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

2. 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

3. 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

4. Imaging

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

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

7. Tube placed and secured to table

8. Identify the “Y”
Cranial lamina
Caudal lamina
Facet

9. Disc material under the root axilla
Exiting root

10. 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

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

12. Possible complications
Neural injury
Vascular injury
Instability
Excessive bleeding
Infection

13. 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