Original ArticleSafe Route for Cervical Approach: Partial Pediculotomy, Partial Vertebrotomy Approach for Posterior Endoscopic Cervical Foraminotomy and Discectomy
Introduction
Cervical radiculopathy is a common cervical spine condition leading to significant disability from nerve root dysfunction.1 Conservative therapy is recommended for at least 6 weeks in the treatment of cervical radiculopathy without myelopathy.1,2 Time to recovery ranges from 2 weeks to 3 years in 83% of the patients.3 However, a good proportion of patients remain symptomatic, despite being compliant with conservative treatment management.3 Anterior cervical discectomy and fusion and cervical artificial disc replacement have been popular as the gold standard treatment.4 Morbidity attributed to anterior cervical surgery ranges from 13.2% to 19.3%, with pseudoarthrosis and adjacent-segment disease being the most common postoperative complications.5 Posterior cervical foraminotomy has gained popularity as an alternative to anterior cervical discectomy and fusion, sparing patients from problems associated with fusion and surgical instrumentations with equally good clinical results with the added advantage of motion preservation.6, 7, 8 Cervical endoscopic decompression is becoming popular as a soft tissue–conserving minimally invasive technique in performing cervical foraminal decompression and discectomy for prolapsed intervertebral disc and foraminal stenosis.9, 10, 11
One concern about endoscopic cervical foraminotomy and discectomy is the neurologic complications associated with spinal cord and exiting nerve root retraction, leading to significant residual radicular pain and, on rare occasions, paralysis. Incomplete decompression, in contrast, is a leading cause of residual radicular pain, but it needs to be weighed against overly aggressive resection of facet leading to local failure of facet joint.12 Safety of approach to the cervical intervertebral disc is of paramount importance. The authors hypothesize that drilling the medial third of pedicle and corpus ventral to the spinal cord and exiting nerve root by 3–5 mm creates space for efficient discectomy, uncus decompression, and yet is able to preserve the stability of the spinal segment. By creating a space ventral to neural elements, it helps in preventing complications of neural retraction by the endoscopic working channel. We performed the partial pediculotomy, partial vertebrotomy approach for posterior cervical foraminotomy and discectomy (PPPV PECF) to test our hypothesis.
Section snippets
Patient Demographics
This retrospective comparison study was reviewed by the institutional review board of Nanoori Hospital, Seoul, Republic of Korea. Informed consent was obtained from all patients who participated in study.
From January 2017 to December 2019, we included 36 levels of cervical intervertebral discs in 30 patients who underwent PPPV PECF at our institute. Their clinical presentations were intractable cervical radiculopathy not relieved with conservative treatment for more than 6 weeks, motor and/or
Baseline Demographics
From January 2017 to December 2019, 36 levels of PPPV PECF surgery were performed in 30 patients, of whom 24 patients had single-level surgery and 6 patients had 2-level surgery. The follow-up period of PPPV PECF had a mean and SD of 13.7 ± 6.4 months. The mean age of patients was 50.7 ± 12.3 years, respectively. Of the 60 patients treated with radiculopathy, overall, the most common level of cervical radiculopathy was C5–C6 at 43.4%, with 36.2% having C6–C7 radiculopathy. In 36 levels of the
Discussion
Conventional posterior cervical foraminotomy is a motion-preserving procedure with the aim of removing prolapsed soft intervertebral disc and decompressing foraminal stenosis causing cervical radiculopathy. It is indicated in cervical disc herniation and neuroforaminal pathology with radicular symptoms when two-thirds of the soft disc is lateral to the thecal sac of cervical spinal cord and osseous and bony compression is not involving the median and paramedian region. It is contraindicated in
Conclusions
The uniportal full endoscopic PPPV approach for posterior endoscopic cervical foraminotomy and discectomy improved radiologic and clinical outcomes, providing a safe, alternative technique in posterior cervical decompression with low rate of complications.
CRediT authorship contribution statement
Hyeun Sung Kim: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing - original draft, Writing - review & editing. Pang Hung Wu: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing - original draft, Writing - review &
Acknowledgments
We would like to acknowledge scientific team members Ms. Jae Eun Park and Mr. Kyeong Rae Kim for providing assistance in acquiring full text articles and managing digital works.
References (25)
- et al.
The course and prognostic factors of symptomatic cervical disc herniation with radiculopathy: a systematic review of the literature
Spine J
(2014) - et al.
Clinical observation of posterior percutaneous full-endoscopic cervical foraminotomy as a treatment for osseous foraminal stenosis
World Neurosurg
(2017) - et al.
Risk factors for outcome and complications of dorsal foraminotomy in cervical disc herniation
Surg Neurol
(2003) - et al.
Cervical radiculopathy: epidemiology, etiology, diagnosis, and treatment
J Spinal Disord Tech
(2015) - et al.
Cervical radiculopathy
Curr Rev Musculoskelet Med
(2016) - et al.
Cervical arthroplasty: the beginning, the middle, the end?
Br J Neurosurg
(2012) A review of complication rates for anterior cervical diskectomy and fusion (ACDF)
Surg Neurol Int
(2019)- et al.
Anterior cervical discectomy and fusion versus posterior cervical foraminotomy in the treatment of brachialgia: the Leeds spinal unit experience (2008–2013)
Acta Neurochir (Wien)
(2015) - et al.
Clinical and radiological results of posterior cervical foraminotomy at two or three levels: a 3-year follow-up
Acta Neurochir (Wien)
(2017) - et al.
Minimally invasive posterior cervical foraminotomy for treatment of radiculopathy: an effective, time-tested, and cost-efficient motion-preservation technique
Oper Orthop Traumatol
(2018)
Full-endoscopic posterior foraminotomy surgery for cervical disc herniations
Oper Orthop Traumatol
Evolution of Spinal Endoscopic Surgery
Neurospine
Cited by (22)
Endoscopic posterior cervical foraminotomy techniques and outcomes
2024, Seminars in Spine SurgeryNarrative Review of Uniportal Posterior Endoscopic Cervical Foraminotomy
2024, World NeurosurgerySurgical Removal of Cervical Extradural Cysts Using the Biportal Endoscopic Approach
2022, World NeurosurgeryCitation Excerpt :Therefore, cyst resection while sparing normal structures, as much as possible, appears to be essential for minimizing surgery-induced trauma using minimally invasive procedures, including tubular retractors and endoscopic systems. The advantages of endoscopic posterior cervical decompression over conventional open surgery include preservation of normal structures, reduced intraoperative bleeding, fast postoperative recovery, and preservation of motion segments.9-11 The full endoscopic posterior cervical approach has been attempted based on the need for minimal invasiveness, and favorable outcomes have been reported after removing intraspinal extradural cysts while minimizing trauma and destabilization.6,12
Cervical foraminotomy by full-endoscopic posterior cervical approach: A randomized study
2021, Interdisciplinary Neurosurgery: Advanced Techniques and Case ManagementCitation Excerpt :In 2016, Oertel and coworkers [5] first reported treating bony (osseous) foraminal stenosis using endoscopic posterior cervical foraminotomy [19]. FEPCF proved to be less demanding concerning blood loss, inpatient postoperative analgesic use, surgical time, and hospital stay [6,10]. In this study, we randomized a sample of patients with radiculopathy due to foraminal stenosis secondary to disc bulging or osteophytes to either FEPCF or open posterior cervical foraminotomy (OPCF) analyzed the postoperative outcomes.
Fully endoscopic cervical spine surgery: What does the future hold?
2021, Journal of Clinical Orthopaedics and TraumaCitation Excerpt :They found an increase in area of decompression by 996 ± 266 mm2 (p < 0.05) on postoperative 3D CT scan reconstruction. ODI, VAS and McNab scores showed excellent improvements.24 The highest level of evidence that could be gathered from the available literature comprises the 3 RCTs25–27 and 2 meta-analyses.28,29
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Dr. Hyeun Sung Kim and Dr. Pang Hung Wu contributed equally and should be considered as first co–authors of this article.