Results of posterior cervical foraminotomy for treatment of cervical spondylitic radiculopathy

Cervical Radiculopathy: Focus on Factors for Better Surgical Outcomes and Operative Techniques

For patients with cervical radiculopathy, most studies have recommended conservative treatment as the first-line treatment; however, when conventional treatment fails, surgery is considered. A better understanding of the prognosis of cervical radiculopathy is essential to provide accurate information to the patients. If the patients complain of persistent and recurrent arm pain/numbness not respond to conservative treatment, or exhibit neurologic deficits, surgery is performed using anterior or posterior approaches. Anterior cervical discectomy and fusion (ACDF) has historically been widely used and has proven to be safe and effective. To improve surgical outcomes of ACDF surgery, many studies have been conducted on types of spacers, size/height/position of cages, anterior plating, patients' factors, surgical techniques, and so forth. Cervical disc replacement (CDR) is designed to reduce the incidence of adjacent segment disease during long-term follow-up by maintaining cervical spine motion postoperatively. Many studies on excellent indications for the CDR, proper type/size/shape/height of the implants, and surgical techniques were performed. Posterior cervical foraminotomy is a safe and effective surgical option to avoid complications associated with anterior approach and fusion surgery. Most recent literature demonstrated that all three surgical techniques for patients with cervical radiculopathy have clear advantages and disadvantages and reveal satisfactory surgical outcomes under a proper selection of patients and application of appropriate surgical methods. For this, it is important to fully understand the factors for better surgical outcomes and to adequately practice the operative techniques for patients with cervical radiculopathy.

Operative treatment of cervical radiculopathy: anterior cervical decompression and fusion compared with posterior foraminotomy: study protocol for a randomized controlled trial

BACKGROUND

Cervical radiculopathy is the most common disease in the cervical spine, affecting patients around 50-55 year of age. An operative treatment is common clinical praxis when non-operative treatment fails. The controversy is in the choice of operative treatment, conducting either anterior cervical decompression and fusion or posterior foraminotomy. The study objective is to evaluate short- and long-term outcome of anterior cervical decompression and fusion (ACDF) and posterior foraminotomy (PF) METHODS: A multicenter prospective randomized controlled trial with 1:1 randomization, ACDF vs. PF including 110 patients. The primary aim is to evaluate if PF is non-inferior to ACDF using a non-inferiority design with ACDF as "active control." The neck disability index (NDI) is the primary outcome measure, and duration of follow-up is 2 years.

DISCUSSION

Due to absence of high level of evidence, the authors believe that a RCT will improve the evidence for using the different surgical treatments for cervical radiculopathy and strengthen current surgical treatment recommendation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04177849. Registered on November 26, 2019.

A Historical Review of Endoscopic Spinal Discectomy

As an essential component of minimally invasive spine surgery, endoscopic spine surgery (ESS) has continuously evolved and has been accepted as a practical procedure by the worldwide spine community. Especially for lumbar disc herniation (LDH), the percutaneous endoscopic or full-endoscopic discectomy technique has been scientifically proven through randomized controlled trials and meta-analyses to be a good alternative to open discectomy. The initial concept of endoscopic spine discectomy was concerned with indirect disc decompression using various instruments such as blind forceps, a nucleotome, laser, radiofrequency coblation, and some chemical agents. The main surgical field has been shifted from the intradiscal space to the epidural space. Precise and selective discectomy for extruded LDH in the epidural space under high-quality endoscopic visualization is now feasible. Furthermore, the medical applications of ESS is broadening to include spinal stenosis, segmental instability, infection, and even intradural lesions. In this review article, I describe the history of endoscopic spine discectomy and decompression techniques, as well as evolution of the paradigm. This history may help indicate the future of practical ESS.

The Biportal Endoscopic Posterior Cervical Inclinatory Foraminotomy for Cervical Radiculopathy: Technical Report and Preliminary Results

The purpose of the current study was to introduce a surgical technique for posterior cervical inclinatory foraminotomy (PCIF) using a percutaneous biportal endoscopic (BE) approach. Consecutive 7 patients underwent BE-PCIF for their cervical radiculopathy. Postoperative radiologic images (x-rays, computed tomography [CT], and magnetic resonance imaging [MRI]) were evaluated postoperatively for optimal neural decompression status and stability. A visual analogue scale (VAS) for the arm pain and the Neck Disability Index were used to evaluate clinical results in the preoperative and postoperative periods. Mean follow-up periods were 6.42 ± 2.99 months. The mean operative time was 101.42 ± 49.30 minutes. Postoperative MRI and CT revealed complete removal of herniated discs and ideal neural decompression of the treated segments in all patients. Disc height and stability were preserved on postoperative x-rays. Preoperative VAS and Oswestry Disability Index scores improved significantly after the surgery. BE-PCIF may be an effective surgical treatment of the cervical radiculopathic lesions, which provides successful surgical decompression as far as distal part of foramen with better operative view and more easy surgical manipulation. This approach may also minimize iatrogenic damages of the posterior cervical musculo-ligamentous structures and help to maximize the preservation of the facet joint.

Microendoscopic anterior cervical foraminotomy: a preliminary series of 76 cases

Background

Anterior cervical foraminotomy represents a relatively recent minimally invasive approach that can potentially preserve the intervertebral disc and thus the functional motion segment.

Objective

This study aims to evaluate the clinical outcome of microendoscopic anterior cervical foraminotomy (MACF) for patients with cervical unilateral radiculopathy due to single level soft disc herniation or hard disc-osteophyte complex (DOC).

Methods

In the period between August 2009 and March 2015, 76 consecutive patients with symptomatic unilateral cervical radiculopathy were included in this study. There were 40 left-sided cervical radiculopathy cases and 36 right-sided; of those, 42 had soft disc fragment herniation, 18 had DOC, 12 had a migrated disc fragment whether cranial or caudal, and four had far lateral (foraminal) disc herniation. In all cases, MACF with root decompression was performed. Cervical magnetic resonance imaging (MRI), computed tomography (CT) scan, and plain X-rays were performed for all patients and then repeated postoperatively. All patients were followed-up for at least a year. Clinical and functional outcomes were assessed using visual analogue scale (VAS) and Odom’s criteria.

Results

According to VAS score, there was an improvement in neck pain from 6.4 (range 5–10) to 1.5 (1–5) and in arm pain from 7.2 (range 6–10) to 1.2 (0–4) at final follow-up (P < 0.05). Functional outcomes according to Odom’s criteria were excellent in 59 (78%) cases, good in ten (13%), fair in six (8%), and poor in one (1%) case. Success of surgery was considered to be achieved in 91% (excellent + good) of cases. Mean operating time was 81 min, and mean intraoperative blood loss was 21 ml. Most significant complications included a dural tear in one case, transient postoperative dysesthesia in six cases, excess bony work resulting in unintended uncinectomy in three cases, fracture of transverse process in one case, unintended near total discectomy in two cases, infective discitis in one case, and persistent radicular pain due to incomplete osteophyte removal in one case.

Conclusions

This preliminary report suggests that MACF yields overall excellent results in selected patients with unilateral cervical radiculopathy. The technique potentially can preserve the functional motion segment, thus patients typically experience immediate postoperative neck mobility and do not need to wear a cervical collar.

Cervicothoracic junction disc herniation: Our experience, technical remarks, and outcome

Background:

C7-D1 disc herniation is rare in comparison with other cervical levels. The incidence rates are between 3.5% and 8%. The cervicothoracic junction disc herniation can be operated posteriorly or anteriorly. The anterior approach can be challenging because of the difficulty of access resulted from the manubrium. In this article, we present our experience about cervicothoracic junction disc herniation (C7-T1) surgery.

Materials and Methods:

Between January 2008 and December 2017, 21 patients have been operated for solitary C7-T1 disc herniation. We operated 12 male patients and 9 female patients. Eight patients have been operated by the anterior approach, and 13 patients underwent surgery by the posterior approach. The mean symptoms duration was 11.4 months.

Results:

All patients had C8 cervicobrachial neuralgia. Other clinical presentations were numbness, tingling sensation, and weakness. All patients improved after surgery. We had no significant complication.

Conclusion:

We did not find a great difference between the clinical features of cervicothoracic herniated disc and other cervical levels. The anterior approach seems more difficult to carry out in particularly in large patients with the short neck. The posterior approach can be used for all types of patients except in the case of medial disc herniation.

Perioperative complications of inpatient and outpatient single-level posterior cervical foraminotomy: a comparative retrospective study

BACKGROUND CONTEXT

Posterior cervical foraminotomy (PCF) is a relatively safe procedure for the treatment of cervical radiculopathy. Though most often performed as an inpatient procedure, there is an increasing number of patients treated in an outpatient setting.

PURPOSE

This study aimed to compare the perioperative complication rates associated with inpatient and outpatient single-level PCF.

STUDY DESIGN/SETTING

Retrospective database study.

PATIENT SAMPLE

Patients with cervical radiculopathy who underwent inpatient or outpatient single-level PCF between 2007 to the first quarter of 2016.

OUTCOME MEASURES

Charlson Comorbidity Index (CCI) was used as a broad measure of comorbidity. Surgical complications included cervical nerve root injury, dural tear, wound complications, infection, dysphagia, cervicalgia, and revision surgery. Medical complications included pulmonary embolism and lower limb deep vein thrombosis, acute myocardial infarction, acute respiratory failure, pneumonia, sepsis, and urinary complications.

METHODS

This study was a retrospective review of patients who received single-level PCF from 2007 to the first quarter of 2016 as either outpatients or inpatients using the Humana subset of the PearlDiver Patient Record Database. The incidence of perioperative medical and surgical complications was queried using relevant International Classification of Diseases (ICD-9-CM and ICD-10-CM) and Current Procedural Terminology codes. Multivariate logistic regression analysis, adjusted for age, gender, and CCI, was performed to calculate odds ratios (ORs) of complications among inpatients relative to outpatients treated with PCF. Propensity score matching was done, and comparisons were made for postoperative complications.

RESULTS

Throughout the time period, 1,469 and 1,192 patients received inpatient and outpatient single-level PCF, respectively. The mean CCIs±standard deviation of inpatient and outpatient groups undergoing PCF were 2.83±3.11 and 1.46±2.21, respectively (p<.001). After propensity score matching, patients who received PCF in an inpatient setting showed significantly higher rates of wound complications (OR=1.53, 95% confidence interval [CI]=1.04-2.23; p=.029), infection (OR=1.91, CI=1.15-3.15; p=.012), acute respiratory failure (OR=2.50, CI=1.23-5.08; p=.011), and urinary tract infections and incontinence (OR=2.11, CI=1.32-3.38; p=.002).

CONCLUSIONS

Outpatient single-level PCF was associated with a lower rate of perioperative medical and surgical complications. The PCF in the outpatient setting can potentially be a safe procedure for the treatment of cervical radiculopathy with appropriate patient selection.

Current techniques of endoscopic decompression in spine surgery

Endoscopic spine surgery has become a practical, minimally invasive technique for decompression in patients with spinal disc herniation or stenosis. This review aimed to summarize the current techniques of endoscopic decompression technique in spine surgery and to discuss the benefits, limitations, and future perspectives of this minimally invasive technique. Endoscopic spine decompression surgery can be categorized according to the endoscopic property: percutaneous endoscopic (full-endoscopic), microendoscopic, and biportal endoscopic. It can also be classified based on the approach: transforaminal, interlaminar, anterior, posterior, and caudal approaches. Theoretically, each technique can be applied in the lumbar, cervical, and thoracic spine. The various endoscopic spine surgery techniques should be appropriately conducted according to the disease entities, level, and zone of pathologies. Although the current level of evidence is relatively low and the relevance of the technique is controversial, recent clinical results and the critical concept are promising. Development in optics, instruments, and approach will improve its safety and reduce technical complexity. In the meantime, high-quality clinical studies, including randomized trials and meta-analyses, are due for publication. Eventually, endoscopic spine surgery is expected to become the golden standard for spinal surgery.

Posterior percutaneous full-endoscopic cervical discectomy under local anesthesia for cervical radiculopathy due to soft-disc herniation: a preliminary clinical study

OBJECTIVE

To the authors’ knowledge, posterior percutaneous full-endoscopic cervical discectomy (PPFECD) has not been reported before as a procedure performed with patients under local anesthesia (LA). In this study, the authors report the outcomes of 25 patients treated by this technique, the surgical steps, and the procedure’s potential advantages.

METHODS

Twenty-five patients diagnosed with cervical radiculopathy due to soft-disc herniation (SDH) were treated by PPFECD. The intensities of arm and neck pain were measured using the visual analog scale (VAS) and the functional status was assessed using the Neck Disability Index (NDI) preoperatively and at 1, 3, 6, and 12 months postoperatively. Global outcome was also assessed using modified Macnab criteria, and outcomes were grouped as clinical success (excellent or good) and clinical failure (fair or poor). Complications were also recorded.

RESULTS

No patient was lost to the follow-up. Significant and durable pain relief and cervical functional improvement were achieved postoperatively. Clinical success was achieved in 24 patients (96%), including 22 excellent and 2 good outcomes at the last follow-up. No serious complications occurred.

CONCLUSIONS

The authors’ preliminary experience indicates that PPFECD under LA is a feasible and promising alternative for selected cases of cervical radiculopathy due to SDH, though the procedure’s effectiveness and safety still need confirmation from further studies.

Minimally Invasive Posterior Cervical Foraminotomy: Freiburg Experience With 34 Patients

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Assessment of outcome after minimally invasive posterior cervical foraminotomy (MI-PCF).

SUMMARY OF BACKGROUND DATA

Surgical management of cervical radiculopathy represents a controversial area in spinal surgery. Preferred approaches include both anterior cervical discectomy and posterior cervical foraminotomy (PCF). Numerous studies showed comparable results. Employing PCF eliminates risks associated with anterior approach. PCF as originally described by Spurling and Scoville necessitates extensive stripping of cervical muscles to expose the cervical spine, resulting in muscle injury, impaired muscle function, prolonged postoperative neck pain, and increased use of narcotics. There are only few studies investigating outcome after employing MI-PCF.

MATERIALS AND METHODS

Retrospective review of 34 patients who underwent MI-PCF for presenting complaints, postoperative and follow-up outcome.

RESULTS

In the last follow-up the weakness resolved completely in 62.6% of patients, in 4.1% improved and in 16.5% remained unchanged. In the last follow-up 76.7% of patients originally presenting with pain reported complete resolution of pain and 10% reported partial improvement of pain. In total, 23.5% of patients were lost during follow-up as far as pain was concerned. In the last follow-up, 75% of patients achieved relative neck-pain-freedom (Visual Analog Scale≤3) at rest and 62.5% of patients under strain. The mean neck pain on Visual Analog Scale at rest was 2.13 (SD=2.42) and 3.34 (SD=3.01) under strain. In total, 93.8% (n=15) of patients would undergo the same procedure for the same achieved result.

CONCLUSIONS

Minimally invasive cervical foraminotomy is an effective procedure for decompression of cervical nerve roots regardless the type of the stenosis. Even employing minimally invasive technique still causes neck pain in the long term affecting up to 25% of patients. More randomized control studies are required to clarify the benefits of minimally invasive PCF.

Management of cervical monoradiculopathy due to prolapsed intervertebral disc, an institutional experience

Background:

Cervical radiculopathy is the common clinical entity, often caused by “wear and tear” changes that occur in the spine. In the younger population, cervical radiculopathy is a result of a disc herniation or an acute injury causing foraminal impingement of an exiting nerve, whereas in the older individuals, it is due to foraminal narrowing from osteophyte formation, decreased disc height, and degenerative changes of the uncovertebral joints anteriorly and of the facet joints posteriorly. In most (75%–90%), cervical radiculopathy responds well to conservative treatment, whereas the remaining patients, who fail to achieve acceptable recovery with conservative modalities, alone need surgical decompression of the nerve root. Surgical interventions can be categorized into anterior and posterior approaches to the spine. Our study is focused on the surgical outcome of anterior discectomy with fusion versus posterior cervical discectomy with foraminotomy for cervical monoradiculopathy.

Materials and Methods:

Ours is a retrospective study including patients of one level unilateral posterolateral cervical disc prolapse with radiculopathy operated in Department of Neurosurgery, Bangalore Medical College and Research Institute between 2012 and June 2016. The hospital records, imagings, operation notes, and follow-up records were reviewed and analyzed. One hundred and fourteen patients of cervical monoradiculopathy were investigated and operated, 76 operated by anterior cervical discectomy with fusion (ACDF), and 38 operated by posterior cervical laminoforaminotomy (PCL).

Results:

The average operation time in 76 patients of ACDF group was 178 min and in 38 patients of PCL group was 72 min. Sixty-nine (91%) patients of ACDF and 38 (100%) patients of PCL had symptomatic relief but statistically (P > 0.5) was not significant. Three patients in ACDF group had hoarseness of voice due to recurrent laryngeal nerve palsy and there were no fresh permanent neurological deficits in any patients of PCL group over a follow-up period of 36 months. The average postoperative hospital stay was 5 days in ACDF group and 3 days in PCL group. The average intraoperative blood loss was <50 ml in ACDF group and 650 ml in PCL group. The need of analgesic for pain arising from bone graft site in ACDF group was comparable with operative site pain in PCL group.

Conclusions:

PCL is a simple approach, yields gratifying results, and is a promising alternative in selected cases of cervical monoradiculopathy due to disc prolapse.

Microsurgical posterior cervical foraminotomy: a study of 181 cases

BACKGROUND

An unsettled controversy over the appropriate surgical approach in cases of cervical radiculopathy caused by degenerative vertebrae and intervertebral discs is still present. The purpose of this study is to examine the efficacy of microsurgical posterior foraminotomy in the treatment of cervical radiculopathy and to find out whether the underlying pathology (soft disc herniation/spondylosis) is of value in predicting long-term outcome after this procedure.

METHODS

Patients, who underwent posterior cervical foraminotomy (PCF) at our department between 2006 and 2013 for unilateral mono-segmental lateral soft disc herniation, or spondylosis, or both, were enrolled in this study. Demographic, clinical and surgical data were retrospectively reviewed. The patients were subsequently interviewed by telephone to identify their long-term outcome. The clinical outcomes were evaluated using Odom's criteria. Descriptive statistics were frequencies and percentage of occurrence for categorical variables and mean and range for continuous variables.

RESULTS

One hundred eighty-one patients were included in this study, with a median follow-up of 58 months (mean 43 months, range 12-96 months). The overall re-operation rate was 7.2% (13 patients); 11 patients (6%) for recurrent root symptoms due to recurrent disc herniation (six patients, 3.3%) and re-stenosis (five patients, 2.8%), one patient (0.55%) for wound infection and one patient (0.55%) for postoperative haematoma. Among the eleven patients who underwent re-operation for recurrent root symptoms there was one patient who additionally had persistent cerebrospinal fluid leak and superficial posterior wound infection. There was no significant difference between lateral soft disc herniation and spondylosis in term of re-operation rate. At discharge, excellent or good outcome was achieved in 89% of patients; the long-term success rate was 97.2% using Odom's criteria.

CONCLUSION

Microsurgical PCF is an effective technique for treating lateral spinal root compression. Proper patient selection is obligatory to achieve the best results.

Posterior Cervical Foraminotomy: Indications, Technique, and Outcomes

Cervical radiculopathy presents with upper extremity pain, decreased sensation, and decreased strength caused by irritation of specific nerve root(s). After failure of conservative management, surgical options include anterior cervical decompression and fusion, disk arthroplasty, and posterior cervical foraminotomy. In this review, we discuss indications, techniques, and outcomes of posterior cervical laminoforaminotomy.

Cervical disc hernia operations through posterior laminoforaminotomy

OBJECTIVE

The most common used technique for posterolateral cervical disc herniations is anterior approach. However, posterior cervical laminotoforaminomy can provide excellent results in appropriately selected patients with foraminal stenosis in either soft disc prolapse or cervical spondylosis. The purpose of this study was to present the clinical outcomes following posterior laminoforaminotomy in patients with radiculopathy.

MATERIALS AND METHODS

We retrospectively evaluated 35 patients diagnosed with posterolateral cervical disc herniation and cervical spondylosis with foraminal stenosis causing radiculopathy operated by the posterior cervical keyhole laminoforaminotomy between the years 2010 and 2015.

RESULTS

The file records and the radiographic images of the 35 patients were assessed retrospectively. The mean age was 46.4 years (range: 34-66 years). Of the patients, 19 were males and 16 were females. In all of the patients, the neurologic deficit observed was radiculopathy. The posterolaterally localized disc herniations and the osteophytic structures were on the left side in 18 cases and on the right in 17 cases. In 10 of the patients, the disc level was at C5-6, in 18 at C6-7, in 2 at C3-4, in 2 at C4-5, in 1 at C7-T1, in 1 patient at both C5-6 and C6-7, and in 1 at both C4-5 and C5-6. In 14 of these 35 patients, both osteophytic structures and protruded disc herniation were present. Intervertebral foramen stenosis was present in all of the patients with osteophytes. Postoperatively, in 31 patients the complaints were relieved completely and four patients had complaints of neck pain and paresthesia radiating to the arm (the success of operation was 88.5%). On control examinations, there was no finding of instability or cervical kyphosis.

CONCLUSION

Posterior cervical laminoforaminotomy is an alternative appropriate choice in both cervical soft disc herniations and cervical stenosis.

Percutaneous endoscopic cervical discectomy using working channel endoscopes

Percutaneous endoscopic cervical discectomy has evolved as an efficient, minimally invasive spine surgery for cervical disc herniation or radiculopathy. The development of the working channel endoscope makes definitive decompression surgery through a percutaneous approach feasible. There are two methods of approach to target the pathology: anterior and posterior approach. The approach can be determined according to the zone of pathology or the surgeon's preference. The most significant benefits of this endoscopic surgical technique are minimal access tissue trauma and early recovery from the intervention. However, this technique is still evolving and have a steep learning curve. Extensive development of surgical technique and working channel endoscopes will enable us to treat cervical disc herniation more practically. The objective of this review is to describe the cutting-edge techniques of endoscopic surgery in the cervical spine and to discuss the pros and cons of these minimally invasive surgical techniques.

Microsurgery or open cervical foraminotomy for cervical radiculopathy? A systematic review

OBJECTIVE

The purpose of this article was to systematically review the clinical outcomes of microendoscopic foraminotomy compared with the traditional open cervical foraminotomy.

METHODS

A literature search of two databases was performed to identify investigations performed in the treatment of cervical foraminotomy with microsurgery or an open approach. Data including blood loss, surgical time, hospital stay, complications, clinical success rate, reduction of arm and neck pain, improvement of neurological function, and repeated surgery rate were summarized, calculated and compared. Results of clinical success were performed by calculattng effect indicators and standard errors based on a single rate to assess heterogeneity in the two groups.

RESULTS

The initial literature search resulted in 713 articles, of which, 26 were determined as relevant on abstract review. An open foraminotomy approach was performed in 16 and a microsurgery approach in ten studies. The open group demonstrated minimal to moderate heterogeneity, with I (2) value of 27 %; and microsurgery group demonstrated minimal heterogeneity, with I (2) value of 1 %. Aggregated data found that patients treated by microsurgery foraminotomy have lower blood loss by 100.1 ml (open: 149.5 ml, microsurgery: 49.4 ml, n = 1257), shorter surgical time by 24.9 minutes (open 88.7 minutes, microsurgery 63.8 minutes, n = 1423),and shorter hospital stay by 3.0 days (open 4.1 days, microsurgery 1.1 days, n = 1350), compared with patients treated by open cervical foraminotomy. The pooled clinical success rate was 89.7 % [confidence interval (CI) 87.7-91.6) in the open group versus 92.5 % (CI 89.9-95.1) in the microsurgery group, with no statistical difference (p = 0.095). Overall complication rates were not statistically significant between groups (p = 0.757). The incidence of dural tears was 1.07 %( 12/1121) in patients undergoing microsurgery versus 0.27 % (2/745) for open surgery (p = 0.091). The incidence of infection was 0.54 % (6/1121) in patients undergoing microsurgery versus 0.40 % (3/745) for open surgery (p = 0.949). The incidence of root injury was 0.80 % (9/1121) in patients undergoing microsurgery versus 1.48 % (11/745) for open surgery (p = 0.166). Revision surgery occurred in 2.32 % (27/1163) in the microsurgery group versus 3.35 % (28/835) for traditional surgery, with no statistical difference (p = 0.164). Pooled reduction in visual analogue scale for the arm (VASA) was 75.0 % (CI 66.0-84.0) in the open group and 87.1 % (CI:76.7, 97.5) in the microsurgery group, with no statistical difference (p = 0.065). Pooled reduction in VAS of the neck (VASN) was 66.2 % (CI:52.2, 80.2) in the open group and 68.1 % (CI:36.4, 99.8) in the microsurgery group, with no statistical difference(p = 0.894). Pooled improvement in neurological function was 55.3 % (CI:18.6, 91.9) in the open group and 64.9 % (CI:34.6, 95.2) in the microsurgery group, with no statistical difference (p = 0.576).

CONCLUSIONS

Although advantages of cervical microsurgery are less blood loss and shorter surgical time and hospital stay over the standard open technique, there is no significant difference in clinical success rate, complication rate, reduction of arm and neck pain and improvement of neurological function between microsurgery and open cervical foraminotomy.

A Transtubular Microsurgical Approach to Treat Lateral Cervical Disc Herniation

OBJECTIVE

Different surgical options are available to treat radicular pain syndromes of the cervical spine. Use of the posterior approach for foraminotomy and sequestrectomy (Frykholm) fusion can be avoided, but neck pain affects the postoperative course. This retrospective study compares the classical Frykholm approach and the transtubular microsurgical approach for foraminotomy.

METHODS

From 2004 to 2012, 40 patients fulfilled the inclusion criteria and were enrolled into this retrospective study. The classical Frykholm approach was performed on 25 affected levels. The transtubular microsurgical approach was used on 19 affected levels. Endpoints were neck pain, radicular pain, surgery time, duration of hospital stay, and long-term outcomes.

RESULTS

For the transtubular microsurgical approach and the classical Frykholm approach, the mean surgery time was 77.65 ± 23 minutes and 104 ± 27.59 minutes (P = 0.003), respectively. Radicular pain improved in all patients regardless of the technical approach. Significant differences were observed in neck pain on the first postoperative day (P = 0.003) and at discharge (P = 0.006), resulting in a shorter hospital stay of 4.82 days ± 2.1 for the transtubular microsurgical approach in comparison with 7.43 days ± 3.2 for the Frykholm approach (P = 0.005). According to the criteria of Odom, the rate of an excellent or good outcome was 97.5% (67.5% excellent and 30% good), without any differences between the compared approaches.

CONCLUSION

The transtubular microsurgical approach shows advantages regarding postoperative neck pain, surgery time, and hospital stay with a trend towards an earlier return to work.

Incidence and prognostic factors of c5 palsy: a clinical study of 1001 cases and review of the literature

BACKGROUND

C5 palsy is a known cause of postoperative deltoid weakness. Prognostic variables affecting the incidence of the palsy have been poorly understood.

OBJECTIVE

To determine the incidence and perioperative characteristics/predictors of C5 palsy after anterior vs posterior operations.

METHODS

All patients undergoing C4-5 operations for degenerative conditions were retrospectively reviewed over 21 years. Anterior operations included an anterior cervical discectomy and fusion (ACDF) or a corpectomy, whereas posterior operations included laminectomy and fusion (± foraminotomies).

RESULTS

Of the total 1001 operations, in 49.0% anterior and 51.0% posterior cases, there was an overall C5 palsy incidence of 5.2% (52 cases): 1.6% and 8.6%, respectively (P < .001). Of the 99 corpectomies, the palsy incidence of 4.0% was not only higher than ACDFs (1.0%), but also followed an upward trend with increasing corpectomy levels (P = .009). Of the 69 posterior and 83 anterior C4-5 foraminotomies, the incidence of C5 palsy was statistically higher in the posterior (14.5%) vs anterior (2.4%) cohort (P = .01). Multiple logistical regression identified older age as the strongest predictor of C5 palsy in the anterior (P = .02) and C4-5 foraminotomy in the posterior (P = .06) cohort. This condition improved within 3 to 6 months in 75% of patients in the anterior and 88.6% in the posterior cohort after a mean follow-up of 14.4 and 27.6 months, respectively.

CONCLUSION

In one of the largest cohorts on C5 palsy, we found in anterior operations an increasing number of corpectomy levels had a higher incidence of C5 palsy; however, older age was the strongest predictor of C5 palsy. In posterior operations, C4-5 foraminotomy carried the strongest correlation.

Cervical laminoforaminotomy for radiculopathy: Symptomatic and functional outcomes in a large cohort with long-term follow-up

Background:

The efficacy and safety of cervical laminoforaminotomy (FOR) in the treatment of cervical radiculopathy has been demonstrated in several series with follow-up less than a decade. However, there is little data analyzing the relative effectiveness of FOR for radiculopathy due to soft disc versus osteophyte disease. In the present study, we review our experience with FOR in a single-center cohort, with long-term follow-up.

Methods:

We examined the charts of patients who underwent 1085 FORs between 1990 and 2009. A cohort of these patients participated in a telephone interview designed to assess improvement in symptoms and function.

Results:

A total of 338 interviews were completed with a mean follow-up of 10 years. Approximately 90% of interviewees reported improved pain, weakness, or function following FOR. Ninety-three percent of patients were able to return to work after FOR. The overall complication rate was 3.3%, and the rate of recurrent radiculopathy requiring surgery was 6.2%. Soft disc subtypes compared to osteophyte disease by operative report were associated with improved symptoms (P < 0.05). The operative report of these pathologic subtypes was associated with the preoperative magnetic resonance imaging (MRI) interpretation (P < 0.001).

Conclusions:

These results suggest that FOR is a highly effective surgical treatment for cervical radiculopathy with a low incidence of complications. Radiculopathy due to soft disc subtypes may be associated with a better prognosis compared to osteophyte disease, although osteophyte disease remains an excellent indication for FOR.

Comparison of posterior foraminotomy and anterior foraminotomy with fusion for treating spondylotic foraminal stenosis of the cervical spine: study protocol for a randomized controlled trial (ForaC)

Background

Cervical radiculopathy caused by spondylotic foraminal stenosis may require surgical treatment. Surgical options include anterior cervical foraminotomy and fusion or posterior cervical foraminotomy. Controversy remains regarding the preferable surgical approach. Pertinent clinical evidence is limited to low-quality observational reports. Therefore, treatment decisions are predominantly based on the individual surgeon’s preference and skill. The study objective is to evaluate the efficacy and safety of posterior foraminotomy in comparison to anterior foraminotomy with fusion for the treatment of spondylotic foraminal stenosis.

Methods/design

This is a multicenter randomized, controlled, parallel group superiority trial. A total of 88 adult patients are allocated in a ratio of 1:1. Sample size and power calculations were performed to detect the minimal clinically important difference of 14 points, with an expected standard deviation of 20 in the primary outcome parameter, Neck Disability Index, with a power of 80%, based on an assumed maximal dropout rate of 20%. Secondary outcome parameters include the Core Outcome Measures Index, which investigates pain, back-specific function, work disability, social disability and patient satisfaction. Changes in physical and mental health are evaluated using the Short Form-12 (SF-12) questionnaire. Moreover, radiological and health economic outcomes are evaluated. Follow-up is performed 3, 6, 12, 24, 36, 48 and 60 months after surgery. Major inclusion criteria are cervical spondylotic foraminal stenosis causing radiculopathy of C5, C6 or C7 and requiring decompression of one or two neuroforaminae. Study data generation (study sites) and data storage, processing and statistical analysis (Department of Medical Statistics, Informatics and Health Economics) are clearly separated. Data will be analyzed according to the intention-to-treat principle.

Discussion

The results of the ForaC study will provide surgical treatment recommendations for spondylotic foraminal stenosis and will contribute to the understanding of its short- and long-term clinical and radiological postoperative course. This will hopefully translate into improvements in surgical treatment and thus, clinical practice for spondylotic foraminal stenosis.

Trial registration

Current Controlled Trials: ISRCTN82578069.

Electronic supplementary material

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Complications, outcomes, and need for fusion after minimally invasive posterior cervical foraminotomy and microdiscectomy

BACKGROUND CONTEXT

Posterior cervical foraminotomy (PCF) with or without microdiscectomy (posterior cervical discectomy [PCD]) is a frequently used surgical technique for cervical radiculopathy secondary to foraminal stenosis or a laterally located herniated disc. Currently, these procedures are being performed with increasing frequency using advanced minimally invasive techniques. Although the safety and efficacy of minimally invasive PCF/PCD (MI-PCF/PCD) have been established, reports on long-term outcome and need for secondary surgical intervention at the index or adjacent level are lacking.

PURPOSE

To determine the rates of complications, long-term outcomes, and need for secondary surgical intervention at the index or adjacent level after MI-PCF and microdiscectomy.

STUDY DESIGN

Retrospective analysis of a prospective cohort.

PATIENT SAMPLE

Seventy patients treated with MI-PCF and/or MI-PCD for cervical radiculopathy.

OUTCOME MEASURES

Visual Analog Scale for neck/arm (VASN/A) pain and Neck Disability Index (NDI).

METHODS

Ninety-seven patients underwent MI-PCF with or without MI-PCD between 2002 and 2011. Adequate prospective follow-up was available for 70 patients (95 cervical levels). The primary outcome assessed was need for secondary surgical intervention at the index or adjacent level. The secondary outcomes assessed included complications and improvements in NDI and VASN/A scores. All complications were reviewed. Mixed-model analyses of variance with random subject effects and autoregressive first-order correlation structures were used to test for differences among NDI, VASA, and VASN measurements made over time while accounting for the correlation among repeated observations within a patient. All statistical hypothesis tests were conducted at the 5% level of significance.

RESULTS

Patients were followed for a mean of 32.1 months. Of 70 patients operated, there were 3 (4.3%) complications (1 cerebrospinal fluid leak, 1 postoperative wound hematoma, and 1 radiculitis), none of which required a secondary operative intervention. Five patients required an anterior cervical discectomy and fusion (eight total levels fused) on average 44.4 months after the index surgery. Of those, five (5.3%) were at the index level and three (2.1%) were at adjacent levels. Neck Disability Index scores improved significantly (p<.0001) immediately postoperatively and continued to decrease gradually with time. Visual Analog Scale for neck/arm scores improved significantly (p<.0001) from baseline immediately postoperatively but tended to plateau with time.

CONCLUSIONS

Minimally invasive PCF with or without MI-PCD is an excellent alternative for cervical radiculopathy secondary to foraminal stenosis or a laterally located herniated disc. There is a low rate (1.1% per index level per year) of future index site fusion and a very low rate (0.9% per adjacent level per year) of adjacent-level disease requiring surgery.

Long term effect on adjacent segment motion after posterior cervical foraminotomy

Objective

Posterior cervical foraminotomy (PCF) is a motion-preserving surgical technique. The objective was to determine whether PCF alter cervical motion as a long-term influence.

Methods

Thirty one patients who followed up more than 36 months after PCF for cervical radiculopathy from January 2004 to September 2008 were enrolled in this study. The range of motion (ROM) of whole cervical spine, the operated segment, the cranial and the caudal adjacent segment were obtained. The clinical result and the change of ROMs were compared with those in the patients performed anterior cervical discectomy and fusion (ACDF) during the same period.

Results

In PCF group, the ROM of whole cervical spine had no significant difference in statistically at preoperative and last follow up. The operated segment ROM was significantly decreased from 11.02±5.72 to 8.82±6.65 (p<0.05). The ROM of cranial adjacent segment was slightly increased from 10.42±5.13 to 11.02±5.41 and the ROM of caudal adjacent segment was decreased from 9.44±6.26 to 8.73±5.92, however these data were not meaningful statistically. In ACDF group, the operated ROM was decreased and unlike in PCF group, especially the ROM of caudal adjacent segment was increased from 9.39±4.21 to 11.33±5.07 (p<0.01).

Conclusion

As part of the long-term effects of PCF on cervical motion, the operated segment motions decreased but were preserved after PCF. However, unlikely after ACDF, the ROMs of the adjacent segment did not increase after PCF. PCF, by maintaining the motion of the operated segment, imposes less stress on the adjacent segments. This may be one of its advantages.

Posterior cervical foraminotomy: anatomic study in cadavers

OBJECTIVE: This study was designed to use different segments of the cervical spine in cadavers to determine how much lateral mass should be resected for adequate foraminal decompression. METHODS: Six cadavers were used. The region of the cervical spine from C1 to the C7-T1 transition was dissected and exposed. The lateral mass of each vertebra was measured bilaterally before the foraminotomy in the following segments: C2-C3, C3-C4, C4-C5, C5-C6 and C6-C7. The procedure was performed with a high-speed drill and through surgical microscopy. Three foraminotomies were performed (F1, F2, F3) in each level. Lateral masses were measured after foraminotomy procedures and compared to the initial measurement, creating a percentage of lateral mass needed for decompression.. The value of the entire surface was defined as 100%. RESULTS: There was a statistical difference between the amounts of the resected lateral mass through each foraminotomy (F1, F2, F3) at the same level. However, there was no statistical significant difference among the different levels. The average percentage of resection of the lateral masses in F2 were 27.7% at C2-C3, 24.8% at C3-C4, 24.4% at C4-C5 and 23.8% and 31.2% at C5-C6 and C6-C7, respectively. In F3, the level that needed greater resection of the lateral masses was C6-C7 level, where the average resection ranged between 41.2% and 47.9%. CONCLUSION: In all segments studied, the removal of approximately 24 to 32% of the facet joint allowed adequate exposure of the foraminal segment, with visualization of the dural sac and the exit of the cervical root.

Minimally Invasive versus Open Cervical Foraminotomy: A Systematic Review

Posterior cervical laminoforaminotomy is an effective treatment for cervical radiculopathy due to disc herniations or spondylosis. Over the last decade, minimally invasive (i.e., percutaneous) procedures have become increasingly popular due to a smaller incision size and presumed benefits in postoperative outcomes. We performed a systematic review of the literature and identified studies of open or percutaneous laminoforaminotomy that reported one or more perioperative outcomes. Of 162 publications found by our initial screening, 19 were included in the final analysis. Summative results indicate that patients undergoing percutaneous cervical laminoforaminotomy have lower blood loss by 120.7 mL (open: 173.5 mL, percutaneous: 52.8 mL, n = 670), a shorter surgical time by 50.0 minutes (open: 108.3 minutes, percutaneous: 58.3 minutes, n = 882), less inpatient analgesic use by 25.1 Eq (open: 27.6 Eq, percutaneous: 2.5 Eq, n = 356), and a shorter hospital stay by 2.2 days (open: 3.2 days, percutaneous: 1.0 days, n = 1472), compared with patients undergoing open procedures. However, the heterogeneous nature of published data calls into question the reliability of these summative results. Further structured trials should be conducted to better characterize the risks and benefits of percutaneous laminoforaminotomy.

Cervical radiculopathy: a review

BACKGROUND

Cervical radiculopathy is defined as a syndrome of pain and/or sensorimotor deficits due to compression of a cervical nerve root. Understanding of this disease is vital for rapid diagnosis and treatment of patients with this condition, facilitating their recovery and return to regular activity.

PURPOSE

This review is designed to clarify (1) the pathophysiology that leads to nerve root compression; (2) the diagnosis of the disease guided by history, physical exam, imaging, and electrophysiology; and (3) operative and non-operative options for treatment and how these should be applied.

METHODS

The PubMed database was searched for relevant articles and these articles were reviewed by independent authors. The conclusions are presented in this manuscript.

RESULTS

Facet joint spondylosis and herniation of the intervertebral disc are the most common causes of nerve root compression. The clinical consequence of radiculopathy is arm pain or paresthesias in the dermatomal distribution of the affected nerve and may or may not be associated with neck pain and motor weakness. Patient history and clinical examination are important for diagnosis. Further imaging modalities, such as x-ray, computed tomography, magnetic resonance imaging, and electrophysiologic testing, are of importance. Most patients will significantly improve from non-surgical active and passive therapies. Indicated for surgery are patients with clinically significant motor deficits, debilitating pain that is resistant to conservative modalities and/or time, or instability in the setting of disabling radiculopathy. Surgical treatment options include anterior cervical decompression with fusion and posterior cervical laminoforaminotomy.

CONCLUSION

Understanding the pathophysiology, diagnosis, treatment indications, and treatment techniques is essential for rapid diagnosis and care of patients with cervical radiculopathy.

Posterior cervical inclinatory foraminotomy for spondylotic radiculopathy preliminary

Posterior cervical foraminotomy is an attractive therapeutic option in selected cases of cervical radiculopathy that maintains cervical range of motion and minimize adjacent-segment degeneration. The focus of this procedure is to preserve as much of the facet as possible with decompression. Posterior cervical inclinatory foraminotomy (PCIF) is a new technique developed to offer excellent results by inclinatory decompression with minimal facet resection. The highlight of our PCIF technique is the use of inclinatory drilling out for preserving more of facet joint. The operative indications are radiculopathy from cervical foraminal stenosis (single or multilevel) with persistent or recurrent root symptoms. The PCIFs were performed between April 2007 and December 2009 on 26 male and 8 female patients with a total of 55 spinal levels. Complete and partial improvement in radiculopathic pain were seen in 26 patients (76%), and 8 patients (24%), respectively, with preserving more of facet joint. We believe that PCIF allows for preserving more of the facet joint and capsule when decompressing cervical foraminal stenosis due to spondylosis. We suggest that our PCIF technique can be an effective alternative surgical approach in the management of cervical spondylotic radiculopathy.

Cervical laminoforaminotomy for the treatment of cervical degenerative radiculopathy

OBJECT

The objective of this systematic review was to use evidence-based medicine to examine the efficacy of posterior laminoforaminotomy in the treatment of cervical radiculopathy.

METHODS

The National Library of Medicine and Cochrane Database were queried using MeSH headings and key words relevant to posterior laminoforaminotomy and cervical radiculopathy. Abstracts were reviewed, and studies meeting inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I-III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations which contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons.

RESULTS

Posterior laminoforaminotomy improves clinical outcome in the treatment of cervical radiculopathy resulting from soft lateral cervical disc displacement or cervical spondylosis with resulting narrowing of the lateral recess. All studies were Class III. The most frequent design flaw involved the lack of utilization of validated outcomes measures. In addition, few historical studies included a detailed preoperative analysis of the patients. As such, the vast majority of studies that included both pre- and postoperative assessments with legitimate outcomes measures have been performed since 1990.

CONCLUSIONS

Posterior laminoforaminotomy is an effective treatment for cervical radiculopathy.

Cervical nerve root decompression by lateral approach as salvage operation after failed anterior transdiscal surgery: technical case report

Cervical nerve root compression caused by disco-osteophytic changes is classically operated by anterior transdiscal approach with disc replacement. If compression persists or recurs, reoperation via the same surgical route may be difficult, because of scar tissue and/or implants. An alternative approach may be necessary. We recommend the lateral cervical approach (retrojugular) as salvage operation in such cases. We report a patient with cervical nerve root compression operated by anterior transdiscal approach with plate and bone graft. As some compression persisted clinically and radiologically, the patient was re-operated via a lateral approach. The surgical access was free of scar tissue. The arthrodesis could be left intact and did not prevent effective nerve root decompression. The patient became asymptomatic. The lateral cervical approach (retrojugular) as reported here, is an excellent alternative pathway if reoperation after anterior transdiscal surgery with disc replacement becomes necessary.

Microsurgical cervical nerve root decompression via an anterolateral approach: clinical outcome of patients treated for spondylotic radiculopathy

OBJECTIVE

We previously reported our technique of selective microforaminotomy via an anterolateral approach for the treatment of spondylotic radiculopathy. We now report the clinical long-term results.

METHODS

A retrospective study of 40 patients who consecutively underwent operation via this technique was performed. Patients' demographic, clinical presentation, and radiological and surgical data were recorded by chart review. Long-term clinical outcome was assessed by a questionnaire, office visits, and intensive telephone interviews. The results were compared with the literature.

RESULTS

The study was comprised of 22 women and 18 men with a mean age of 50.6 years (age range, 33.1-75.2 yr). Preoperatively, 98% (n = 39) of the patients presented radicular pain, 88% (n = 35) of the patients presented with neck pain, 75% (n = 30) of the patients presented with a sensory deficit, and 45% (n = 18) of the patients presented with a motor deficit. Patients underwent operation at one level (n = 15), two levels (n = 23), or three levels (n = 2). One patient underwent operation bilaterally in a two-step procedure. In total, 68 cervical nerve roots were completely decompressed by this technique. On the basis of preoperative x-ray criteria of instability, two patients (5%) required graft arthrodesis, which was performed during the same surgery after the nerve root decompression. After a mean follow-up period of 4.3 years (range, 2.7-7.4 yr), 85% of the patients have no residual radicular pain, 94% of the patients have no more neck pain, 90% of the patients recovered from their sensory deficits, and 83% of the patients recovered from their motor deficits. According to Odom's criteria, 95% achieved an excellent or good outcome (Odom Grades I and II). No postoperative instability occurred. The transient and permanent morbidity rates were 7.5% (n = 3) and 2.5% (n = 1), respectively; one patient has permanent Horner's syndrome.

CONCLUSION

The technique of microsurgical cervical nerve root decompression by selective microforaminotomy via an anterolateral approach is safe and efficient for the treatment of spondylotic radiculopathy. The morbidity rate is low. Clinical results are good after a long-term follow-up period. This technique allows the preservation of cervical motion and spinal stability. The results compare favorably to those of the literature.

Same-segment and adjacent-segment disease following posterior cervical foraminotomy

Object

The cervical foraminotomy was pioneered in the 1940s to address radicular symptoms via a posterior approach, but the long-term outcome has not been adequately studied.

Methods

The authors retrospectively analyzed data obtained from 303 patients (188 male and 115 female, mean age 49.2 years) who had consecutively undergone a single-level posterior foraminotomy for cervical radiculopathy between 1972 and 1992. The median follow-up duration was 7.1 years. The major end point studied was the development of symptomatic adjacent- or same-segment disease. Incidence rates per 1000 person-years were calculated, and the natural history of the disease was predicted using Kaplan–Meier survivorship analysis.

In 15 (4.9%) of 303 patients, symptomatic adjacent-segment disease developed, yielding a rate of 6.4/1000 person-years at risk. This included nine (2.9%) of 303 patients requiring reoperation, yielding a rate of 3.8/1000 person-years. Kaplan–Meier survivorship analysis suggested a relatively stable annual 0.7% rate for developing adjacent-segment disease, with a 10-year rate of 6.7%. Ten patients developed same-segment disease, yielding a risk rate of 3.9/1000 person-years.

Kaplan–Meier survivorship analysis demonstrated a 5- and 10-year risk rate of developing same-segment disease of 3.2 and 5.0%, respectively.

Conclusions

Although additional study is needed, analysis of the present data suggests that posterior foraminotomy is associated with a low rate of same- and adjacent-segment disease.

Posterior foraminotomy or anterior discectomy with polymethyl methacrylate interbody stabilization for cervical soft disc disease: results in 292 patients with monoradiculopathy

STUDY DESIGN

Retrospective study of patients who underwent either ventral microdiscectomy and polymethyl methacrylate (PMMA) interbody stabilization or posterior foraminotomy for the treatment of cervical monoradiculopathy caused by soft disc disease.

OBJECTIVES

To evaluate the long-term outcome after 2 different surgical procedures in the treatment of cervical radiculopathy, compare them with each other and with previous data from other surgical techniques, and outline the indications, advantages, and disadvantages of each procedure.

SUMMARY OF BACKGROUND DATA

Cervical disc disease can lead to morphologic different disc lesions, which again may differ in clinical presentation, operative treatment, and outcome. This study provides a clinical long-term follow-up of ventral and dorsal approaches.

METHODS

Follow-up evaluation (mean 72.1 +/- 25.9 months) after surgery of monoradicular symptoms was performed in 292 patients. Patients with hard disc disease, myelopathy, neoplasms, or traumatic or recurrent cervical disc disease were excluded. A total of 124 patients (42.5%) underwent ventral microdiscectomy and PMMA stabilization (group A), and in 168 patients (57.5%), a posterior foraminotomy was performed (group B). The outcome was determined according to Odom criteria based on a questionnaire or a telephone interview and was related to the following variables: morphologic findings, neurologic findings, duration of symptoms, operation technique applied, age, sex, and cervical level involved.

RESULTS

The success rate (Odom I + II) without consideration of morphologic findings was higher after anterior microdiscectomy with PMMA stabilization (93.6%) than after posterior foraminotomy (85.1%) (P < 0.05). The success rate was higher in cases with pure soft discs in both groups (A: 96.6%; B: 85.8%) than in cases with a mixture of soft and hard discs (A: 90.6%; B: 80%), without gaining statistical significance. Complications related to surgery occurred in 6.5% (group A) and 1.8% (group B) of patients (P < 0.05).

CONCLUSION

The findings show that apparently a higher success rate results after anterior microdiscectomy with PMMA interbody stabilization for treatment of degenerative cervical monoradiculopathy than after posterior foraminotomy. Considering the type of morphology of the pathology that causes the radiculopathy, pure soft discs have a better outcome than mixtures of soft and hard discs, independent of the chosen approach. Although statistically significant differences in clinical data were found in both groups, both approaches seem to have equivalent value in individual indications.

Minimally Invasive Lateral Mass Screw Fixation in the Cervical Spine: Initial Clinical Experience with Long-term Follow-up

OBJECTIVE:

Lateral mass screw fixation of the subaxial cervical spine has been a major advancement for spinal surgeons. This technique provides excellent three-dimensional fixation from C3 to C7. However, exposure of the dorsal spinal musculature can produce significant postoperative neck pain. The incorporation of a minimal access approach using tubular dilator retractors can potentially overcome the drawbacks associated with the extensive muscle stripping needed for traditional surgical exposures.

METHODS:

A retrospective analysis was performed on the first 18 patients treated using lateral mass screws placed in a minimally invasive fashion. All patients, except 2 who were lost to follow-up, had a 2-year minimum clinical follow-up. All patients had a computed tomography (CT) scan in the immediate postoperative period to check the positioning of implanted hardware. Operative time, blood loss, and complications were ascertained. Fusion was assessed radiographically with dynamic radiographs and CT scans.

RESULTS:

Sixteen of the 18 patients underwent successful screw placement. Two patients had the minimal access procedure converted to an open surgery because radiographic visualization was not adequate in the lower cervical spine. Six cases involved unilateral instrumentation and 10 had bilateral screws. A total of 39 levels were instrumented. There were no intraoperative complications, and follow-up CT scans demonstrated no bony violations except in cases where bicortical purchase was achieved. All patients achieved bony fusion.

CONCLUSION:

A minimally invasive approach using tubular dilator retractors can be a safe and effective means for placing lateral mass screws in the subaxial cervical spine. Up to two levels can be treated in this manner. This approach preserves the integrity of the muscles and ligaments that maintain the posterior tension band of the cervical spine but requires adequate intraoperative imaging.

Unusual cervical nerve root arrangement exposed during surgery: case report and review of the literature

Anatomical variations of neural structures in the cervical spine are rare and are not necessarily visible on pre-operative imaging. The authors report an unusual arrangement of neural structures identified during cervical foraminotomy. Anatomical variations of the cervical nerve roots are reviewed and their importance in neurosurgical practice is discussed.

Microsurgical Posterior Herniotomy With En Bloc Laminoplasty

OBJECTIVE

At the present time, the anterior cervical discectomy and fusion procedure is widely accepted for treating cervical disc herniation. Recently, however, several authors have reported new disease due to degeneration of an adjacent segment. On the other hand, posterior discectomy, which can preserve mobility at the affected disc level, has been considered risky and technically difficult, especially for central or paracentral disc herniation. We are performing a new surgical technique, microsurgical posterior herniotomy with en bloc laminoplasty, for patients with myelopathy and radiculomyelopathy caused by cervical disc herniation.

METHODS

Here, the surgical outcomes and radiographic changes were retrospectively investigated. Thirty patients (13 patients with myelopathy, 13 patients with radiculomyelopathy, and 4 patients with C5 dissociated motor loss) who underwent this procedure were reviewed. The average age was 50 years (range 31-70 years), and the average follow-up period was 28 months (range 12-76 months). Neurologic improvements were evaluated using the Japanese Orthopaedic Association (JOA) Scoring System as well as radicular pain and deltoid muscle power. Postoperative axial symptoms were scored, and radiographic changes were noted.

RESULTS

The mean JOA score improvement was 74.2% (range 27.3-100%). In all 13 patients, preoperative radicular pain completely resolved after surgery. Deltoid power (in cases of C5 dissociated motor loss) markedly increased postoperatively. Cervical lordosis significantly increased at the time of the last follow-up (P = 0.01). The postoperative axial symptom score significantly correlated with the numbers of opened laminae (P = 0.03).

CONCLUSIONS

This technique was safe and effective. Radiographically, the range of motion in the cervical spine and at the affected disc levels was preserved. In the future, this surgical procedure can become an alternative method for cervical disc herniation treatment.

The effect of posterior cervical distraction on foraminal dimensions utilizing a screw-rod system

STUDY DESIGN

Cadaveric human cervical spine anatomic study using posterior lateral mass screw-rod instrumentation to assess foraminal enlargement via distraction techniques.

OBJECTIVES

To determine the role of posterior cervical distraction on foraminal dimensions and to ascertain the impact of this technique on segmental kyphosis.

SUMMARY OF BACKGROUND DATA

Management of cervical spondylotic radiculopathy includes removal of offending compressive structures and enlarging the neuroforamen via anterior discectomy with interbody fusion or posterior laminoforaminotomy.

METHODS

Six human cervical spines were prepared and posterior exposure performed. Lateral mass screws were inserted from C5 to C7 and a longitudinal rod attached. Distraction was applied between the screw heads at 2 mm intervals and accuracy confirmed with digitized calipers. Pre- and postdistraction computed tomography was performed including axial and reformatted images. Foraminal area, height, and width and sagittal alignment and disc heights were evaluated.

RESULTS

The results suggest that minimal posterior distraction of 4 to 6 mm at C5-C6 and C6-C7 may enlarge the neuroforamen by 10 to 18 mm. Foraminal height and width increased minimally from baseline to maximum distraction; however, these measurements did not reach statistical significance at either level. A decrease of segmental lordosis at C5-C6 was noted from baseline to 8 mm of distraction. Statistically significant kyphosis from baseline was present at 6 mm of distraction leading to overall 5.2 +/- 1.4degrees change in alignment. At C6-C7, statistically significant kyphosis was not present until 8 mm of distraction (4.62 +/- 2.23degrees).

CONCLUSIONS

This study suggests that posterior cervical instrumented distraction in the setting of foraminal stenosis is a reasonable supplement to direct laminoforaminotomy and nerve root decompression. Distraction leads to minimal segmental kyphosis, allowing this technique to serve as an adjunct for additional foraminal enlargement.