ACDF
Removes the disc and fuses the level. Handles central compression and collapsed discs that a foraminotomy cannot.
About ACDF ›Posterior cervical foraminotomy
The smallest of the cervical operations. A little bone is removed from the back of the neck to widen the tunnel a trapped nerve exits through. Nothing is fused, no implant goes in, and the level keeps moving. For one pinched nerve in the right anatomy, it does the job with less hardware than any alternative.
At a glance
Anaesthetic
General
Approach
From the back of the neck
Levels treated
Usually one, one side
Implant
None
Fusion
None, the disc stays in place
Driving
Restricted for about 4 to 6 weeks
Swimming
Avoided for 4 to 6 weeks
Lifting
Heavy lifting avoided early on
The practice's published guidance for cervical spine surgery is that driving is restricted for about four to six weeks, swimming is avoided for four to six weeks, and heavy lifting is avoided during the initial recovery period. Separate figures are not published for a foraminotomy, so anything specific to this operation is set at your consultation.
WHAT IT INVOLVES
Widen the tunnel, leave everything else alone
Each nerve root leaves the spine through a small bony tunnel. If that tunnel has narrowed, opening it releases the nerve without touching the disc, the alignment or the movement of the level.
1
The small amount of bone removed to open the tunnel
2
Nerve root, now leaving the spine without being pinched
3
Vertebral body and disc, both left untouched
01
Approached from the back
A small incision at the back of the neck, often through a tube or with a microscope, working between the muscle fibres. This avoids the throat entirely, which is why swallowing problems and voice change are not features of this operation.
02
A few millimetres of bone
The upper edge of the tunnel and a small part of the facet joint are trimmed to give the nerve room. Enough to free it, not enough to destabilise the level. Where a fragment of herniated disc sits behind the nerve it can often be removed through the same window.
03
Nothing is added
No spacer, no plate, no artificial disc, no fusion. The level keeps its own disc and its own movement. That simplicity is the appeal, and it also means there is no implant to fail or fuse to wait for.
WHO IT SUITS
A narrower set of patients, treated very well
A good fit when
Arm pain from a single nerve root, on one side, that has not settled
The compression is to the side, in the tunnel, rather than centrally in front of the cord
Disc height and alignment are preserved, with no instability
Avoiding a fusion and an implant is a priority, and the anatomy allows it
Not the right operation when
The spinal cord is compressed from the front, which this does not address
A large central disc herniation is the problem
The disc has collapsed and height needs restoring, which requires a spacer
There is instability, deformity or significant neck pain as well as arm pain
THE EVIDENCE
How it compares with the front-of-neck operations
A systematic review pooled ten studies comparing minimally invasive foraminotomy against anterior fusion and against disc replacement. The findings are worth reading in full, because they cut both ways.
No difference
Compared with ACDF
Complication rates were essentially the same, 3.97 per cent for foraminotomy against 3.89 per cent for ACDF, and reoperation rates were not significantly different either. Operating time and hospital stay tended to be shorter for foraminotomy.
Systematic review and meta-analysis, 10 studies
Mixed
Compared with disc replacement
Against disc replacement, foraminotomy had fewer complications, 5.1 per cent against 18.89 per cent, but a significantly higher rate of further surgery, 15.29 per cent against 3.89 per cent. Fewer problems, more chance of needing something else later.
Same review
How to read this
Foraminotomy is a smaller operation, and the honest trade-off is that it addresses less. Against a fusion it holds up well on complications and reoperation. Against a disc replacement it is gentler but more likely to need revisiting.
The patient groups in these studies were not identical, and people selected for a foraminotomy tend to have more focal disease to begin with. The review's authors called for longer follow-up and larger studies, which is a fair caveat to attach to all of these numbers.
RISKS, HONESTLY
What can go wrong, and how often
Common, short lived
Neck muscle soreness
The approach passes between the muscles at the back of the neck, so aching and stiffness in that area is expected rather than a complication.
About 4 in 100
Complications overall
Pooled data put the overall complication rate at 3.97 per cent, essentially the same as ACDF at 3.89 per cent.
Uncommon
Nerve irritation or injury
The nerve root is being worked around directly, so temporary irritation with increased tingling can occur. Lasting injury is uncommon.
Uncommon
Fluid leak or wound problems
A small leak of spinal fluid is possible if the lining is breached, and wound problems occur occasionally. Both are usually manageable.
The main trade-off
Needing further surgery
Reoperation rates were no different from ACDF in pooled data, but higher than disc replacement at 15.29 per cent against 3.89 per cent. If the disc itself is the ongoing problem, opening the tunnel may not be the end of it.
Rare
Instability at the level
Removing too much of the facet joint could destabilise the level, which is why the amount of bone taken is deliberately limited.
Notably absent from this list: difficulty swallowing, voice change, and anything to do with a fusion setting. Those belong to the front-of-neck operations. Avoiding them is a genuine advantage of approaching from behind, and for some patients it is the deciding factor.
RECOVERY
What recovery involves
IN HOSPITAL
Assessed before you go home
A physiotherapist assesses your recovery in hospital. How long you stay depends on the operation and on how you are progressing; the practice does not publish a set figure for a foraminotomy.
AT HOME
Looking after the wound
Keep the wound clean and dry, adapting bathing or covering it as instructed, and avoid touching it. The muscles at the back of the neck are commonly sore after this approach.
4 TO 6 WEEKS
Driving and swimming
The practice's guidance for cervical spine surgery is that driving is restricted for approximately four to six weeks and swimming is avoided for four to six weeks.
GOING BACK TO WORK
Modified duties first
Time away from work is needed to allow healing, and a temporary return on modified or restricted duties is common. Heavy lifting is avoided during the initial recovery period, with activity increased gradually.
As with any nerve decompression, pain tends to improve fastest while numbness and weakness recover more slowly, over weeks to months. Cervical radiculopathy explains why.
The smallest operation that solves the problem is usually the right one
No implant, no fusion, and the disc stays where it is. That simplicity is the appeal, and it is also the limit: opening the tunnel at the side does nothing for a central disc pressing on the cord, or for a collapsed level that needs its height restored. Whether it applies to you depends entirely on where the compression sits.
COMMON QUESTIONS
The things people ask most
Why is this not offered to everyone?
Because it only addresses compression in the tunnel at the side. If the problem is a central disc pressing on the cord, or a collapsed level needing height restored, opening the tunnel does not solve it.
Is it as effective as an ACDF?
For the right patient, pooled data show similar complication and reoperation rates, with shorter operating time and hospital stay. For the wrong patient it is not comparable, because it is treating a different thing.
Will I avoid the swallowing problems?
Yes. Difficulty swallowing and voice change come from the front-of-neck approach passing the oesophagus and the nerve to the voice box. Approaching from behind avoids both entirely.
Does the bone grow back?
Some bone can re-form over time, and occasionally the tunnel narrows again. That is part of why the reoperation rate is not zero, and it is worth knowing before choosing this over a procedure that removes the disc.
Is it done with a tube or a microscope?
Both approaches are used and both are well established. What matters more than the instrument is whether the tunnel is adequately opened and the nerve properly freed.
Can it be done on both sides?
It can, though most cases are one-sided because the symptoms are one-sided. Bilateral compression, or compression at several levels, usually points toward a different operation.
ALTERNATIVES
The other options worth knowing about
Cervical disc replacement
Also motion preserving, with a lower reoperation rate than foraminotomy but a higher complication rate in pooled data.
Compare the options ›Non-surgical treatment
More than eight in ten people with acute nerve pain improve without surgery. This comes first unless the cord is at risk.
Do I need surgery? ›About this information
This page is general information about a procedure and is not advice about your own case. The outcome and complication figures come from the published studies listed below and describe large groups of patients. The practice does not publish separate recovery timings for this operation, so anything specific to your own recovery is set at your consultation. More about Dr Tollesson.
References
Minimally invasive posterior cervical foraminotomy versus anterior cervical fusion and arthroplasty: systematic review and updated meta-analysis, pooling 10 studies, for the complication and reoperation rates quoted above.
Cervical Radiculopathy, StatPearls, National Library of Medicine, for the natural history of nerve root pain.
A smaller operation is only the better one if it treats the right problem.
Whether that is a foraminotomy depends on exactly where your nerve is being compressed. A consultation will establish that and set out the honest alternatives. A GP or specialist referral is needed for a Medicare rebate.