Clinical Findings

• 
  

  A 39-year-old female soprano singer presented with pain in the neck and left arm.

  
  
• 
  

  The level of pain was noted using a visual analog scale (VAS). The pain in the patient’s neck was scored as 5/10, whereas the pain in the patient’s left arm was scored as 9/10.

  
  
• 
  

  The patient’s chief complaint was left arm pain.

  
  
• 
  

  The magnetic resonance imaging (MRI) sagittal and axial views show a left foraminal disk extrusion at the C5-C6 level ( Figs. 8.1 and 8.2 ).

  
  
• 
  

  The computed tomographic (CT) scan shows a soft disk ( Fig. 8.3 ).

  
  
• 
  

  The decision was made to treat this patient with percutaneous endoscopic cervical diskectomy (PECD) for the extrusion at C5-C6.

Surgical Procedures

1. 
   

   A right-sided approach is selected. After retracting the trachea toward the opposite side with the index finger and the carotid artery to the ipsilateral side with the middle finger, an 18-gauge needle is inserted into the disk space through the space between the tracheoesophageal unit and the carotid artery under fluoroscopic guidance ( Fig. 8.4 ).

• 
  

  The needle is withdrawn after passing a guide wire through its channel. A series of dilators are sequentially passed over the guide wire and introduced into the disk space. Finally a 3-mm working cannula is passed over the 2-mm dilator ( Figs. 8.5, 8.6, and 8.7 ).

• 
  

  The disk is removed using cervical BEI forceps under C-arm guidance ( Fig. 8.8 ).

  
  
• 
  

  Under endoscopic guidance, the herniated fragment is then removed using small forceps ( Fig. 8.9 ).

Endoscopic Findings

• 
  

  The first view upon introduction of the endoscope is usually the blue-stained herniated disk ( Fig. 8.10A ).

• 
  

  The holmium:yttrium-aluminum-garnet (Ho:YAG) side-firing laser is oriented toward the posterior longitudinal ligament (PLL) and the annular tear. The herniated fragment stained blue can be seen through the annular tear ( Fig. 8.10B ).

  
  
• 
  

  The extruded disc fragment is then visualized in the foraminal area ( Fig. 8.10C ).

  
  
• 
  

  The extruded disk fragment is removed with forceps ( Fig. 8.11A ).

  
  
• 
  

  After removal of the main herniated disk fragment, remaining disk fragments can be visualized and removed ( Fig. 8.11B ).

  
  
• 
  

  After complete removal of the herniation, the decompressed nerve root can be seen ( Fig 8.11C ).