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Minimally invasive endoscopic cervical foraminotomy and decompression is designed to treat cervical radiculopathy and other conditions that compress the nerve root. Utilizing an endoscope, surgeons can directly visualize and remove compressive pathology such as disc herniations, osteophytes, and hypertrophic ligaments. This technique minimizes soft-tissue disruption, reduces blood loss, allows for quicker recovery, and has demonstrated high clinical success rates, with a systematic review reporting 91.3% overall and up to 94.2% for posterior approaches.1,2 Additionally, long-term follow-ups show lasting symptom relief, high patient satisfaction, and a lower risk of adjacent segment disease compared to traditional ACDF surgery.3
Potential applications include treatment of cervical radiculopathy, herniated cervical discs, cervical spondylosis, foraminal stenosis, and osteophytes (bone spurs). Research supports its effectiveness in treating both soft disc herniations, where the nucleus pulposus compresses the nerve root, and hard disc herniations caused by calcified disc material.4 A lower incidence of spinal instability has also been reported, suggesting a reduced need for future spinal fusion procedures.5
Careful patient selection is key to optimal surgical outcomes; those with major deformity, instability, or large central herniations may require alternative surgery. With proper selection and advancing technology, this method remains a safe, effective, and motion-preserving option for cervical nerve decompression.1
References
1. Huang CC, Fitts J, Huie D, Bhowmick DA, Abd-El-Barr MM. Evolution of cervical endoscopic spine surgery: current progress and future directions—a narrative review.&nbsp;J Clin Med.&nbsp;2024;13(7):2122. doi:10.3390/jcm13072122
2. Alomar SA, Maghrabi Y, Baeesa SS, Alves ÓL. Outcome of anterior and posterior endoscopic procedures for cervical radiculopathy due to degenerative disk disease: a systematic review and meta-analysis.&nbsp;Global Spine J.&nbsp;2022;12(7):1546-1560. doi:10.1177/2192568221103727
3. Kim HS, Wu PH, Tze-Chun Lau E, Jang IT. Narrative review of uniportal posterior endoscopic cervical foraminotomy.&nbsp;World Neurosurg.&nbsp;2024;181:148-153. doi:10.1016/j.wneu.2023.10.021
4. Bergamaschi JPM, Brito MBS, Araújo FF, et al. Surgical technique of central and over-the-top full-endoscopic decompression of the cervical spine: a technical note.&nbsp;J Pers Med.&nbsp;2023;13(10):1508. doi:10.3390/jpm13101508
5. Zhang C, Wu J, Zheng W, Li C, Zhou Y. Posterior endoscopic cervical decompression: review and technical note.&nbsp;Neurospine.&nbsp;2020;17(Suppl 1):S74-S80. doi:10.14245/ns.2040166.083

This animation reviews the steps for a posterior cervical endoscopic foraminotomy at C4- C5 using the Synergy Vision™ imaging system and a spine-specific endoscope.

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Posterior Cervical Endoscopic Foraminotomy

Posterior cervical frame. Anatomy. The posterior cervical endoscopic foramina approach from Arthrex is an ultra minimally invasive surgery, ideal for patients who have been diagnosed with certain types of cervical stenosis. In this procedure, an endoscope is used to assist access and visualization. The patient is placed in the prone position. The midline is marked by palpation followed by a second mark one centimeter lateral to the midline. A c-arm is used to verify the correct level or levels being treated using both AP and lateral fluoroscopy. Insert and introducer needle one centimeter lateral to midline. Palpate the upper lamina using the needle. Make a vertical skin incision. Then insert the guidewire oriented 90 degrees to the floor. Adjusting the bed as needed. Insert the switching stick and cannula. Free up tissue by medial to lateral movement of the cannula. Confirm cannula placement using lateral fluoroscopy and ensure its placement is 90 degrees to the spine. Expose the upper and lower lamina, revealing a V point. Using a high speed burr and or keratins, Harrison's remove bone to convert the V to a U. Identify the ligamentum flavum. Working from caudal to cranial. Dissect the Ligamentum flavum using kerosene s and other instruments throughout the procedure. Visualize the working end of the instruments prior to removing tissue by rotating the endoscope. Resect the ligament to view the lateral border of the dura. Once you have identified the lateral border of the dura, the nerve root can be identified. The endoscope and cannula can be rotated 90 degrees to visualize the foramen and nerve. To confirm that decompression is complete. Use a ball tip probe to palpate the pedicle and foramen and confirm a complete decompression via a lateral view. The endoscope and cannula can then be removed, followed by wound closure and placement of a JumpStart bandage.

Mazda Farshad, MD (Zurich, Switzerland), performs a posterior endoscopic foraminotomy at the C4-C5 level.

Cervical Foraminotomy

My name is Mazda Farshad from Zurich, Switzerland. We are performing a posterior endoscopic cervical foramina. The patient is positioned like for a standard posterior approach of the cervical spine. You can use a Mayfield frame to fixate the head. Fluoroscopy is positioned 90 degrees to the patient. This is cranial. This is caudal. So we start first by palpating the midline and drawing the midline. Once the midline is identified by palpation and the line is drawn, we make a lateral fluoroscopy shot to identify the level that we're aiming at here we're aiming at levels four five. So we want to aim towards the disc of the level that we're aiming at. That would be level four, five and 90 degree to the spine. We can then insert the needle. The needle should be inserted approximately one centimeter lateral to the midline. This will allow that later on we can have a nice view on the foramen. Now we want to aim a little bit higher. Approximately 2 to 3mm higher to be able to palpate the upper lamina. That would be the lamina number four here. Once we're happy we cut the skin and do. Skin incisions in a vertical direction from cranial to caudal. So that conversion to open surgery would be possible at any time. Once this is done, the K-wires is installed. Make sure that the K-wires is vertical to the floor 90 degrees. Otherwise, adjust the patient and the table. By Trendelenburg or anti Trendelenburg to achieve this position. After that the dilation is done. This can be done stepwise or directly using the switching stick already with the switching stick. You can palpate the upper lamina Over the switching stick, the canyon can be inserted. A fluoroscopy shot will verify that we're on the right level with the switching stick inside, the lamina is freed up from muscles by going from medial to lateral using the sharp edge of the cannula, then the switching stick can be removed. Now we see the position of the cannula aiming at the disc four five, where we want to be at in approximately 90 degree angle to the cervical spine. Once this is done, we could insert the endoscope. For purposes of visualization, we will now do an AP view. The AP view can be used if one is unsure about medial lateral position of the cannula. The endoscope can now be inserted. And make sure to control the cannula so that it doesn't move. And now the soft tissue can be removed with a large pituitary. So the soft tissue is removed and we start to see the upper lamina C4, the bone of the upper lamina. Here we remove a little bit more soft tissue and identify the lower lamina of C5. Here with the bipolar we can clean up the soft tissue nicely and palpate the upper and the lower lamina. So the upper lamina here the medial border the lower lamina. And then we start to identify a V form. This is the so-called V sign formed by the upper lamina and the lower lamina. And this is the entrance to the spinal canal. Here we already see the ligamentum flavum. So now we want to turn the V into a U by using the burr. I usually start with the upper lamina and then we go. We proceed to the lower lamina. Make sure to remove enough of the lower lamina. No pressure on the burr, but more on the cannula if you want to manipulate the position. So now we have removed the bone and converted the V to a U. A little bit of the upper lamina. More on the lower lamina so that actually the ligamentum flavum, the attachment is disconnected to the lamina. Here we see we are already in the spinal canal. And we can start dissecting the ligamentum flavum from caudally to cranially. Once we have disconnected the ligament from the lower lamina, we can use a kerrison to remove it in a stepwise fashion. Before that, you might want to go more lateral by removing more bone. So then we can change the view a bit to resect the ligamentum flavum. I use the kerosene for that. Make sure to turn the scope so that you verify that you're just removing ligament and nothing else. The aim is to visualize the lateral border of the dura. The best view to remove the flavum towards medial is from caudal to cranial, so you can turn your scope around 70 to 90 degrees to visualize the opening of the kerosene to be able to remove the flavum safely. The identification of the lateral border of the dura is extremely important in order to identify the nerve. Once we have identified the lateral border of the dura as seen here, we can basically glide up to the nerve root, and here the nerve root is identified here. We are now in the axilla of the nerve root. The same can be done from cranial to caudal. Identifying the shoulder of the nerve root as demonstrated here. So now we see the dura, the lateral border. The axilla of the nerve root at this condition would be accessible here. And the shoulder of the nerve root here we are pointing towards the foramen. So with the ball tip we can palpate also the pedicle. Here we are palpating nicely the pedicle of the lower vertebra which is c5 in our case. The ball tip can also be used to carefully palpate into the foramen. Once this is done the foramen can be visualized By turning the scope facing the foramen. Once the nerve root is identified, we have to look into the foramen. For that, we position our canal either on the upper or the lower lamina, and turn the cannula and the camera in order to visualize the nerve, as demonstrated here. So now we're looking into the foramen, and we can use our kerosene to remove some more bone. You can always turn your camera to be able to have a better look for verification of a full decompression. Use your ball tip to palpate along the nerve root. So here we have the nerve root and the foramen which is now freed up. This can be also visualized from another view looking how the cranially. Here again we have the lateral border of the dura. The axilla. And here we are in the foramen. And now I'm palpating all through the foramen, making sure that the foramen is fully free and the nerve is decompressed. Once the decompression is completed and you have verified that visually, and also by palpation, you can pull out your camera and your cannula and close the skin with 1 or 2 stitches. Posterior cervical endoscopic approaches allow decompression of the nerves by foramina or and or discectomy. This is not a beginner level surgery for endoscopy. It allows to avoid acdf in many cases, can usually be performed within 45 to 60 minutes in an outpatient setting.

Vincent Hagel, MD (Zurich, Switzerland), performs a unilateral, endoscopic cervical laminotomy for bilateral decompression of central canal stenosis in the cervical spine.

Cervical Central Stenosis Decompression

My name is Vincent Hagle. I'm from the spine center in Zurich, the university hospital, as well as head of a smaller spine unit in Germany. The procedure we will perform today is called cervical endoscopic unilateral laminotomy for bilateral decompression. It's a procedure that is suitable for central canal stenosis in the cervical spine. So we have the patient in prone position in a Mayfield clamp, which is not always necessary. A lot of times a head frame is also suitable. It's important to straighten out the patient, which I usually check with the fluoroscopy in a view to make sure I have the spinous process in the center. Pedicles symmetric to the side. The first step is to define a skin entry point. Therefore we have to mark different lines. First line is midline. Either we mark that by palpation or we do it under Fluoroscopic guidance. That's the floor shot we want to save for midline. Next line is the facet joint line. It's a line along the facet joints usually about a centimeter and a half of midline. So now you see that instrument covering the medial aspect of the facet joints. So that's the second line we want to mark under AP fluoroscopy. So we have defined that facet joint line now. Second line in order to find a crossing point is a line that we take in lateral fluoroscopy through the or parallel to the disc space of our target level. Okay. Chart. So now we have second line parallel to our target levels. Disk space. Our target level is c6 C7. So we mark that line on the skin as well. Now we make more or less a stab incision depending on the size of the of the working cannula. After having made the skin incision. First step is to bring in the guiding rod on to our target level, which is the posterior surface of the facet joint at our level C6, C7. The safest way to do so is under Fluoroscopic guidance in AP, to make sure we really hit that facet joint and don't accidentally slip off toward the canal or lateral of the facet joint. So we place the guiding rod just a little bit. And before we go all the way down. Double check that in AP fluoro to make sure that we are still on the trajectory. Now, you see the tip of that guiding rod pointing towards the facet joint line. So here we are safe, and we can advance the guiding rod down onto that facet joint. Now I have bone contact. So we take another shot to make sure that we're still on that facet joint. And you see again the tip still on the posterior surface of the facet joint. So we're good now with this AP check. And we'll turn to lateral. In lateral position. We double check the position of that guiding rod. And as we see it's on the posterior surface of the facet joint at our target level c67, which is exactly where it's supposed to be from now we can continue with dilating the soft tissue. So after having placed the guiding rod, we use three more soft tissue dilators you carefully rotate them down all the way until you feel bone contact. Now, after having placed that guiding rod, we're using a series of soft tissue dilators. You could also use a switching stick. However, the soft tissue is a little bit tougher in the neck to where a series of dilators are usually safer to dilate that soft tissue. So you introduce that dilator, rotating it down until you feel bone contact introduced the next one and we have one more. Once we have dilated the soft tissue. Next step is to introduce that working cannula over those soft tissue dilators. Again, usually rotating them in is safer than just trying to push them down. The further down, you can push that working cannula onto that posterior surface of the facet joint, the less soft tissue you have in your way. Once you introduce your endoscope now once that working cannula is in place, it's necessary to double check with fluoroscopy the final position of that working tube before we start with the endoscope. So now we see the dilators as well as the working cannula on the posterior surface of that facet joint at our target level. C67. Also I do have bone contact right there to where we are pretty sure to be in the right position with that working cannula. And therefore we can remove our soft tissue. Dilators. Now, after having verified the correct position of the working cannula, we will introduce the endoscope. And the first step is to make sure that we're still on the facet joint. So we'll take any kind of instruments to tap down and make sure that we have bone contact underneath which we do. And typically we do have a layer of soft tissue still covering that facet joint right there. So first step is to remove that soft tissue. Safe way is to use that bipolar just to shrink that soft tissue. If you're not sure that the working cannula is still in the correct position, you might want to verify that with a fluoroscopic shot. However, here we nicely see the facet joint. This is the cranial part of it. Then we have a little bit of a step down before we see down here already the lower part of the facet joint. So we just keep cleaning up that soft tissue until we completely expose the facet joint. And eventually go a little bit towards medial, where we will find the so-called V point. V point is the main landmark that we want to find, which is more or less the interlaminar window. And here you already see the beginning of it. Again we have caudal lamina down here, cranial lamina here. And we have here right in between the inter lamina window, which mostly looks like a V shape and therefore is called V point. Now, since we want to eventually decompress all the way over to the contralateral side, we'll just clean up a little bit more of that soft tissue towards the spinous process to make sure it's not in our way later on when we do the contralateral decompression. Now, to effectively remove that soft tissue, you just go back and forth between cautery and pituitaries. Exactly. So again we have lamina here, lamina here. You see the facet joint moving right here made up with the inferior articular process here, the superior articular process here. And if I push a little bit against it, you see the facet joint moving like the cranial lamina is moving away from that lower lamina right there. So again this is the actually nicely looks like a V shape right here. And that is the V point which again is the landmark. We want to have to start our procedure. Now. Once we get more towards midline we start to see spinous process which we do also want to expose a little bit just again to not have that much soft tissue in our way when we will do the contralateral decompression. I'm just doing a laminotomy like removal of the bone of the lamina. First I start towards cranial toward the upper lamina, and usually at some point I reach the cranial end of the yellow ligament right there. So that's my orientation as far cranial as I want to go now after having done Laminotomy, Ipsilaterally will move over to the contralateral side, undercutting the spinous process and doing a laminotomy over to the contralateral side. Apart from using kerosene punches as we just did ipsilaterally, we alternatively have the option of using burr. Most suitable for the cervical spine is diamond burr, and here we're using a coarse diamond burr to do that. Undercutting. We were finished with performing this contralateral laminotomy, which means we have widely exposed the yellow ligament ipsilaterally from the caudal end all the way here to the upper end and the same over to the contralateral side. Here we have the upper end of the yellow ligament on the contralateral side. And the same thing down here on the lower end. So after having widely performed this laminotomy, Next step is to remove the yellow ligament after bony decompression. Nice view on the yellow ligament. Widely decompressed here. Ipsilaterally. And then over here to the contralateral side. So next step after laminotomy bilaterally is now to remove the yellow ligament. So first step is to detach it just to make sure that no adhesions to the dura to the thecal sac underneath right there. And once it's detached we start at midline with a kerosene sponge to step by step remove it when removing the yellow ligament. I try to not bite all the way down with the kerosene, but just get a good hold on it and then twist it. Try to pull it in order to remove larger pieces at one time. As you see here, it's not just a bite, it's a larger piece of yellow ligament removed, which overall makes the ectomy just more effective and faster. So now we see the lateral edge of the thecal sac right here. We have the exiting route in there in between. And that's the lateral edge here in the upper part. And again here we have the exiting route. Now if I do a forearm anatomy I don't do it now because I concentrate more in the central stenosis on a bilateral decompression first. So we'll come back later. But now you nicely see the dura there. Ipsilaterally widely exposed. Now, usually in a pressurized thecal sac, we would not see the lateral edge, and especially not exiting route on the contralateral side. However, here in the cadaver where the thecal sac is collapsed, we now do see the lateral edge of the thecal sac here. This is already the contralateral bone right there. The pedicle we're tapping. Happing. And this here is the lateral edge of the thecal sac. The same down here caudal of the exiting route. We also have here the lateral edge of the thecal sac. And in between here we have the exiting route running out into the foramen. And when we lift up a little bit of that soft tissue now you can appreciate the exiting route running out there. So after being done with that contralateral phlebectomy we have now widely bilaterally performed the decompression. And we see the complete thecal sac right there from here, the ipsilateral edge all the way over to the contralateral edge. So again we have the lateral edge of the thecal sac here on the ipsilateral side. We go across midline. We have the lateral edge here of the thecal sac on the contralateral side as well, in case we have an associated foraminal stenosis. We can also perform a foramen anatomy. Usually we turn the endoscope 180 degrees around to make use of that off axis view. Looking from medial to lateral into the foramen. And here we see the exiting root running out of the foramen being stenotic right here. So we'll do a little bit more of bony decompression here as a frame anatomy. And we see the facet joint line running along right there to where we have now superior articular process here inferior articular process here. We see the joint actually right here running back and forth here. That's the cartilage of the joint right here of the superior articular process. So we'll just take a few cares and punches along the exiting route right there to also decompress that out into the foramen. So again now we can nicely probe out into the foramen, with the C7 root being sufficiently decompressed. Also, when we turn it back now, we nicely see exiting from the thecal sac the exiting root with some fat tissue up there on the shoulder. That's the shoulder of that exiting root here and down here. We're in the axilla of it. This bilateral decompression procedure is a challenging procedure, especially the contralateral decompression. Therefore, it's level three procedure, especially crossing the thecal sac. To perform that contralateral decompression has to be performed very carefully, because slight compression on the thecal sac can easily cause severe neurological deficits, and therefore a certain amount of experience is necessary before performing this procedure.

Foraminotomy and Decompression

Cervical Foraminotomy and Decompression