Cervical disc herniations are a common cause of neck and arm pain, often leading to surgical intervention when conservative treatments fail. Traditionally, the standard surgical approach has been anterior cervical discectomy and fusion (ACDF), which provides direct decompression and stabilization. Despite its clinical effectiveness, ACDF is associated with certain limitations, including implant related complications, adjacent segment disease, and restriction of segmental mobility.

In recent years, there has been a marked shift towards minimally invasive spinal procedures, driven by the goal of reducing soft tissue damage, blood loss, and recovery times while maintaining or improving clinical outcomes [1]. Among these, posterior cervical foraminotomy and discectomy (PCF/D) techniques, particularly those performed via full-endoscopic uniportal approaches, have gained significant popularity. These methods offer targeted decompression with minimal disruption of posterior cervical musculature and bony structures, preserving spinal stability and motion [2,3].

In cases of soft cervical disc herniations, endoscopic posterior approaches allow for direct visualization and removal of the offending disc material while sparing the need for instrumentation or fusion. Biomechanical analyses have shown that such techniques better preserve natural spinal kinematics and reduce stress concentrations compared to ACDF [4]. Clinical studies further support comparable, and in some aspects superior, outcomes in terms of recovery, complication rates, and long term spinal health [5,6].

In this technical note, we present a case of uniportal full-endoscopic posterior cervical discectomy and foraminotomy in a patient with a unilateral soft disc herniation. The operative steps are demonstrated through a structured surgical video, highlighting the key technical nuances and advantages of this minimally invasive approach.

We present a 42-year-old woman with a 3-month history of neck and right arm pain. She had previously undergone conservative treatment, including physical therapy and algological interventions, without relief. Neurological examination showed 20% weakness in right forearm and wrist extension and hypoesthesia in the C6 dermatome. Magnetic resonance imaging (MRI) of the cervical spine revealed a right-sided C5–6 soft disc herniation compressing the C6 nerve root with associated foraminal stenosis (Figure 1).

The presence of motor weakness and the failure to respond to prior conservative treatments prompted the decision to proceed with surgical intervention. At this stage, the surgical options considered included ACDF, anterior cervical arthroplasty, anterior endoscopic discectomy with fusion, posterior microscopic foraminotomy, and posterior endoscopic cervical foraminotomy and discectomy (PECF/D).

In this patient, several factors favored the posterior endoscopic approach: the herniated disc was soft in consistency and located within the foraminal zone; there was no evidence of degenerative changes such as osteophytes or ossification of the posterior longitudinal ligament; and the procedure has been associated with improved pain and functional outcomes [7], better preservation of segmental range of motion, and therefore, a reduced risk of adjacent segment disease compared to anterior fusion techniques [8]. Additionally, PECF/D has been correlated with shorter hospital stays, reduced intraoperative blood loss, and lower complication rates [9]. Collectively, these considerations led us to select posterior endoscopic cervical foraminotomy and discectomy as the most appropriate surgical option in this case.

The procedure was performed under general anesthesia with the patient in a prone position. The head was secured in a Mayfield head clamp with the neck slightly flexed, and the shoulders were gently pulled caudally using adhesive tapes to optimize fluoroscopic visualization. Continuous neuromonitoring was employed throughout the operation.

A high-definition endoscopic camera system (Richard Wolf GmbH, Germany; 6.9-mm outer diameter, 15° viewing angle) and endoscopic instruments were used via a uniportal posterior approach. After sterile draping, the target level (C5–6) was localized using lateral fluoroscopic guidance. A 1-cm skin incision was made approximately 2 cm lateral to the midline, over the C5–6 level. A working cannula was inserted and docked on the lamina-facet junction under fluoroscopic and endoscopic control (Figure 2).

Endoscopic visualization allowed for identification of the anatomical landmarks, including the inferior lamina of C5, the superior lamina of C6, the ligamentum flavum, and the medial aspect of the facet joint. A high-speed diamond burr was used to perform the keyhole foraminotomy which is a partial undercutting of the facet joint of C5-6. Facet joint preservation is a key consideration during posterior cervical foraminotomy to avoid iatrogenic instability. Several biomechanical and clinical studies have demonstrated that resection of up to 50% of the facet joint does not significantly compromise spinal stability. However, exceeding this threshold has been associated with increased segmental hypermobility and reduced torsional stiffness [10-13]. Endoscopic and microscopic decompression techniques therefore emphasize limited undercutting, typically involving only the medial one-third to one-half of the superior articular process, while preserving the joint capsule and lateral facet integrity [12,13]. Recent comparative studies, including randomized controlled trials, have further supported the clinical safety and motion-preserving advantages of posterior foraminotomy when facet joint resection remains within safe limits [14]. Thus, during foraminotomy, it is critical to avoid resecting more than 50% of the facet joint while drilling with a high-speed burr to prevent postoperative instability. Facet preservation during foraminotomy was verified intraoperatively by limiting total facet removal to less than one-half of the joint. The lamina-facet junction and the superior articular process were used as bony reference points to guide limited undercutting, while the facet capsule and lateral facet margin were kept intact. Orientation and safe boundaries were further confirmed by visualizing the exiting C6 root within the enlarged foramen and by identifying the caudal C6 pedicle as the inferior landmark. This approach is consistent with data indicating that exceeding one-half facet resection may compromise stability, whereas limited undercutting with capsule preservation maintains motion and safety.

Keyhole foraminotomy widened the neural foramen and exposed the ligamentum flavum overlying the exiting C6 nerve root. The ligamentum flavum was carefully removed using endoscopic punches and dissectors to reveal the dura and the exiting nerve root. (Figure 3A) The herniated soft disc material was visualized protruding into the foraminal space, compressing the C6 nerve root. It was meticulously extracted with the dissector manipulation (Figure 3B and C). Although the preoperative MRI suggested an axillary-type herniation, intraoperatively the extruded fragment was first visualized and removed from the shoulder aspect of the exiting C6 root. After completing the shoulder discectomy, the axillary region was carefully inspected to confirm full decompression and the absence of residual fragments. This sequence represents a case-specific finding rather than a routine practice, and the procedure was completed without any neural irritation or complication. Care was taken to avoid direct manipulation or injury to the nerve root or spinal cord, which were clearly identified and protected during the entire procedure. During the final stage of decompression, the intact posterior annulus of the disc and the adjacent epidural vein were observed beneath the exiting C6 root after fragment removal. The caudal C6 pedicle was identified as the inferior landmark to confirm the correct anatomical orientation during foraminotomy, although it was not prominently visible in the video due to viewing angle. Hemostasis was achieved with bipolar cautery under saline irrigation. The surgical field was inspected for any residual disc fragments or bleeding. The working cannula was withdrawn, and the skin was closed with a single subcuticular suture. Total operative time was approximately 45 minutes, and no intraoperative complications were encountered.

The patient experienced immediate relief of radicular pain following the procedure. Sensory symptoms, including numbness in the affected dermatome, resolved completely during the early postoperative period. No new motor deficits were observed in addition to the patient’s preoperative findings. The patient was mobilized without difficulty and was discharged on postoperative day one in stable condition.

The presented video highlights minor technical modifications that facilitate safer decompression and clearer anatomical orientation, including docking on the caudal lamina-facet junction and emphasizing limited facet undercutting. Anatomical landmarks such as the lamina-facet junction, exiting root, and pedicle were clearly identified and labeled to enhance educational value for readers and trainees.

This technical report demonstrates the feasibility and efficacy of uniportal full-endoscopic posterior cervical foraminotomy and discectomy (PECF/D) as a minimally invasive alternative for the treatment of soft, foraminal cervical disc herniations. In carefully selected patients, PECF/D enables targeted neural decompression while preserving spinal motion and minimizing approach-related morbidity. The presented case highlights key advantages of this approach, including rapid postoperative recovery, symptom resolution, and avoidance of segmental fusion. With increasing familiarity and growing evidence base, posterior endoscopic cervical procedures represent a valuable addition to the modern spine surgeon’s armamentarium.