Posterior microscopic tubular cervical foraminotomy (PMTCF) Case for plenary or small group discussions MISS Curriculum Taskforce Muhammed Assous July 1, 2019 2019 and 2020

Learning objectives Describe the indications and patient selection for PMTCF Discuss the decision making process for PMTCF Outline important aspects of performing PMTCF Recognize possible complications and how to avoid/manage them

Presentation 37-year-old man, severe pain and numbness in right shoulder for six months Clinically painful range of motion No neurological deficit and no signs of myelopathy Failed conservative treatment

Imaging

Treatment options ACFD TDR Posterior foraminotomy Open MISS (tube/endoscope) Anterior discectomy/foraminotomy

Pearl Mayfield, head high up to reduce bleeding Slight flexion of neck to keep head parallel to floor, flex the knees for stability

Tube placed and secured to table

Identify the “Y” Cranial lamina Caudal lamina Facet

Disc material under the root axilla Exiting root

Outcome Immediate relief of shoulder pain, mild neck pain, no neck collar required postoperative Hospital stay 1 day Returned to his office job after 2 weeks

Patient selection for PMTCF Soft foraminal disc herniation or foraminal stenosis Unilateral radiculopathy without significant axial neck pain No instability

Possible complications Neural injury Vascular injury Instability Excessive bleeding Infection

Take-home messages PMTCF is a safe and effective MISS procedure Indications are foraminal soft disc and stenosis It avoids unnecessary fusion and complications of anterior surgery Key to success is to resect enough facet to expose the exiting nerve root and disc