Endoscopic cervical foraminotomy

In one minute

Endoscopic cervical foraminotomy opens the foramen (the bony tunnel where a nerve root leaves the spinal canal in the neck) from the back, through a keyhole incision, and removes the disc fragment or bone spur pressing on the root. Our incision is 7 mm; the published technique describes one under 1 cm. It is for cervical radiculopathy (arm pain, numbness or weakness from one pinched nerve root) at one level and one side that has not settled with a proper course of non-surgical care, or that comes with weakness. Published operating times for the posterior endoscopic operation average 50 to 80 minutes, with single series reporting from under half an hour to nearly three hours. Most of our patients walk the same day and go home within 24 hours. The disc stays, the neck keeps moving, nothing is implanted.

What the operation is

The literature calls it posterior endoscopic cervical foraminotomy (PECF), posterior endoscopic cervical discectomy (PECD) or posterior percutaneous endoscopic keyhole foraminotomy (PPEKF); a biportal (UBE, unilateral biportal endoscopic) version uses two portals. It is the open "keyhole" foraminotomy performed through an endoscope instead of a wound.

The surgeon removes the inner edge of the facet joint and lamina over the root, the ligament under it, and the fragment or spur pressing on the nerve. The disc space is not emptied and no cage, plate or screw is placed. That is the difference from ACDF (anterior cervical discectomy and fusion), which removes the whole disc from the front and fuses the level, and from cervical disc replacement.

Who it is for

The patient this operation suits has arm pain from one root, matched by an MRI (magnetic resonance imaging) showing a soft disc fragment or bony narrowing in the foramen on that side and at that level.

It is not for compression from the front of the spinal cord, a central herniation, or myelopathy (spinal cord dysfunction) from an anterior disc or calcification; the Neurospine technical review lists those as contraindications because of the risk to the cord. Instability, kyphosis (a neck bent forward) and disease at several levels point elsewhere. Neck pain without arm pain is not an indication.

Most radiculopathy settles on its own. The North American Spine Society (NASS) work group's consensus is that for most patients the symptoms are self-limited and resolve over a variable time without specific treatment; the guideline suggests surgery for the rapid relief of symptoms compared with medical and interventional treatment (grade B).

How it is done

You lie face down with the head held still and the neck gently flexed. The published technique description (the Neurospine technical note) uses general anaesthesia with nerve monitoring prepared; in our practice the anaesthetist and surgeon decide per patient, and most of our endoscopic decompressions are done under local anaesthesia with sedation.

An X-ray marks the level. Through a small incision a little to the side of the midline (7 mm in our practice), a dilator passes between the neck muscles to the joint and a working tube follows. The endoscope goes in with a stream of saline that keeps the view clear. A fine burr thins the bone where the lamina meets the facet, the ligament is lifted away and the root comes into view. The surgeon lifts the root gently, removes the fragment beneath it or shaves the spur, checks that the root moves freely, and closes with one stitch.

Endoscopic compared with open surgery

Ruetten and colleagues randomised 175 patients with lateral cervical disc herniations to full-endoscopic posterior foraminotomy or microsurgical ACDF. At two years 87.4% had no arm pain, results were the same in both groups, and revisions and complications did not differ.

The FACET trial (Foraminotomy ACDF Cost-Effectiveness Trial) randomised 265 patients in nine Dutch hospitals to posterior foraminotomy or ACDF. At one year success was 88% after posterior and 76% after anterior surgery, serious surgery-related adverse events were 6% in each arm and reoperations 5% versus 3%; at two years success was 81% versus 74%, still noninferior, with 9 reoperations after posterior and 7 after anterior surgery. The posterior operations in FACET were conventional open foraminotomies, not endoscopic; the trial tested the approach, not the instrument.

The meta-analyses agree. Across 24 studies and 1,345 patients, effective rates were 94.3% for microscopic ACDF and 93.3% for the endoscopic keyhole, complications 7.1% versus 4.7%, reoperations 1.8% versus 1.1%, none significantly different. The two fail differently: ACDF brings swallowing difficulty and sinking of the graft or cage into the bone, the keyhole transient nerve root palsy.

Risks and how we reduce them

Transient nerve root irritation is the commonest problem: tingling or weakness that fades over days to weeks. The 2025 systematic review of full-endoscopic cervical surgery puts transient neurological deficits at 3 to 5% of cases and dural tears (a leak of the fluid around the nerves) at 3 to 6% of posterior operations, usually sealed on the spot. Revision for a missed fragment, a recurrence or a new level was 4 to 6% for posterior approaches there and 1.1% pooled in the 2023 meta-analysis. Removing more than half of the joint can loosen the segment, so the published protocol keeps the resection under that. Conversion to an open or anterior operation is rare but possible.

How the risks are reduced: the published protocol reads the MRI and a CT (computed tomography) of the foramen before surgery to plan how much bone must go, keeps the facet resection small, and checks that the root moves freely before closing. Across all the team's operations our complication figure is well below 1%; our own figure, not a comparison.

Recovery, week by week

What the evidence says

The NASS guideline of 2010 found no adequate studies of the untreated course of cervical radiculopathy and settled on the consensus that most cases resolve on their own; it suggests MRI after failed conservative care and surgery for faster relief, both grade B.

Ruetten 2008 is the one randomised trial of the full-endoscopic posterior technique against ACDF: same results, mobility kept.

FACET 2023 and 2024 randomised 265 patients to posterior foraminotomy or ACDF: noninferior at one and two years, similar serious adverse events.

The 2024 updated meta-analysis in Brain and Spine found no significant difference in operating time, hospital stay, complications or reoperations between minimally invasive posterior foraminotomy and ACDF, and calls its findings preliminary.

How we do it at spine.uz

We are Tashkent's first endoscopic spine team, five surgeons operating as one, with 27,600+ endoscopic and spine operations. Cervical pages are reviewed by Dr. Akhror Yakubov, neurosurgeon. The foraminotomy is done through a 7 mm incision with no implants; most patients walk on the day of surgery and go home within 24 hours; most of our endoscopic decompressions are done under local anaesthesia with sedation, the anaesthetist and surgeon deciding per patient. We operate on all levels, including multilevel cervical cases, and offer ACDF or disc replacement when the anatomy calls for it.

Send your MRI on Telegram or WhatsApp; a doctor from the team replies by voice within 48 hours, free of charge. After surgery you receive a written conclusion and follow-up on Telegram.

Preparing for the operation

Photograph every slice of your cervical MRI, plus any CT or X-ray, and send it ahead. Bring your medicines list and tell us about blood thinners and anti-inflammatory drugs; the surgeon decides when to pause them. Fast from the night before, arrange someone to accompany you, and expect to be walking the same day.