A disappointing 5-year personal experience in the consistency with which cervical radicular pain responded to accepted surgical techniques prompted this author to reassess his surgical failures in 1971. In the absence of intrinsic neural disease, persisting foraminal pathology either unrecognized or unreachable during a previous surgical operation seemed the most probable etiology. Because anterior foraminal pathology was protected by the vertebral artery and even the anterior foramen entrance could not be surgically reached without inflicting serious morbidity on the intervertebral disc, a conservative microsurgical technique was developed that allows neurolysis and decompression of any posterior irritative foraminal pathology. This technique is termed microcervical foraminotomy (MCF).

Since 1972, 574 patients with 1571 symptomatic cervical nerve roots have been treated by this conservative posterior surgical approach. As many as six roots from C4 to C8 have been treated at one sitting. In the absence of intrinsic neural disease, preoperative correlation between abnormal radiodiagnostic studies and symptomatic nerve root levels has become minimally important because foraminal pathology treatable by this operation lies largely outside the spinal canal. Surgical indications for MCF are intractable pain or neurologic deficit of a radicular distribution unresponsive to either exhaustive conservative management or previous cervical operations. Regardless of any preoperative structural radiographic pathology, this operation is only applied to those foraminal levels with clinical radicular symptoms. A expert knowledge of cervical radicular neuroanatomy including dermatonal, myotomal, and reflex distributions seems all that is necessary to localize a clinically symptomatic cervical nerve root and thus its associated neural foramen [2].

Accurate placement of the skin incision is paramount to ensure minimal operating time and maximal hemostasis. After palpation of a familiar spinous process, a 1-inch needle is inserted well lateral to the midline and localized by lateral radiogram. A 1.5-inch skin incision is then marked in the midline after reviewing the anatomical placement of the needle. Once the wound is open, a visible spinous process is then notched with a rongeur for future identification and grasped on its tip with a metallic clamp. A second lateral cervical X-ray is then obtained to accurately identify the vertebral level. Once the metallic clamp has been removed, the notched spinous process can be followed inward on its lateral surface by finger palpation to locate the symptomatic interlaminar level. A self-retaining retractor is then applied for direct visualization of the deeper anatomy.

This technique has proven absolutely necessary for the exact localization of foraminal levels, because it is extremely easy for even the most experienced spinal surgeon to become disorientated in the depths of a microsurgical cervical wound. If there is any doubt as to the location, check and recheck again until the appropriate interlaminar level is without question. This operation is so successful for the relief of radicular pain that any persistence in its intensity for even 24 hours following surgery likely indicates that the surgeon was in the wrong place.