A posterior cervical discectomy is a minimally invasive surgical procedure performed to remove a herniated disc in the neck (cervical spine) through a posterior (back of the neck) approach. This technique aims to relieve pressure on the spinal cord or nerve roots, alleviating pain and neurological symptoms. It’s important to note that while the traditional approach to cervical discectomy is typically anterior (from the front), the posterior approach, especially with endoscopic techniques, is less commonly available and has specific indications (which are the reasons and limits).

The use of the endoscope significantly reduces the invasiveness of the surgery to remove a fractured or herniated disc. By causing less harm to the spine, our patients often experience improved outcomes, including reduced postoperative pain and medication use, quicker recovery and return to activities, and diminished risks.

Most importantly, the endoscopic posterior cervical discectomy achieves success in

• Ensuring motion preservation: Many anterior cervical approaches involve fusion surgery. This limits neck mobility, may increase the odds of adjacent level arthritis and break down, which in turn may lead to more surgeries in the future
• Smaller options for revisions: Patients are often sent to Dr. Mahan by other surgeons to look for options to fix problems from other surgeries. For example, there may be residual disc fragments from a prior anterior cervical fusion or disc arthroplasty (cervical disc replacement). In contrast to open surgeries, endoscopic posterior cervical decompression can produce nerve root decompression
• Anatomy that is too challenging: Certain areas of the cervical spine are hard to access without causing instability when performing open approaches. In contrast, the endoscopic approach preserves muscles and ligaments, so that the structure of the spine is not compromised in approaching these difficult-to-reach spots, such as the base of the neck, like C7-T1¹, and the upper cervical spine, like C2-3.

We often use the terms posterior cervical discectomy or foraminotomy interchangeably. The foraminotomy refers to surgery to open the space where the nerve comes out of the spinal column (foramen). Essentially, we have to perform a foraminotomy (opening) to perform the discectomy (removal of herniated disc fragments). In some case, the cause of the impingement or narrowing is all bone. In this case, we just perform a foraminotomy.

Reasons for Endoscopic Posterior Cervical Discectomy and Foraminotomy Surgery

This procedure is considered when there is narrowing in the cervical spine, which may cause:

• Radiculopathy: Pain, numbness, tingling, or weakness that radiates from the neck into the shoulder, arm, and hand.
• Myelopathy: In more severe cases, the herniation can compress the spinal cord itself, leading to problems with gait, balance, and bowel/bladder function.

Specifically, endoscopic posterior cervical discectomy and foraminotomy might be considered for:

• Soft disc herniations: When the disc material is not heavily calcified. When these are unilateral (one side, left or right) and the other side is normal, an endoscopic approach is often ideal. When both sides of the body (left and right) or it is a broad disc herniation that is in the middle of the spine, an anterior approach is often selected.
• Recurrent (or persistent) disc herniations: Potentially, there might be a second or further cervical disc herniation (recurrence) or a prior surgery was not able to remove all of the disc fragments (persistent fragments).
• Difficult to reach locations¹ : The upper most and lowest levels of the cervical spine can be difficult (if not nearly impossible) to reach from anterior approaches and the open approaches may require extensive fusion. In some select cases, an endoscopic approach may be ideal for certain problems, like nerve compression, but not necessarily large problems, like cervical instability

It is crucial to understand that the anterior approach (such as ACDF – Anterior Cervical Discectomy and Fusion or cervical disc arthroplasty / total disc replacement, i.e., CDA or TDR) is more common for many cervical disc herniations. The posterior endoscopic approach has more limited applications due to the anatomy of the cervical spine and the location of the spinal cord.

Benefits of a Posterior Cervical Discectomy Surgery

While the posterior approach itself has some limitations (and some specific advantages), when the endoscopic technique is applied, potential benefits include:

• Ultra-minimally invasive: Smaller incisions lead to less tissue disruption compared to traditional open surgery.
• Reduced Muscle Damage: Endoscopic techniques substantially minimize muscle retraction, resulting in less post-operative pain and a faster recovery.
• Avoiding an anterior approach:  Anterior neck procedures require moving the esophagus (and swallowing anatomy) away from the spine. The realistic rate of difficulty swallowing (dysphagia) after ACDF is around 60%, and persists in about one-third of patients at 2-years after ACDF surgery² .
• Motion sparing: Unlike ACDF procedures, an endoscopic posterior cervical discectomy preserves neck motion. Moreover, this may reduce the likelihood of needing another surgery on your neck in the future.
• Faster Recovery: Patients return home the same day of surgery, without needing a hospital stay. Patients experience a quicker return to daily activities compared to open surgery.
• Less Scarring: Smaller incisions result in less visible scarring.
• Targeted Approach: The endoscope allows for a focused approach to the herniated disc, potentially minimizing disturbance to surrounding structures in carefully selected cases.

Please note that no research has compared the outcomes between endoscopic posterior cervical discectomy and ACDF or cervical arthroplasty. Other studies have investigated open posterior cervical foraminotomies versus ACDF. There is a difference between open and endoscopic approaches.

Details of the Endoscopic Posterior Cervical Discectomy Surgery

Here’s a general overview of the procedure:

Anesthesia: You are placed under general anesthesia. Unfortunately, due to the delicate anatomy of the neck and spinal cord, awake procedures cannot be done.

Positioning: You are positioned face down (prone) with your arms at your sides.

Incision: A small incision (about 6-7 mm, for approximately width of your pinky fingernail) is made in the back of your neck, over the affected cervical level.

Endoscope Insertion: A tubular retractor and an endoscope (slender camera and light) are inserted through the incision to visualize the surgical area.

Foraminotomy: A small portion of the bones overlying the nerve and disc are removed (foraminotomy) to widen the access to the herniated disc and compressed nerve.

Disc Removal: Using specialized micro-instruments guided by the endoscopic view, we carefully removes the herniated portion of the disc that is compressing the nerve root or spinal cord.

[Video here]

Closure: The instruments are removed, and the small incisions are closed with sutures and skin tape.

Risks of Endoscopic Posterior Cervical Discectomy Surgery

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

Recurrence of Herniation: The most common complication, in terms of frequency, is that another disc fragment herniates out.  In some cases, another surgery to remove a second fragment may be beneficial in improving your quality of life.

Incomplete relief of symptoms: Sometimes, particularly with large disc fragments and severe nerve compression or longstanding disc herniations, the nerve does not recover perfectly.  This can lead to a disappointing resolution of pain, weakness, or numbness. We may only be able to improve one cause of neck pain. Moreover, surgery cannot erase age. Age-related neck pain is universal; unfortunately, spine surgery cannot make you 18 years old again.

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 infection, 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 bleeding, there is still a small risk of bleeding after the surgery -which may require revision surgery.

Dural Tear: A tear in the membrane (dura mater) surrounding the spinal cord, which can cause a cerebrospinal fluid (CSF) leak. Dural tears are minimized with the fluid irrigation of the endoscope – which pushes away the dura. CSF leaks are exceptionally rare in endoscopic surgery, unlike open surgeries, since there is less muscle injury.

Nerve or spinal cord Injury: Because the nerve has to be moved to remove the disc fragment, there is a slight risk of damaging nearby 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 is 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 the risks specific to you and your health.

What to Expect After Surgery

Recovery following endoscopic posterior cervical discectomy varies, but here are some general expectations:

Same-day surgery: Most patients go home immediately after an endoscopic posterior cervical discectomy and foraminotomy

Postoperative Care: You may experience mild discomfort or soreness at the incision site, which is typically managed with anti-inflammatory pain medications. Most patients will not need to start a narcotic / opioid pain medication for an endoscopic posterior cervical discectomy.

Activity Restrictions: Initially, we recommend that you avoid strenuous activities, such as lifting heavy objects or bending your neck excessively, 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 herniated disc has been adequately removed and that no further issues are present.

The success of the surgery and the recovery process depend on various factors, including your overall health, the severity of the condition, and following post-operative instructions.

1. Kim, R. B., Kundu, B. & Mahan, M. A. Endoscopic Posterior Approach for Cervicothoracic and Upper Thoracic Foraminotomies: 2-Dimensional Operative Video. Oper. Neurosurg. 20, opab003- (2021).
2. Xie, R. et al. Realistic long-term dysphagia rates after anterior cervical discectomy with fusion: is there a correlation with postoperative sagittal alignment and lordosis at a minimum 2-year follow-up? J. Neurosurg.: Spine 37, 767–775 (2022).