Aging is a pain in the neck.  Literally, as we age, our spinal ligaments thicken and buckle, and we develop arthritis of the joints of the neck.  This age-related degeneration leads to narrowing or compression of the spinal cord and nerve roots.  When the spinal nerve is compressed, we experience pain, weakness and often numbness in the arm as well as in the neck.  The pinching of the nerve in the neck is known as a cervical radiculopathy.  In contrast, when the spinal cord is compressed, we experience a condition known as myelopathy.  When this myelopathy occurs in the neck, it is called cervical myelopathy.  Cervical myelopathy classically steals functioning from hands and oftentimes from the legs, often noticed by imbalance or discoordination of the legs. Sometimes cervical myelopathy and radiculopathy occur together.  Thus, some people experience symptoms of both pain in the arms as well as loss of function, such as fine motor control.

Cervical myelopathy is a very serious disorder and, when the narrowing is severe, can only be treated with surgical decompression.  However, there are ways to reduce the risk and consequences of treating cervical myelopathy.  Whenever possible, Dr. Mahan utilizes an endoscopic approach to minimize muscle trauma, risks of complications, and speed recovery. 

There is a difference between a cervical foraminotomy [link] and cervical decompression for stenosis.  The cervical foraminotomy treats nerve root compression, also known as radiculopathy.  Cervical decompression for stenosis treats the symptoms of cervical myelopathy, and may be referred to others as a cervical laminectomy.  However, using an endoscopic approach, we typically do not remove the entire bone (lamina).  Rather, we are removing only the thickened and buckled ligament (ligamentum flavum) that causes the narrowing and pressure on the spinal cord.

Reasons for Posterior Cervical Decompression Surgery

Posterior cervical decompression surgery is primarily recommended for patients with cervical stenosis that causes myelopathy when conservative treatments have failed.

• Cervical Spinal Stenosis: Narrowing of the spinal canal compresses the spinal cord or nerve roots, causing symptoms such as neck pain, weakness, numbness, and difficulty with balance
• Cervical Myelopathy: Compression of the spinal cord leads to neurological deficits, including gait disturbances, hand dysfunction, and loss of fine motor skills.

Symptoms Indicating a Need for Surgery:

Symptoms of cervical stenosis and myelopathy can be progressive and may include:

• Neck pain and stiffness
• Pain, numbness, or tingling that radiates from the neck into the shoulders, arms, and hands (radiculopathy)
• Weakness in the arms and hands, leading to difficulty with fine motor skills like buttoning a shirt or writing
• Balance and coordination problems, an unsteady gait, and a tendency to fall
• In advanced cases, loss of bowel or bladder control

Surgery is typically considered when these symptoms are significant, progressive, and have not improved with non-surgical treatments like physical therapy, medication, or steroid injections.

Not every condition, anatomy, or patient is appropriate for endoscopic cervical decompression surgery.  We will guide you to determine whether it is appropriate for you to consider pursuing surgery.

What is Endoscopic Decompression?

Endoscopic decompression is a cutting-edge surgical technique aimed at removing narrowing from inside the spinal canal.  The endoscopic technique is fundamentally different than open surgical techniques. Endoscopic surgery works inside the spinal canal to decompress from within; whereas open surgery removes bone from the outside in order to decompress inside. The procedure involves the use of an endoscope, a thin tube equipped with a light and camera, which is inserted through a small incision to access the narrowed spinal levels. We remove the thickened ligamentum flavum, remove the underside of the lamina, and, occasionally, sometimes disc fragments, relieving pressure on the spinal nerves and alleviating pain, weakness, or numbness.

Benefits of Endoscopic Posterior Cervical Decompression Surgery

• Ultra-Minimally Invasive: Smaller incisions result in reduced blood loss, minimal scarring, and less trauma to muscles and the joints of the neck.
• Faster Recovery: Patients typically experience quicker rehabilitation and shorter hospital stays compared to traditional open surgery.
• Reduced Pain: Less postoperative pain and discomfort due to minimal tissue disruption.
• High Precision: Enhanced visualization with the endoscope allows for greater accuracy and preservation of spinal stability.
• Outpatient Procedure: Many cases are performed on an outpatient basis, allowing same-day discharge.
• Preservation of Mobility: No hardware placement or fusion is required, preserving normal neck motion.
• Preservation of Spinal Stability: By avoiding extensive removal of bone and ligaments, the endoscopic technique helps to maintain the natural stability of the cervical spine.
• Reduction in risks: Including reduced blood loss, infection risk, and others.

Details of the Surgical Procedure

The primary goal of the surgery is to create more space for the spinal cord and nerve roots, thereby relieving the compression that is causing the symptoms.

Anesthesia: Because the surgery is located in the neck and requires very fine, detailed and meticulous surgical steps, it is generally a requirement for the surgery to be performed under general anesthesia.

Preparation: You are positioned comfortably lying face down. Imaging, which refers to X-rays or fluoroscopy, is used to correctly locate the spinal level (vertebrae) where the stenosis is located. Because the endoscopic approach solely focuses on the problem (and is not exploratory), we are ultra-precise in planning.

Incision: A small incision (about 6-7 mm, for approximately width of your pinky fingernail) is made in the skin at the level of the affected spinal level. A tube is inserted through this incision, and the endoscope is carefully navigated to the narrowed spinal level.

Visualization: The endoscope provides beautiful images of the spinal elements, including the nerves, joints, ligamentum flavum and lamina.  The ligamentum flavum is carefully sculpted away from the lamina using a very small drill.  Once the ligamentum flavum is detached from it bone anchors, it is carefully removed from the spine.

Closure: The instruments and endoscope are removed, and the skin is closed with tiny dissolving sutures.

Risks and Potential Complications

Like any surgical procedure, endoscopic decompression carries risks, though these are generally lower than those associated with open surgery. Some of the potential complications include:

Incomplete relief of symptoms: Sometimes, particularly with severe spinal cord compression or longstanding symptoms, the spinal cord does not recover.  Often, in these situations, our goal is to prevent further worsening -rather than reverse the consequences of time.  Nevertheless, some individuals are disappointed that we cannot resolve all pain, weakness, or numbness that occurred from spinal cord injury.

Need for revision surgery: Sometimes, particularly if the cause of compression is due to movement of the neck, decompression alone is insufficient and they may require a fusion surgery.  We discuss this risk upfront, as every patient is unique.  Generally, we strive to preserve individual’s spine flexibility; recommending fusions only when necessary.

Infection: Although rare, infection at the incision site or deeper in the spine can occur. In our series, only 1 patient of approximately 1,200 patients had an infection² , which occurred after swimming.  We therefore recommend avoiding submersion, including pools, hot tubs, and bathtubs, until 1 month after surgery

Bleeding: While the endoscopic approach minimizes bleeding³ , there is still a small risk of bleeding after the surgery -which may also require revision surgery.

Dural tear: The use of irrigation and endoscopy reduces the incidence (frequency of occurrence) of inadvertent tears of the spinal fluid membrane, also known as dura mater.  In certain cases, there are adhesions to the dura, such as facet cysts, which greatly increases the likelihood of an unavoidable and unintentional tearing of the dura (incidental durotomy).  Because the tools are smaller with an endoscopic approach, durotomies tend to be smaller.  Thus, they are frequently managed less aggressively than those caused in open surgeries.  For example, lumbar drains are more frequently used in management of dural tears from open surgery , but rarely in endoscopic surgery

Spinal cord or nerve Injury: Because this is a technically complex surgery, there is a remote risk of damaging the compressed spinal cord or nerves during the surgery, which could result in weakness, numbness and/or new pain.  Fortunately, in most cases, any worsening in function usually recovers with time.

Anesthesia-related complications: Adverse reactions to the anesthesia. The risks of your anesthesia are reviewed with you by our anesthesia team immediately prior to surgery. In some cases, when individuals have multiple medical problems, we may ask you to see our anesthesiologists prior to surgery to make the best plans.

Need for Conversion to Another Surgery: In unforeseen circumstances, our team may need to convert to a traditional open surgical approach during the procedure. This is exceptionally rare.

Medical complications: These are problems that are independent of the surgery, but may occur because in association with surgery. For example, blood clot may form in the legs (deep vein thrombosis – DVT) or lungs (pulmonary embolism – PE) if you are not moving much after surgery. Other examples include: opioid or other pain medication problems, such as drug dependence or addiction, bowel obstruction, etc.

It is important to understand risk factors are often patient-specific, and that we will provide our best estimate of your risks – not generalized estimates.

What to Expect After Surgery

After the procedure, you will spend a short period in a recovery area to allow the sedating medications to wear off, and most can go home the same day.

Postoperative Care: You may experience mild discomfort or soreness at the incision site, which is typically managed with anti-inflammatory pain medications.

Activity Restrictions: Initially, you may be advised to avoid strenuous activities, such as lifting heavy objects or excessive neck activity, for a few weeks to allow your body to heal.

Physical Therapy: A physical therapy program may be recommended to strengthen the muscles around the spine and improve mobility. Everyone tends to do well with a coach helping them out to achieve their goals.

Follow-up Appointments: a 6 week follow-up appointment is set prior to surgery. Additional follow-up appointments are established to assess the success of the surgery, additional needs or other considerations. Imaging tests, such as MRI or X-rays, may be used to confirm that the stenosis has been adequately removed and that no further issues are present.

Recovery and Long-Term Outlook

Recovery from endoscopic decompression is typically quicker compared to traditional open spinal surgery. Many patients report a significant reduction in pain and an improved ability to perform daily activities within a few weeks. However, full recovery may take several months as the body continues to heal.

While most patients achieve lasting relief, it’s important to maintain a healthy lifestyle, engage in regular exercise, and avoid activities that could strain the spine to reduce the risk of future problems.

 

 

1. Akçakaya, M. O. et al. Serum creatine phosphokinase levels as an indicator of muscle injury following lumbar disc surgery: Comparison of fully endoscopic discectomy and microdiscectomy. Clin. Neurol. Neurosurg. 145, 74–78 (2016).
2. Mahan, M. A. et al. Full-endoscopic spine surgery diminishes surgical site infections – a propensity score-matched analysis. Spine J 23, 695–702 (2023).
3. Chin, B. Z. et al. Full-endoscopic versus microscopic spinal decompression for lumbar spinal stenosis: a systematic review & meta-analysis. Spine J. 24, 1022–1033 (2024).
4. Tong, Y., Ezeonu, S., Kim, Y. H. & Fischer, C. R. Single-Level Unilateral Biportal Endoscopic versus Tubular Microdiscectomy: Comparing Surgical Outcomes and Opioid Consumption. World Neurosurg. 190, e754–e761 (2024).