He then saw me for a second opinion.
His clinical exam was consistent with a left cervical 5 radiculopathy which means that the nerve root exiting the spinal canal between the 4th and 5th cervical vertebrae on the left side was being irritated. When nerve roots are irritated, they cause pain going down the length of the nerve (in this case into the left arm), numbness in the sensory area covered by that particular nerve, and weakness of the muscles that are innervated by that nerve root. This combination of pain, numbness and weakness is called radiculopathy. Radiculopathy is one of the main reasons to do a decompression in the cervical or lumbar spine.
His primary spine surgeon had obtained an MRI that showed compression of the C5 and C6 nerve roots in the left C4/5 and C5/6 neural foramen (the bony opening allowing nerve roots to exit the spinal canal).
The patient was not sure he wanted to have an ACDF.
At our initial meeting, I asked him not to tell me the recommendation of the primary spine surgeon. I wanted to give him an unbiased opinion. My recommendation was for a left side C4/5 and C5/6 foraminotomy (the C4/5 level was the main one but C5/6 was so tight that I felt it should be decompressed as well). This operation means approaching the spinal canal from the back rather than the front. The intervertebral disc would not be touched. We would simply drill the bone of the facet joint (covering the nerve root) and expand the size of the neural foramen. It would not require any hardware or a fusion.
He opted for the foraminotomy rather than the ACDF.
He underwent surgery almost 1 year ago and was sent home a day after surgery. His arm pain and numbness resolved immediately and his weakness resolved over a few weeks. He was back to normal within 6 weeks.
The more common approach for cervical radiculopathy is an ACDF, especially since most of the time the condition is related to a herniated disc. But in selected patients, a cervical foraminotomy works very well and avoids the need for fusion (preserving motion of the spine at that level).
This patient had a very good outcome with minimal disruption of the anatomy of the cervical spine and without any fusion.