Technique
If surgery is undertaken, it is usually performed as a minimally-invasive procedure. The procedure can be performed as a day stay surgery, but most patients stay in hospital for 1-2 nights. General anesthesia is utilized and the surgery is performed through an incision of 2-4 cm. Much emphasis is placed on performing the surgery through tiny incisions. Usually a small window is made on one side of a spinous process, at the junction of the lamina and facet joint, through the removal of some bone and ligament to allow visualization of the involved root. Using a high speed drill and microinstruments, once the nerve root affected is identified, the whole out of which the nerve passes is enlarged. This is the foraminotomy (see below):

The amount of bony removal (in red) is shown below:

The nerve root is then gently elevated and if there is a disk bulge this is palpated. If identified, the disk bulge is incised and typically a tiny piece of disk is removed. The whole disk is not removed. The operation is then complete and after placing cortisone over the nerve root, closure is effected, typically, with dissolving sutures for skin. Typically this takes 1-2 hours to perform.

(Above): A preop and postop CT to show the extent of bone removal (arrowed) in order to effect an adequate foraminotomy.

Risks
The greatest risk is injury to one or more nerves or spinal cord and this is typically 1-2%. The risks of infection, bleeding etc. are similar to those for any other spinal operation as are the risks of general complications. A small proportion of patients will have a recurrent disk protusion, either at the same side and level or at different levels on the opposite side. This operation will not alter the future likelihood to get neck pain.

The small but real risks from surgery are the reason why all patients with disc protrusions do not immediately have surgery.

Expectations
In uncomplicated cases the likelihood of good/excellent relief of arm pain is 80-90%. Numbness is slow to recovery and may persist. Weakness also may take 6-12 weeks to return to normal. Pins and needles usually starts to improve immediately.

Recovery
After surgery, patients are monitored on the ward overnight. A soft collar is worn for comfort if desired, and typically patients are discharged within 1-2 days. At home, for the first 6 weeks, nothing greater than 5-10 lbs must be lifted and after this a return to normal activities can be effected. The sutures do not require removal and dissolve with time.

Non-Surgical Options
Despite the length discussion about surgery, most patients get better without surgery.

Conservative therapy comprises:

· Analgesia with NSAIDs (e.g. Vioxx, voltaren or Celebrex)

· Analgesia with other medications such as Tramadol

· Avoidance of bending/lifting and ergonomics at work

· Physiotherapy (traction may help)

· Perineural steroid and local anaesthetic injections (these can be very helpful)

· Possibly acupuncture

Other Points
A posterior cervical foraminotomy is an excellent operation for the patient with arm symptoms secondary to a cervical disk protusion that avoids implantation of foreign devices and spinal fusion. Not all patients are suitable for this operation but those who are generally do very well.