Why we do Microforaminotomy surgery instead of fusions for neck and arm pain
My neurosurgical partner, Dr. Dimitrov, and I got interested in cervical microforaminotomies in 2010. Our very first patient was a local big wave surfer who had arthritis and disk herniations at three levels in the cervical spine. With 3 level cervical disk disease, and occasional episodes of severe neck pain, he had been told over and over again that #1 he needed a 3 level fusion, and #2 after the fusion, he wasn’t going to be able to surf big waves again. I know him socially, and he asked me for a second opinion.
When I had the chance to examine him, it was clear that he only had pain in his left C6 nerve root distribution. When I gave him a pain diagram to complete, he circled this image.
His MRI scan showed that he while he did have 3 level degenerative disk disease in his cervical spine, he had a large extruded disk fragment and a bone spur compressing the nerve root on the left side. We discussed his options and because he was adamant that he would rather live with the pain and the muscle weakness than have a fusion and have to give up surfing, we discussed performing an anterior cervical foraminotomy. I gave him a number of articles from the literature to read and he agreed that this seemed like a very reasonable approach. We did his operation, his pain disappeared, and his strength came back. Understandly, he was delighted. Even better, he was convinced that he’d avoided a big operation that would have left him partially disabled. I agreed. He sent his friends, and they sent their friends, and now this is an operation that we perform frequently. Happy surfers make for happy surgeons.
Here’s an explanation of the anterior cervical microforaminotomy as an alternative to a cervical fusion.
Medical definitions that you need to know
First, a couple of simple definitions. The medical term for neck and arm pain caused by a herniated disk is “cervical radiculopathy”.
The word radiculopathy is composed to two words with latin origins. The word “radix” means root and the word “opathy” means a disease of. A herniated disk puts pressure on the root of the nerve and causes pain every where the nerve travels.
A herniated disk usually squeezes the nerve root as it tries to leave the spinal canal through a small bony tunnel called the neuroforamen. The word neuroforamen also has latin origins. “neuro” is the latin word for nerve and “foramen” is the latin word for an opening.
MRI findings that cause cervical radiculopathy
Ok, now that we understand those two terms, let’s look at an MRI scan of the cervical spine. This view is called the saggital view and there are 7 vertebrae in the cervical spine, C1 through C7. Between each of these bones are the intervertebral disks. Here at the C5-6 level there is a disk herniation. On this view we can see how the disk is bulging out towards the spinal cord and the nerve roots and when we switch to a cross-section, called the axial view, we can see how the disk bulge is off to one side and putting pressure on the nerve root as it travels through the neuroforamen.
The location of the pain is a clue as to which nerve root is being affected. The cervical nerve roots travel to particular parts of the arm and the hand. We have our patients complete a pain diagram and a pain journal and this helps us confirm which nerve root is irritated and inflamed by the herniated disk.
Non-operative treament and fusion surgery
When the symptoms of a cervical radiculopathy do not get better with non-operative treatment that includes physical therapy and anti-inflammatory medications, most patients realize that they may need a surgical solution for their pain. They need the pressure to be taken off the nerve root so that the pain will stop.
The standard operation for a herniated cervical disk is something called an anterior cervical discectomy and fusion. This is a surgical procedure that removes the damaged intervertebral disk and replaces it with a spacer and titanium plate, stabilizing that level. This operation reliably alleviates the pain from a herniated disk, but unfortunately, fusing one level in the cervical spine increases the mechanical stress on the adjacent levels in the cervical spine and accelerates the natural degenerative process that occurs with age. This can lead to a loss of range of motion, more pain, and more surgery in the future.
The results of cervical fusion surgery can be very good, but many younger patients who are athletically active would really like to avoid a fusion.
Cervical microforaminotomy — an alternative to fusion surgery
There is an excellent operation for this problem that completely avoids a fusion. This operation is called an anterior cervical microforaminotomy. It has an excellent track record in the medical literature.
In fact, the former head of neurosurgery at the University of California in Los Angeles remarked in one of his papers that “Patients treated with the anterior cervical neural foraminotomy procedure have equivalent or better outcomes than those who undergo current cervical procedures. It appears to be a good procedure for carefully selected patients with one sided cervical radiculopathy and avoids a fusion of the disc space.”
In this operation, a small incision about 1 inch long is made in the front of the neck and the damaged disk is exposed with the help of a microscope. A tiny tunnel is created in the disk and the surgeon works all the way back to the nerve root, lifting the herniated fragments of disk off the nerve root. Because the operation requires removing less than 20% of the disk, a fusion is not necessary.
In these still images from an operating microscope we can see the surgeon using a special neurosurgical tool called a kerrison rongeur to clean the herniated disk off the nerve root. The surgeon is working through a small channel in the disk that measures 1/8 of an inch by 1/4 of an inch.
Here are the before and after MRI images of the spine demonstrating removal of the herniated disk with an increase in the size of the neuroforamen.
After this procedure the patient can return to normal activities within two weeks. We advise patients to avoid sports such as mountain biking, horseback riding, and surfing for 6 weeks, but after everything has healed we expect all of our patients to have normal range of motion of the neck and no activity restrictions.
At the minimus institute in Monterey, California, we specialize in motion preserving procedures for cervical disk disease. We want to see all of our patients free from pain and able to return to the activities that they love.
If you are interested in a cervical microforamiotomy or alternatives to fusion surgery, contact our concierge and we will arrange to have your MRI scan reviewed by one of our surgeons.