Search

The posterior cervical foraminotomy (PCF) approach was first described by Spurling and Scoville for the treatment of posterolateral cervical soft disc herniations with concordant radiculopathy [1]. Subsequently, multiple surgical series have demonstrated a high rate of clinical success using this approach, citing a low complication rate, morbidity, rate of disk recurrence, and rate of reoperation [2–6]. The ideal management of cervical radiculopathy is still contested. Proponents of the ventral approach argue that the anterior discectomy and fusion (ACF) has less postoperative pain and cervical deformity due to the avoidance of posterior muscular dissection, providing a wider exposure of the pathology affording safe disc removal, as well as a lower rate of iatrogenic nerve injury [7, 8]. One important drawback of the ACF is that it does not preserve mobility. The cervical disc arthroplasty, an alternative anterior option is motion-sparing, but still carries risks inherent to an anterolateral approach. One of the most common complications is dysphagia which can persist after surgery while the least common and most concerning of outcomes is injury to the esophagus or vertebral artery [9]. In the postoperative months, the risks of graft subsidence and pseudoarthrosis are unique to the anterior approach [7]. Moreover, after successful fusion, adjacent segment degeneration (ASD) can complicate an uneventful ACF with approximately a 25% risk of occurrence in the first ten postoperative years [10, 11]. Muscle-sparing tubular approaches for PCF have gained popularity, as well as ‘keyhole foraminotomy’ approaches that allow for less-invasive corridor with microscopic or endoscopic assistance or in conjunction with a muscle-splitting tubular retractor.

Low back pain, or spinal pain, is the second most common chief complaint in the adult population seeking medical care in the ambulatory care setting. Treatment is often initiated due to the high rate of concomitant degenerative pathology seen on magnetic resonance imaging in both symptomatic and asymptomatic adults. However, in the absence of radicular pain localizing to a compressive pathology, and clear evidence of the appropriate spinal pain generator, a more thorough work-up is warranted. The algorithm for localization of the appropriate lumbar level of disease can be complex and still leave the surgeon without a definitive answer. This is in part due to the complex innervation of the spine where in the case of the facets and disc space a mixed innervation from somatic peripheral and autonomic nerve system supply is seen. Additionally, chronic compression of the neural elements and inflammation of neural fibers may result in hyperexcitability of nociceptive neuronal pathways. In this case, neuronal excitability can be spontaneous or with a greatly lowered threshold, and surgical compression may not always provide pain relief. As a result, more patients are diagnosed with failed back surgery syndrome, a loosely defined term in the spinal literature referring to painful symptoms persisting beyond the expected postoperative time course. The authors highlight several pain generators of the spine and highlight potential nonsurgical interventions that should be considered in the spinal surgeon’s armamentarium as a means of addressing this problem in the clinic.