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Key points
- This operation frees a nerve root trapped at the side of the neck by a disc bulge or bone spur, working from the back of the neck through a small tube and camera.
- It keeps the disc and the movement at that level, so no fusion or implant is needed.
- Trials show that operating from the back for this kind of arm pain gives results similar to the common front-of-neck operation, ACDF.
- The endoscopic version appears to mean less pain medicine early on, while longer-term results look similar to other approaches.
- It is suitable only for problems at the side of the spinal canal, needs specific training and is offered in a limited number of centres.
What is the problem it treats?
Each nerve root leaving the neck passes through a small bony opening called the foramen. A disc bulging out to the side, or a bone spur from wear in the joints, can narrow this opening and squeeze the nerve. The result is cervical radiculopathy: pain, pins and needles, numbness or weakness running into the shoulder, arm or hand. Many people improve without surgery. When they do not, an operation to relieve the pressure may be offered.
What the operation involves
A posterior cervical foraminotomy is done from the back of the neck. The surgeon removes a small amount of bone from the edge of the lamina and the facet joint to widen the foramen and, where needed, takes out a fragment of disc lying against the nerve. In the traditional open version, used in the Dutch FACET trial, the surgeon makes a midline cut, exposes the bone on one side and works with an operating microscope or magnifying loupes.[1]
The endoscopic version reaches the same spot through a much smaller opening. In a 2008 randomised trial, the surgeons used endoscopes 5.9 mm wide.[2] There are now several variations. Uniportal surgery uses a single tube carrying the camera and instruments. Biportal surgery uses two small cuts, one for the camera and one for the instruments. Some systems use a larger working channel. A 2026 network meta-analysis of 11 studies found these three techniques gave broadly similar results and complication rates, although all the studies were retrospective.[3]
How does it compare with ACDF?
The most common alternative is anterior cervical discectomy and fusion (ACDF), done from the front of the neck. The whole disc is removed and the space is held open with a cage so the two vertebrae fuse. Both operations can work well, and the choice depends on where the pressure is coming from.
The FACET trial randomised 265 adults with arm pain from one-sided, single-level foraminal narrowing to posterior foraminotomy or ACDF. At one year, success rates were 88% after posterior surgery and 76% after ACDF, and posterior surgery met the trial’s test for being no worse.[4] At two years, predicted success was 81% and 74%, and arm pain results were also similar. Serious surgery-related problems affected 8% after posterior surgery (including 9 reoperations) and 9% after ACDF (including 7 reoperations).[5] FACET used open foraminotomy, not the endoscopic technique.[1]
For the endoscopic operation specifically, a 2008 German trial remains the main randomised study, which is why it is still cited. It compared full-endoscopic posterior foraminotomy with anterior decompression and fusion in 175 people with lateral disc herniations. After two years, 87% had no arm pain and about 9% had occasional pain, with no difference between the groups in clinical results, revisions or complications. The endoscopic group kept movement at that level and recovered faster.[2]
A 2023 meta-analysis of 24 studies (1,345 patients) compared endoscopic keyhole foraminotomy with microscopic ACDF for single-level, one-sided radiculopathy. Success rates (93% and 94%), overall complications and reoperations did not differ significantly. The type of complication did: problems after ACDF were mainly swallowing difficulty and the cage sinking into the bone, while after endoscopic surgery the most common problem was weakness of a nerve root.[6]
How does it compare with open foraminotomy?
There are no large randomised trials comparing endoscopic and open foraminotomy. A 2026 American study of 138 patients from one hospital found that people having endoscopic or other minimally invasive surgery were less likely to need opioid painkillers six weeks later than those having open surgery. Short-term complications, reoperations and pain relief were similar across all three approaches.[7] Because the study looked back at existing records, the groups may have differed in ways the authors could not fully account for.
Who may and may not be suitable?
The operation is designed for pressure at the side of the spinal canal. The trials included people with lateral disc herniations[2] or one-sided narrowing of the foramen at a single level, and FACET excluded people whose only symptom was neck pain without arm pain.[4] It may suit you if arm pain is your main problem and your scan shows a matching foraminal disc or bone spur.
It is less likely to be the right choice if a disc is pressing in the middle of the canal, if the spinal cord itself is squeezed (cervical myelopathy), or if several levels need treatment. In those situations the studies above do not apply, and your surgeon will discuss other options. Some people prefer to avoid a fusion; others are better served by one. A careful discussion with your surgeon, with the scan in front of you, is the best way to decide.
Training and availability
Endoscopic neck surgery takes practice. A 2024 review pooling the experience of four surgeons found they reached competence after about 21 operations. Complications ran at 10.9% during the learning phase and 1.2% afterwards, although the difference was not statistically significant in this small sample of 203 patients.[8] The technique is not offered by every spinal unit, and NHS availability varies. Ask your surgeon how often they perform it and what their own results are.
Before, during and after
You will have a pre-operative assessment, and your team will advise you about stopping blood thinners and other medicines. On the day the surgeon confirms the correct level with X-ray before starting.[1] Your anaesthetist will explain the anaesthetic. Afterwards you can usually move your neck gently, since nothing has been fused. Your surgeon will advise when to return to driving, work and exercise, as this depends on your job and how quickly the arm symptoms settle.
Risks and complications
The studies on endoscopic neck surgery are smaller than those for the lower back, so the figures below are less precise and vary between reports.
| Risk | Approximate frequency (published studies) |
|---|---|
| Any complication after endoscopic keyhole foraminotomy | 4.7% pooled across studies, against 7.1% after microscopic ACDF (ref 6) |
| Weakness of a nerve root | The most common complication after endoscopic foraminotomy; not reported as a separate rate in the review summary (ref 6) |
| Further surgery at the same or a nearby level | 1.1% after endoscopic foraminotomy and 1.8% after ACDF, pooled (ref 6). In FACET, 9 reoperations after open posterior surgery and 7 after ACDF within 2 years (ref 5) |
| Serious surgery-related problem, open posterior surgery | 8 in 100 within 2 years, against 9 in 100 after ACDF (ref 5) |
| Complications while a surgeon is learning the technique | 10.9% during the learning phase and 1.2% after it, in a small pooled analysis (ref 8) |
| Difficulty swallowing | A common problem after front-of-neck ACDF, not a typical risk of surgery from the back (ref 6) |
Like any spinal operation, this surgery carries risks of infection, bleeding, a tear in the lining around the nerves (dural tear) and blood clots. The reviews cited here did not report separate rates for these, so ask your surgeon for figures from their own practice.
Seek urgent medical help (A&E or 999) if you have:
- New or rapidly worsening weakness or numbness in your arms or legs, or difficulty walking
- Loss of bladder or bowel control
- Clear fluid leaking from the wound with a severe headache
- A fever, or a wound that becomes red, hot, swollen or starts to leak
- A painful, swollen calf, or sudden chest pain or breathlessness
References
- Broekema AE, Kuijlen JM, Lesman-Leegte GA, et al. Study protocol for a randomised controlled multicentre study: the Foraminotomy ACDF Cost-Effectiveness Trial (FACET) in patients with cervical radiculopathy. BMJ Open. 2017;7(1):e012829. Link
- Ruetten S, Komp M, Merk H, et al. Full-endoscopic cervical posterior foraminotomy for the operation of lateral disc herniations using 5.9-mm endoscopes: a prospective, randomized, controlled study. Spine. 2008;33(9):940-948. Link
- Mo Y, Deng S, Zhang H, et al. Pain relief and functional outcomes after minimally invasive endoscopic decompression for cervical radiculopathy. Medicine (Baltimore). 2026;105(28):e49692. Link
- Broekema AEH, Simões de Souza NF, Soer R, et al. Noninferiority of posterior cervical foraminotomy vs anterior cervical discectomy with fusion for procedural success and reduction in arm pain among patients with cervical radiculopathy at 1 year: the FACET randomized clinical trial. JAMA Neurol. 2023;80(1):40-48. Link
- Simões de Souza NF, Broekema AEH, Reneman MF, et al. Posterior cervical foraminotomy compared with anterior cervical discectomy with fusion for cervical radiculopathy: two-year results of the FACET randomized noninferiority study. J Bone Joint Surg Am. 2024;106(18):1653-1663. Link
- Guo L, Wang J, Zhao Z, et al. Microscopic anterior cervical discectomy and fusion versus posterior percutaneous endoscopic cervical keyhole foraminotomy for single-level unilateral cervical radiculopathy: a systematic review and meta-analysis. Clin Spine Surg. 2023;36(2):59-69. Link
- Ansari D, Greeneway GP, Talbot G, et al. A retrospective comparative analysis of postoperative opioid utilization following uniportal endoscopic versus minimally invasive versus open approaches for posterior cervical foraminotomy. J Neurosurg Spine. 2026;44(3):330-339. Link
- Baumann AN, Callaghan ME, Walley KC, et al. Outcomes and complications associated with the learning curve for endoscopic cervical foraminotomy: a systematic review and meta-analysis. Spine. 2024;49(7):470-477. Link
This guide is general information and is not a substitute for advice about your own situation. Please discuss the benefits and risks of any procedure with your surgeon.
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