Carefully review the preoperative x-rays for cervical alignment, presence of any instability, and any anatomic anomalies that might influence intraoperative identification of the spinal levels.

Review the preoperative magnetic resonance imaging or computed tomography myelogram to appreciate the presence/size of any disk herniation, whether there is a component of intraforaminal disk herniation, direction of nerve root displacement, and the degree of bony resection necessary to achieve a successful decompression.

Patient is positioned prone on a reversed regular OR table with Mayfield head holder and chest bolsters.

Table is placed in 20° to 30° of reverse Trendelenburg and Mayfield is adjusted as needed to achieve neck flexion to reduce redundant posterior neck skin and reduce the shingling of the facets to expose the underlying superior articular facet.

Shoulders are taped down to assist with radiographic localization.

Overall, the positioning is similar to laminoplasty (see Chapter 4).

Palpate the external occipital protuberance and the prominent C2 and C7 spinous processes to aid in determining the cranial and caudal extent of the incision.

Use a lateral C-arm x-ray before prep and drape with a metallic instrument on the skin to approximate the level.

Once down to the facet, use an intraoperative lateral C-arm x-ray with a spinal needle on the facet joint to confirm levels before performing the foraminotomy (Figures 6-2 and 6-3).

For bilateral foraminotomies, use a midline incision. For unilateral foraminotomies, may use an incision 2 cm lateral to the midline, or go directly midline.