---
title: 'Dr. Hartl - Posterior'
type: 'lesson'
url: 'https://doc.social/courses/cervical-radiculopathy-spectrum-of-presentation-and-continuum-of-care/dr-hartl-posterior'
course: 'Cervical Radiculopathy: Spectrum of Presentation and Continuum of Care'
course_url: 'https://doc.social/courses/cervical-radiculopathy-spectrum-of-presentation-and-continuum-of-care'
position: '2 of 6'
author: 'Dr. Paul Houle'
transcript: 'yes'
---

# Dr. Hartl - Posterior

## Summary

_This lesson is a recording without a written summary._

## Transcript

2,830 words · 17 min · 4 speakers · automatically transcribed (aws-transcribe) and not checked by a person; it may contain errors, particularly in names, drugs and dosages. The recording is the source.

[0:00] Speaker 1: So Doctor Hartle, why don't you go ahead and uh give us your presentation.
[0:06] Speaker 2: Thank you, Paul. So my name is Roger Hart in New York. Paul was talking about his career as a fisherman and he was talking about the white sharks, Cape Cod, and I feel like I'm surrounded by the Spine sharks tonight here.
[0:21] Speaker 2: But I'm just joking, of course, but I, I wanna talk to you, uh, next slide. I wanna talk to you about my disclosures next slide.
[0:32] Speaker 2: So I wanna talk to you why I believe that for this particular case, posterior decompression without fusion is a great solution and if you recall the case of this patient, uh, the films, this patient has a radicular problem, this patient didn't have any axial neck Pain.
[0:53] Speaker 2: In a neurological deficit clearly defined from one level at reasonable low doses, there was no deformity. Why do I believe that a decompression from the back without any type of implant or fusion is a great solution for this particular Pathology? I'll give you the six reasons why I think that a cervical foramaminotomy slash discectomy from the back is a great solution in this, in this case. First.
[1:20] Speaker 2: It, it, you're going in from the back, so you avoid anterior access related morbidities. I was seeing patients today and uh there's a morbidity from anteo Surgery. I had one patient come in from a different institution who had a vocal cord paralysis after ACDS, so it can happen. It's a rare complication, but if it happens in somebody who's young and active, it's a terrible complication. So you, you avoid those types of complications. Second, Paul, if you, uh, just scroll ahead.
[1:49] Speaker 2: It's an incredibly cost-effective operation. There are no implants involved, uh, patients go back to work very quickly, and there are studies that show that it is cost-effective and, uh, and, and, and very reasonable in terms of, uh, the, the cost of the Surgery. Next, Paul, uh, it's motion motion preserving. We're gonna hear later about disc arthroplasty, which is great because it preserves motion, while the posterior foraminotomy by definition will preserve motion. Next one, Paul.
[2:18] Speaker 2: It's ambulatory. These patients typically go home the, the same day. It is true that with anterior Surgery, you can send patients home sometimes the same day, but it's still not really common practice. Usually these patients stay at least one night in the hospital. With posterior foraminotomies, they frequently go home the same day. Next, Paul, has a great track record and I'll show you some data. And finally.
[2:41] Speaker 2: Uh, uh, Paul, one more, it allows future anterior approaches. So in those cases where you still have to go back, maybe at a later point to do a revision, you can still go in from the front and do an ACDF, a fusion or disc arthroplasty or whatever you have to do. Next slide.
[2:58] Speaker 2: Now, the laminar foraminotomy has been described in the in the late 1940s. Uh, Frick Holm here published that in 1949, as you can probably see. And then since the mid, since the early 2000s, we've been increasingly, at least in North America, we've used tubular access, uh, retractors and the microscope to perform this operation. Next slide.
[3:22] Speaker 2: And how do you make that decision and I think, you know, this talk or this, this whole evening is really about decision making and that that that's why I wanted to walk you through this algorithm that that I use when I select these patients.
[3:36] Speaker 2: Now, if obviously if somebody has spinal cord compression, as the patient here on the right side, that's not a good indication for poster foramina, that's actually a contraindication. But patients with ridiculous symptoms like here on the left side, where you have compression laterally, where that nerve root is coming out of the frame and in those patients, a posterior Approach may be a perfect option. Next slide.
[3:58] Speaker 2: So what is the option? Next slide, uh, it depends on the clinical presentation. If somebody has a lot of, uh, neck Pain, axial neck Pain, I tend to, uh, uh, uh, prefer a fusion or a disc arthroplasty, but it's, if it's purely radicular, like in the patient that, that we discussed earlier, a posterior Approach with just a decompression is a great option. Next slide.
[4:22] Speaker 2: So, uh, radicular symptoms, no myelopathy, no axial neck Pain. Option for posterior Approach. Next slide.
[4:32] Speaker 2: No exit neck Pain and then, and then we look at the alignment of the Spine. If if a patient has normal low doses like uh the MRI scan on the left side, that is in favor of a poster decompression without fusion. If somebody has reversal of the cervical loidosis or kyphosis like the patient on the right, then I go from the front and I most likely will do a fusion. Next slide.
[4:57] Speaker 2: So again, the indications are no axial Pain, noloidosis, and then lateral disc. If somebody has a central lateral disc with spinal cord compression, a posterior foraminotomy is obviously contraindicated. But if the patient meets these three criteria here on the left, a posterior cervical discectomy or foraminotomy is a very, very viable, cost-effective and safe option. Next slide. Next one.
[5:25] Speaker 2: And you can do it, and this is from the operating room, and X-ray. You can do it adjacent to a previously uh performed ACDF or disc arthroplasty. This is a patient who had 22 anterior surgeries done before rather than going back from the front and doing another fusion or disc arthroplasty, we decided to do a posterior foraminotomy in this patient, and you can do this safely even above multi-level fusion cases, as long as you are careful not to remove too much bone, of course. Next slide.
[5:54] Speaker 2: Uh, posterior foraminotomy, again, you can, uh, do this for bony compression as indicated or shown on the CT scan. This patient has severe left-sided foraminal bony compression.
[6:06] Speaker 2: Or you can do it for a soft disc hernation as in the patient that we had introduced in the beginning. Next slide, just scroll through it. The main, uh, next slide, the main, the main disadvantage here is really that there's no Reimbursement for, for this type of Surgery. It's not as favorable as it is for any type of Surgery where you, uh, where you, uh, use implants, unfortunately. Next slide.
[6:31] Speaker 2: And how do we do this in the operating room? There are many different ways of doing the Surgery. For a while, I used to do it the way that it is described here with Gardner-Wells tongs and traction, and I would make a small incision, place a tubular retractor under fluoroscopy guidance. Currently I use a Mayfield head holder because I will frequently use navigation.
[6:53] Speaker 2: Uh, for localization in these patients, next slide, I always use ejection table, a small tubular retractor. I use a, a 14 or 15 millimeter tubular retractor for a cervical foraminotomy. On the right side, you see a postoperative CT scan that shows the defect. Obviously you have to be careful not to remove too much bone. You want to leave at least 50% of the lateral mass and the facet joint. Next slide.
[7:20] Speaker 2: Localization, I typically use fluoroscopy in the lower cervical Spine that can be a challenge, uh, next picture, uh, sometimes you can use AP fluoroscopy for localization or next uh picture.
[7:34] Speaker 2: For many cases now I use navigation. We have 3 or 4 navigation systems available in the operating room, and it just makes it so much more streamlined. If you use navigation, you can use it for localization of the Pathology, the tubular retractor, and then also for to make sure you don't, you don't remove too much of the facet joint. Next slide.
[7:57] Speaker 2: And then, uh, we bring in bayoneted instruments under the microscope, uh, next slide, and, uh, the landmarks are the V-shaped gap between the between the lamina above and below. Uh, you wanna see the junction of the facet joint here next slide, and then you remove a little bit of bone above and below with micro instruments to expose the pedicle above and below. Next slide.
[8:23] Speaker 2: Uh, once you see the next slide, once you find the pedicle, you know that the nerve, the exigent, the exiting nerve root is going to be between those pedicles. You identify the nerve root, find the disc hernation, and remove the disc herination microsurgically. Next slide. Next slide.
[8:42] Speaker 2: Now the anatomy is, uh, you know, you've got to be careful because, uh, there are sometimes two nerve roots there, the motor branch and the sensory branch. You got to make sure that you identify both. Sometimes if you're not careful, you can think that the sensory nerve root is the disc hernia, and that is obviously not good. So you gotta be, uh, you gotta be aware of this, uh, of, of, of that intraoperative finding. Next slide.
[9:07] Speaker 2: Uh, that's an intraoperative image of the exiting nerve root here in the sickle sac and the disc herniation typically caudal to the exiting nerve root. Next slide. Next slide. This is the cake, yeah, this next, and then studies. I'm gonna go through a few studies if you go to the next slide.
[9:26] Speaker 2: Uh, uh, this, this study showed, uh, uh, it was a cost effectiveness study comparing ACDF Surgery to cervical foraminotomy and showing that it is very cost effective because, uh, the surgical in the direct costs are less. There's no implant, and patients tend to go back to work earlier in that particular series that was done in the military, it was cervical foraminotomy.
[9:49] Speaker 2: This is a study that was published recently in 2018, a meta-analysis comparing clinical outcomes from, uh, different types of surgeries, ACDF versus cervical disc replacement versus posterior cervical foraminotomy, and this particular study found that clinical outcomes were very similar, but there was a difference, a significant difference in terms of secondary surgical procedures. Uh, next, next, uh, picture, if you just click down.
[10:19] Speaker 2: Uh, so they, the offices here looked at almost 360 studies and they found that the rate of secondary procedures was much greater after ACDF Surgery and uh the uh incidence of adverse effects was the lowest in patients who underwent a posterior cervical foraminotomy, so it was the safest operation and a very low rate of secondary procedures.
[10:45] Speaker 2: Now the next two studies I want to show you, try to look at long term or longer term outcome. One of the biggest concerns with posterior cervical foraminotomy is the longevity of the success of the operation.
[10:58] Speaker 2: Uh, critics say that, uh, yeah, you decompress the, the nerve root, but then down the line patients develop a deformity and may need more Surgery to have that fixed. At 2 years, however, and this is a study that was published recently, uh, if you click through this and show us the text 790 patients.
[11:16] Speaker 2: They matched patients who had ACDF Surgery versus posterior cervical foraminotomy done and there was no difference in two-year reoperation rates at these, at these uh in these patients. Next slide.
[11:30] Speaker 2: This is a study that was just published a few months ago, a 5 year outcome study from a Swedish patient registry where they have a really good handle on following these patients long term. Clinical outcomes here, ACDF versus posterior cervical foraminotomy was the same. There was a slightly higher rate of re-operation, however, in the cervical foraminotomy group, but it was not significant. If you click through this.
[11:59] Speaker 2: So, uh, adjacent segments, there was no difference. Next slide.
[12:06] Speaker 2: And uh another reason why I like the posterior Approach because you can also do a direct decompression of the spinal canal. There's an older patient who we operated on. We did a foraminotomy and we did a decompression of the spinal stenosis at the same time. It's something you cannot do if you're going in from the front. Next slide and next slide.
[12:30] Speaker 2: And that concludes my presentation. Again, I feel pretty strongly or very strongly that for the right patient, this is an amazing operation. It's cost effective. Patients go home the same day. It's very safe. It's got a great track record and it saves patients an implant.
[12:49] Speaker 2: So thank you so
[12:49] Speaker 2: much.
[12:50] Speaker 1: So Doctor Hurdle, one of the hurdles that I hear from people who are doctors who want to do posterior cervical is that they feel that especially in the prone position, there's an awful lot of bleeding and it's oftentimes difficult to control. And I know in Dr. Kork's group that's done in the sitting position and I think nowadays the sitting position is kind of a lost art. So how do you feel about that?
[13:11] Speaker 2: Yeah, I think that's a, that's a very good point.
[13:13] Speaker 2: Uh, I use a Jackson table in reverse Trendelenberg, and the, the, the higher you elevate the head, the less bleeding. You have to use, uh, sometimes standies to use an, you know, standard, so you can really get the height, the height up of the head, uh, and, uh, uh, but that is, that is a concern. But if you elevate the head with reverse trend Dallenberg, you get a really nice handle on that.
[13:38] Speaker 1: Excellent. Tom, do you have anything to add?
[13:41] Speaker 3: Yeah, I, uh, um, we'll touch base upon, uh, that. I think, you know, the sitting cervical, there's a lot of advantage to, and, uh, and, and I think Roger hit some salient points. Uh, I'm just gonna have to apologize to my student colleagues, Roger and, uh, and Rick about the beatdown. I'm gonna have to deliver a
[14:01] Speaker 3: particular patient.
[14:01] Speaker 1: I know I saw your slide, so, um, you guys just wait till it's coming.
[14:06] Speaker 1: But 11 last question, Doctor Hartle, because I know that you are involved in cervical in uh spinal endoscopy and wonder what role do you see in the future for, uh, spinal endoscopy for cervical foraminotomy.
[14:20] Speaker 2: I think it's definitely a good option and there's still Research being done. I think we don't really know if it's, if it's really significantly better than tubular decompression, but it is an option. There are some surgeons, especially in Asia and a few surgeons in North America who, who are really good with that.
[14:36] Speaker 2: And we've got to look at the outcome data, but essentially it's the same, it's a very similar procedure to the tubular through a smaller incision.
[14:44] Speaker 2: What, what, what is not a good option is endoscopic percutaneous without visualization that, that has been discussed also that I think is dangerous, but as long as you have direct visualization, it's probably very similar to the tubular decompression.
[15:00] Speaker 1: Excellent. So we'll just tell us
[15:02] Speaker 4: in terms of imaging, uh, Roger, what do you use for imaging to try and determine if you've got a patient with a significant foraminal disc? Uh, what, what do you use for imaging to determine whether or not that disc may be something that you can actually fish out versus, uh, if it might be more of a, a calcified, I'm saying complex or
[15:18] Speaker 2: I, I, I will firm, yeah, I, I will fre frequently get a CT scan, and that can be very helpful because it helps you determine what to expect once you're in there.
[15:27] Speaker 2: If you expect a soft disc herrination, you will look for that and if you, if you know based on the CT scan that it's really calcified, you're not gonna manipulate, do unnecessary manipulations of the nerve root looking for a soft disc hernation and you will essentially unmove the nerve root. So that's a very good point and that's a very important point.
[15:47] Speaker 2: So, uh, and
[15:48] Speaker 4: Roger, if you got a patient who's truly got weakness, do you, do you, do you favor an Anterior approach, or do you think you can do as reliable a job on a patient with weakness with a foraminotomy?
[15:59] Speaker 2: Oh, absolutely. I, I have no doubt you can, if, especially if it's a soft disc hernation, you can, you can completely treat that from the back and, and very, very successfully.
[16:10] Speaker 2: I'm just not not sure if, if, if they're two sick bourbons or is that just an old picture.
[16:19] Speaker 4: So a little bit of unstable internet connection here.
[16:22] Speaker 1: There you go. So I just like a little plug. I know, uh, Doctor Harley, you've been hosting, uh, a, uh, MIS course, uh, for quite a long time. Unfortunately, I've never had a chance to attend, but you have another one coming up in December? Yeah,
[16:35] Speaker 2: it's going to be virtual this year, and you're always invited, of course.
[16:39] Speaker 2: And, uh, and, uh, yeah, it's going, we try to focus on navigation, endoscopy, and virtual reality, all the fancy new technologies. Wonderful. Thanks for pointing that out.
[16:51] Speaker 1: Oh, thank you very much.

## In this course

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- [All lessons: Cervical Radiculopathy: Spectrum of Presentation and Continuum of Care](https://doc.social/llms/courses/cervical-radiculopathy-spectrum-of-presentation-and-continuum-of-care.md)