Elsevier

World Neurosurgery

Volume 140, August 2020, Pages e273-e282
World Neurosurgery

Original Article
Safe Route for Cervical Approach: Partial Pediculotomy, Partial Vertebrotomy Approach for Posterior Endoscopic Cervical Foraminotomy and Discectomy

https://doi.org/10.1016/j.wneu.2020.05.033Get rights and content

Introduction

Cervical radiculopathy is a common cervical spine condition. There is a paucity of literature discussing the effect of partial pediculotomy and partial vertebrotomy for posterior endoscopic cervical foraminotomy (PPPV PECF) on cervical radiculopathy. We investigated the radiologic and clinical outcomes of this approach.

Methods

This was a retrospective evaluation of 30 cases with cervical radiculopathy who underwent PPPV PECF. Preoperative, postoperative roentgenogram for evaluation of stability, computed tomography (CT) evaluation of foraminal dimensions, and area in sagittal view was performed. Three-dimensional reconstruction area of decompression evaluation was performed. Clinical outcomes of the visual analog scale, Oswestry Disability Index, and Macnab score were evaluated.

Results

There was no complication and recurrence in our PPPV PECF cohort during the study period. At preoperative, 1 week postoperative, and 3 months postoperative and final follow-up, the mean visual analog scale score had significant improvement, with scores of 7.6, 3.0, 2.1, and 1.7, respectively, P < 0.05, and also the mean Oswestry Disability Index, with scores of 73.9, 28.1, 23.3, and 21.5 respectively, P < 0.05. Macnab criteria showed all patients scoring good and excellent. Radiologic results showed PPPV PECF had a significant increase in decompression in the foramen area in all CT-measured parameters, as compared with the mean preoperative values; 1) sagittal area increased 60.1 ± 23.1 mm2, 2) CT craniocaudal length increased 4.0 ± 1.54 mm, 3) CT ventrodorsal length increased 4.0 ± 1.97 mm, and 4) 3-dimensional CT scan reconstruction decompression area increased 996 ± 266 mm2, P < 0.05.

Conclusions

PPPV PECF is a safe route of decompression of cervical spine with good clinical and radiologic outcome.

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.

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    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.

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