Foraminal disc herniation at the C2–3 level is a very rare entity, for which a consensus treatment protocol has not been established. This case report explains that unilateral biportal endoscopic foraminotomy is a very effective, minimally invasive, and safe procedure for this condition. A 62-year-old woman presented to our clinic with complaints of a 6-week history of posterior axial neck pain and sudden onset of hypoesthesia over the right periauricular region, face and lip. Magnetic resonance imaging (MRI) revealed C2–3 right foraminal disc herniation, and posterior cervical foraminotomy was done using the unilateral biportal endoscopic technique. The patient reported complete relief of the axial neck pain soon after surgery and gradual improvement of the hypoesthesia. Postoperative MRI showed complete removal of the compressing disc fragment. In conclusion, this case shows that a minimally invasive biportal endoscopic procedure can be a better choice for decompression than many extensive and destructive procedures. This is the first case report in the literature describing the management of C2–3 foraminal disc herniation by posterior cervical unilateral biportal endoscopic foraminotomy.
The disc herniation incidence at C2–3 level is relatively not that common when compared to that of its occurrence in the subaxial cervical spine. Therefore, early diagnosis can be difficult for the clinicians and there are high chances that this can go undiagnosed. Even after diagnosing a C2–3 disc herniation, many spine surgeons are relatively very inexperienced in performing any sort of minimally invasive surgery at this level as it can be very challenging. Various extensive and traumatic surgical techniques like the Cloward’s technique [
A 62-year-old female presented in the outpatient clinic of our hospital with complaints of 6 weeks duration posterior axial neck pain and sudden onset hypoesthesia over the right preauricular region, face and lip. The patient initially had relief of the posterior neck pain on taking analgesics and doing physiotherapy but later did not have any significant improvement. The intensity of the neck pain increased during the off period from analgesics and now even after taking analgesics there is no relief at all in her neck pain.
On performing neurological assessment, the patient was not able to move her head owing to the severity in pain. She was in complete distress as there was no resolution in the pain and her sleep was seriously affected for many days. All her neck movements were restricted due to pain but did not show any myelopathic symptoms or signs. Magnetic resonance imaging of the brain was normal but that of the cervical spine showed a C2–3 level foraminal disc herniation that was compressing the right C3 root (
*4.0-mm diameter zero-degree arthroscope
*4-mm solid diamond burr
*4-mm shaver with protective sleeve
*3.75-mm ninety-degree radiofrequency ablator and 1.4 mm thirty-degree micro ablator radiofrequency probe for controlling intraoperative bleeding
*Serial dilators
*Commonly used foraminotomy instruments like 1 mm & 2 mm Kerrison punches, 1.5 mm standard and upbite pituitary forceps, nerve hook (ball tip probe) and small curettes.
For the surgery, patient taken in prone position after giving general anesthesia. The H shaped pillow was used to relax the abdomen so as to avoid an increased abdominal pressure. The eye ball and face were protected from direct high pressure using a gel type facial pad. The neck kept in flexed position and upper back to the slanting down manner to get a good venous return and thereby reduces the chance of excessive intra operative bleeding. The head was fixed in flexed position and both the shoulders were pulled and fixed with a plaster tape. No head rest or any cervical traction kit was used. With strict aseptic precautions, sterile painting and draping of the entire posterior neck was done. Since the lesion was on the right side and the surgeon right handed, so the surgeon stood on the left side (
It is believed that intervertebral disc herniation results because of a long-term degenerative process happening in the disc. This C2–3 disc herniation is a rare case [
In this case, the patient did not have any classical radicular symptoms of nerve root compression instead the patient presented with not improving posterior axial neck pain of almost 6 weeks duration and sudden onset of right side periauricular, lip and face hypoesthesia.
The patient was put initially on oral analgesics and steroid medications along with physiotherapy by other treating physicians since the onset of neck pain. Since the patient did not have any significant improvements in the symptom during the off period from medications and as a part of our treatment protocol to diagnose the underlying pathology, MRI (magnetic resonance imaging) of the cervical spine was done which showed a C2–3 disc herniation of foraminal type compressing the C3 nerve root. As the conservative trials did not yield any promising results, a surgical intervention was planned to give a better outcome. The most commonly practiced surgical procedures were ACDF (anterior cervical discectomy and fusion) and PCF (posterior cervical foraminotomy). Since we wanted to offer a safe and less traumatic procdure, a minimally invasive endoscopic technique with a biportal approach to conventional arthroscopic systems for spinal disease [
The rationale for choosing this approach was that a direct access could be gained to the foraminal lesion site thereby not needing to do an extensive discectomy, preserving the movement and major portion of the intervertebral disc. Since this is not a fusion procedure, so the graft related complications are avoided and reduces the chance of adjacent segment disease. This minimally invasive cervical foraminotomy is also a better cost effective procedure than ACDF [
In the year 1996, first case of unilateral biportal endoscopic (UBE) technique was reported for treatment of lumbar discectomy [
Postoperative radiological study (
Posterior cervical unilateral biportal endoscopic foraminotomy technique is a minimally invasive and safe supplement which can replace the traditional extensive and destructive open procedures when the indication criteria are fulfilled.
Not applicable.
No potential conflict of interest relevant to this article.
Magnetic resonance imaging. (A) Sagittal view showing a herniated disc, marked by an arrow mark. (B) Axial view showing foraminal disc herniation at the C2–3 level compressing the right C3 root, marked by an arrow mark.
(A) Surgeon standing on the left side and working on the lesion on the right. (B) Drilling the lower aspect of the cranial lamina.
C–arm fluoroscopy images. (A) Anteroposterior view confirming the level. (B) Lateral view showing two 18 G needles placed at the C2 and C3 pedicle levels before performing a skin incision.
Intra-operative images. (A) Removal of the herniated disc fragment using pituitary forceps. (B) Decompressed nerve root.
Computed tomography images. (A) Coronal and (B) axial views showing the bony defects made to access the herniation.
Postoperative T2-weighted magnetic resonance imaging. (A) Sagittal and (B) axial views showing adequate decompression of the right nerve root.