Application of Triggered EMG in the Intraoperative Neurophysiological Monitoring of Posterior Percutaneous Endoscopic Cervical Discectomy

Complications of Cervical Endoscopic Spinal Surgery: A Systematic Review and Narrative Analysis

BACKGROUND

There are no systematic evidence-based medical data on the complications of endoscopic cervical spinal surgery. This narrative analysis compiled data from various studies that examined endoscopic complications, such as cervical disc herniation and foraminal stenosis. This study aimed to investigate the efficacy and safety of endoscopic surgery in cervical radiculopathy.

METHODS

We searched the PubMed/MEDLINE databases to identify articles on endoscopic spinal surgery, and keywords were set as "endoscopic cervical spinal surgery", "endoscopic cervical discectomy", "endoscopic cervical foraminotomy", and "percutaneous endoscopic cervical discectomy". We analyzed the evidence level and classified the prescribed complications according to the literature. Endoscopic cervical surgery was divided into three categories: full endoscopic anterior, endoscopic posterior, and unilateral biportal approaches. We excluded duplicate publications, studies without full text, studies without complications or incomplete information, and studies that did not provide the necessary data for extraction, animal experiments, or reviews.

RESULTS

Difficulties in swallowing, hematoma, and hoarseness are common complications associated with the anterior cervical approach. In contrast, complications of the posterior approach include nerve root injury, hematoma, and dysesthesia. However, endoscopic cervical spinal surgery, including the full endoscopic anterior, posterior, and unilateral biportal approaches, is a safe and effective treatment for cervical radiculopathy.

CONCLUSIONS

Complications of full endoscopic cervical spinal surgery differ significantly depending on the anterior and posterior approaches. In the anterior approach, swallowing difficulty, recurrent disc, hematoma, and dysphonia are the common complications. In contrast, transient dysesthesia, dural tears, upper limb motor deficits, and persistent arm pain are commonly reported with the posterior approach.

Complications and Management of Endoscopic Spinal Surgery

In the past, the use of endoscopic spine surgery was limited to intervertebral discectomy; however, it has recently become possible to treat various spinal degenerative diseases, such as spinal stenosis and foraminal stenosis, and the treatment range has also expanded from the lumbar spine to the cervical and thoracic regions. However, as endoscopic spine surgery develops and its indications widen, more diverse and advanced surgical techniques are being introduced, and the complications of endoscopic spine surgery are also increasing accordingly. We searched the PubMed/MEDLINE databases to identify articles on endoscopic spinal surgery, and key words were set as “endoscopic spinal surgery,” “endoscopic cervical foramoinotomy,” “PECD,” “percutaneous transforaminal discectomy,” “percutaneous endoscopic interlaminar discectomy,” “PELD,” “PETD,” “PEID,” “YESS” and “TESSYS.” We analyzed the evidence level and classified the prescribed complications according to the literature. Endoscopic lumbar surgery was divided into full endoscopic interlaminar and transforaminal approaches and a unilateral biportal approach. We performed a comprehensive review of available literature on complications of endoscopic spinal surgery. This study particularly focused on the prevention of complications. Regardless of the surgical methods, the most common complications related to endoscopic spinal surgery include dural tears and perioperative hematoma. transient dysesthesia, nerve root injury and recurrence. However, Endoscopic spinal surgery, including full endoscopic transforaminal and interlaminar and unilateral biportal approaches, is a safe and effective a treatment for lumbar as well as cervical and thoracic spinal diseases such as disc herniation, lumbar spinal stenosis, foraminal stenosis and recurrent disc herniation.

Cervical Transdural Discectomy with Laminoplasty for the Treatment of Multi-segment Cervical Spinal Stenosis Accompanied with Cervical Disc Herniation: Technical Note and Clinical Outcome

Objective

To describe the surgical technique of cervical transdural discectomy with laminoplasty (CTDL) for the treatment of multi‐segment cervical spinal stenosis (CSS) accompanied with cervical disc herniation (CDH) and investigate its surgical outcomes and complications.

Methods

This was a clinical study. Between 2012 and 2018, 31 patients (13 males and 18 females) with multi‐segment CSS (over two cervical segments) accompanied with huge CDH and underwent CTDL were enrolled in this study. The details of CTDL technique with general anesthesia was described by the authors. The average follow‐up period of patients was 65.03 months (range from 24 to 126 months). Perioperative parameters such as age, sex, operative level, operative time, estimated blood loss, ambulation time, and operative complications were recorded. The results of clinical metrics such as the visual analog scale (VAS) and Japanese Orthopaedic Association (JOA) scores in the preoperative and during the follow‐up period were obtained and used to evaluate clinical outcomes. Radiographic improvement was evaluated by the compression ratio, sagittal maximum spinal cord compression (SMSCC), and cervical range of motion (ROM). The preoperative and postoperative follow‐up parameters (VAS, JOA, Compression ratio, SMSCC, and ROM) were assessed with paired t test. A P‐value <0.05 was considered statistically significant.

Results

In the study, the mean age of the 31 patients was 55.23 ± 10.97 years. The mean operative time was 192.45 ± 24.17 min (ranging from 150 to 245 min), and intraoperative blood loss was 322.58 ± 129.00 mL (ranging from 150 to 600 mL). The VAS neck pain was improved significantly over the follow‐up period (P < 0.05, respectively). The VAS arm pain improved significantly from 6.26 ± 0.93 preoperatively to 1.74 ± 0.63 at 24 months postoperatively (P < 0.001). There was no significant difference in improvement of VAS arm pain between 24 months postoperatively and final follow‐up (P = 0.180). Compared with preoperative JOA score, JOA score was significantly improved at 24 months postoperatively (14.79 ± 1.84 vs 9.66 ± 2.81, P < 0.001). Meanwhile, there were no statistically significant differences between the final follow‐up and the postoperative JOA scores (15.08 ± 1.71 vs 14.79 ± 1.84, P = 0.051). Postoperative patients showed significantly higher index of compression ratio (58.30 ± 8.51 vs 27.17 ± 3.89, P < 0.001) and lower SMSCC (25.12 ± 5.67 vs 33.66 ± 5.38, P < 0.001). In addition, there was no significant difference between preoperative and postoperative cervical ROM (P = 0.740). One patient observed postoperative symptom of C₆ nerve root injury, which was resolved within 24 months after the surgery; meanwhile, the neurological monitoring also reflected the intraoperative stretching of the C₆ nerve root. Two cases involved postoperative cerebrospinal fluid (CSF) leakage which may have been related to laceration of dura mater.

Conclusions

This study suggested that CTDL technique could acquire satisfactory surgical outcomes for patients with multi‐segment CSS accompanied with CDH, but the surgical indications of the patients need to be selected strictly.