Anterior or posterior approach of full-endoscopic cervical discectomy for cervical intervertebral disc herniation? A comparative cohort study

Usage of Bone Wax to Facilitate Percutaneous Endoscopic Cervical Discectomy Via Anterior Transcorporeal Approach for Cervical Intervertebral Disc Herniation

BACKGROUND

Currently, anterior transdiscal access and posterior interlaminar approach are the main approaches for percutaneous endoscopic cervical discectomy (PECD). To overcome access shortcomings, we previously described a novel anterior endoscopic transcorporeal approach on a migrated cervical disc. We innovatively introduced bone wax into endoscopic surgery to aid hemostasis and facilitate the process of drilling an intracorporeal tunnel.

METHODS

Five patients with cervical intervertebral disc herniation (CIDH) were treated by PECD via the anterior transcorporeal approach. During the operation, we marked the punctured tunnel with bone wax containing indigo carmine as a guide and smeared bone wax on the endoscopic burr to aid hemostasis.

RESULTS

A satisfactory clinical outcome was observed in all 5 patients postoperatively; pain and neurologic condition were dramatically improved. Surgery-related complications, such as esophageal injury, vascular rupture, hematoma, intervertebral disc infection, or postoperative headache, were not encountered. A computed tomography scan was used to observe the process of bone healing. At 3-month postoperative follow-up, the bone defect within the drilling tunnel had partially shrank and was completely healed at 6 months postoperatively.

CONCLUSIONS

The anterior endoscopic transcorporeal approach for PECD is a novel, valuable alternative for the treatment of CIDH. Bone wax could indeed facilitate the operation by guiding the drilling process and instantly controlling the bleeding without obvious interference with bone healing. Long-term follow-up is warranted in further clinical studies.

Percutaneous Endoscopic Retrieval of Intraspinal Cement Leakage: Technical Note

OBJECTIVE

We sought to preliminarily explore the efficacy and safety of percutaneous endoscopic spinal surgery for epidural cement leakage. We report a case series of patients who underwent percutaneous retrieval of leaked epidural cement and achieved spinal decompression under endoscopy.

METHODS

Five patients with neurologic impairment due to epidural cement leakage after percutaneous vertebroplasty were treated with percutaneous endoscopic spinal decompression. Computed tomography reconstruction and 3-dimensional imaging were used to evaluate the extruded material. During follow-up at 3, 6, and 12 months postoperatively, all patients were advised to undergo plain radiograph and computed tomography examinations.

RESULTS

The leaked epidural cement was successfully removed in all patients under percutaneous endoscopy through a unilateral or bilateral approach. At the 12-month follow-up, the visual analog scale score of all patients improved. In addition, the neurologic function of each patient improved to at least 1 grade level, as evaluated using the American Spinal Injury Association. According to the modified MacNab criteria, 2 patients had excellent recovery, whereas the other 3 patients had good recovery.

CONCLUSIONS

We described a novel and minimally invasive procedure to ameliorate intractable epidural cement extrusion. As an alternative to conventional laminectomy, percutaneous endoscopic retrieval achieved the targeted decompression without damaging the posterior lamina. Moreover, the whole operation was performed under regional anesthesia accompanied with dexmedetomidine sedation, allowed real-time neural function evaluation, and had lower risks of anesthesia-related complications, compared with general anesthesia.

CERVICAL ENDOSCOPIC DISC SURGERY: PRECISE APPROACH FOR MINIMALLY INVASIVE DECOMPRESSION

ABSTRACT Objective: Technological advances in recent decades have led to a complexity of choice of the most effective method for treating cervical disc herniations. The idea of removing disc herniations using endoscope techniques is not new, and is successfully used in the treatment of lumbar disc herniations. But in the case of the cervical spine, full endoscopic procedures only started to be performed at the beginning of 2014, by Yang JS and coauthors, and their effectiveness was and still is a matter of controversy. The proposed method of endoscopic portal disc herniation removal was used for the past two years, and its results were compared with the anterior microsurgical approach using a single-level cage implantation. Methods: Twenty-five patients were included in this study, with a comparator group of 25 patients operated by ordinary anterior cervical discectomy with a single-disc fusion. All patients were operated on by the same group of surgeons. Results: During the analysis of VAS data, it was confirmed that the degree of local and radicular pain in the two groups was not significantly different (p > 0.05). According to the Neck Disability Index (NDI) there was a significant difference between the two groups in relation to the endoscopic patient group. Data using the Odom criteria showed significantly better results for the endoscopic group. During the research it was observed that the patients in the endoscopically operated group were discharged from hospital more quickly, after 3 [2; 5] days compared to 5 [4; 6] days in the microsurgery group. Conclusion: The method performed is a safe and reliable alternative to convenient surgical techniques. Level of Evidenced II; Therapeutic study, investigating the results of treatment.

Endoscopic Anterior Approach for Cervical Disc Disease (Disc Preserving Surgery)

OBJECTIVE

To report our experience of endoscopic disc removal by anterior approach for management of cervical myelopathy in 210 patients.

METHODS

A retrospective study of 187 cases of single- and 23 cases of double-level disc disease was performed. Cases of myelopathy with or without unilateral or bilateral radiculopathy and unilateral radiculopathy with either soft or hard disc prolapse were included. Patients with ≥3 disc levels, unstable spine, infections, trauma, significant posterior compression, congenital canal stenosis, disc extending more than half the vertebral body height, and prior surgery at the same level were excluded.

RESULTS

C5-6 (n = 119 patients), C6-7 (n = 58 patients), C4-5 (n = 49 patients), C3-4 (n = 6 patients), and C2-3 (n = 1 patient) levels were represented. Visual analog scale and Nurick grading system were used to assess severity of neck and arm pain and functional outcomes, respectively. Preoperative mean visual analog scale scores for arm and neck pain were 6.7 and 3.2, respectively, which improved to 1.7 and 1.1 at 3 months after surgery. The average preoperative Nurick grade improved from 2.64 to 0.81 at 6 months postoperatively. Follow-up was 6-54 months.

CONCLUSIONS

Endoscopic anterior discectomy (disc preserving surgery) is an effective and safe alternative in cervical disc disease. Although there was reduction in disc height, clinical outcome was good at an average 29 months of follow-up. Long-term follow-up is required to assess any progressive disc degeneration and clinical results.

The Recovery of Motor Strength after Posterior Percutaneous Endoscopic Cervical Foraminotomy and Discectomy

OBJECTIVE

Cervical radiculopathy infrequently presents with motor weakness. Motor weakness was improved in >90% of patients after anterior cervical discectomy and fusion or posterior cervical foraminotomy. Posterior percutaneous endoscopic cervical foraminotomy and discectomy (PECF) is an alternative surgical technique, but the outcome of motor weakness has not been reported. Our objective was to demonstrate the longitudinal outcomes of motor weakness after PECF.

METHODS

A retrospective review of 106 consecutive patients was performed. Preoperative motor weakness was graded as mild (IV/V strength) or severe (less than III/V strength). The patients visited the outpatient clinic at 1, 3, 6, and 12 months after surgery and yearly thereafter. Improvement was defined as an improved weakness of more than 1 grade, and normalization was defined as the recovery of complete motor strength.

RESULTS

Motor weakness preoperatively presented in 76 of 106 (72%) patients (49%, mild weakness; 23%, severe weakness). After PECF, the weakness improved in 72 of 76 (95%) patients and normalized in 65 of 76 (86%) patients. In the patients with mild weakness, the normalization rates were 48%, 81%, 90%, and 96% at postoperative months 1, 3, 6, and 12, respectively. In the patients with severe weakness, the improvement rates were 50%, 71%, 83%, 88%, and 92%, and the normalization rates were 8%, 38%, 58%, 58%, and 63% at postoperative months 1, 3, 6, 12, and 24, respectively.

CONCLUSIONS

Preoperative motor weakness was improved in 95% of the patients after PECF, but motor weakness was not normalized in 37% of the patients with severe weakness.

Percutaneous endoscopic cervical discectomy: a technical review

The treatment of cervical disc herniations has evolved in the last 2 decades. While the anterior cervical discectomy and fusion continues being the gold standard for the treatment of radicular pain triggered by cervical disc herniation, other surgical approaches have been developed. Percutaneous endoscopic cervical discectomy has demonstrated the ability to decompress the exiting nerve root and dural sac correctly and encouraging clinical outcomes has been reported in the literature. One of the most important advantages offered by the endoscopic technique is the capability to resolve the patient's symptoms without the need for interbody fusion. Also, a specific and selective decompression under continuous visualization with minimal surgery-related trauma can be achieved. There are two percutaneous endoscopic cervical discectomy approaches: anterior and posterior. The decision to perform each other depends on pathology site. However, the endoscopic technique requires previous surgical training, a steep learning curve, and proper patient selection. The development of new hardware such as endoscopes with better optics, lighting systems, and endoscopic surgical tools have allowed using endoscopic techniques in more complex cases. The objective of this review is the technical description of the anterior and posterior percutaneous endoscopic cervical discectomy.

Modified posterior percutaneous endoscopic cervical discectomy for lateral cervical disc herniation: the vertical anchoring technique

PURPOSE

During the long-term practice of percutaneous endoscopic cervical discectomy (PECD) at our institution, we have modified the protocol to include the vertical anchoring technique (VAT), which we will describe in detail in this article. The objective of this study was to compare the clinical outcomes associated with the conventional posterior PECD technique with that associated with the modified technique to determine the safety and efficacy of the latter technique.

METHODS

From December 2014 to January 2016, a total of 44 patients with single cervical disc herniation were randomly divided into two groups. One group underwent conventional posterior PECD, and the other group underwent posterior PECD combined with VAT. The operative time, fluoroscopy times and perioperative complications were recorded. The visual analog scale (VAS) for neck and arm pain and the modified MacNab criteria at 1 day, 3, 6, and 12 months after surgery were used to evaluate the postoperative outcomes.

RESULTS

All patients underwent surgery successfully without severe complications. The operative time and intraoperative fluoroscopy times were significantly less in patients treated with VAT than in those who underwent conventional posterior PECD (P < 0.05). Both types of surgery significantly improved the symptoms of patients. According to the results of the follow-up period, there were no significant differences in VAS scores for neck and arm pain or the modified MacNab criteria between the two groups (P > 0.05). There was no recurrence in either group during the follow-up period.

CONCLUSIONS

Although the clinical outcomes of the two surgical techniques were similar, the VAT decreased the operative time and intraoperative fluoroscopy times in posterior PECD surgery. The learning curve for posterior PECD could be shortened by using the VAT. These slides can be retrieved under Electronic Supplementary Material.

Local Spinal Cord Decompression Through a Full Endoscopic Percutaneous Transcorporeal Approach for Cervicothoracic Ossification of the Posterior Longitudinal Ligament at the T1-T2 Level

OBJECTIVE

To describe a percutaneous full endoscopic transcorporeal procedure to excise local ossification of the posterior longitudinal ligament (OPLL) lesions and decompress the spinal cord at the cervicothoracic transitional segment is safe and effective with respect to surgical complications.

METHODS

A 67-year-old woman presented with nuchal pain and numbness below the T2 dermatome for 3 months and a 2-week history of paraplegia. T1-T2 myelopathy and paraplegia caused by OPLL was diagnosed based on clinical presentation, computed tomography, and magnetic resonance imaging. An anterior percutaneous full endoscopic transcorporeal procedure addressed local OPLL and achieved local spinal cord decompression at T1-T2. After surgery, magnetic resonance imaging was repeated to evaluate degree of spinal cord decompression. Visual analog scale, Neck Disability Index, and Japanese Orthopaedic Association scores were evaluated at each follow-up.

RESULTS

The patient tolerated the full endoscopic operation successfully. Operative time was 225 minutes. On postoperative day 6, muscle strength of the bilateral lower extremities had progressed from grade 0/5 preoperatively to grade 2-/5 on the right and grade 2+/5 on the left. No surgery-related complications were discovered.

CONCLUSIONS

The percutaneous full endoscopic transcorporeal procedure is an alternative to previously described surgical methods of local spinal cord decompression for T1-T2 OPLL with fewer complications, effective spinal cord decompression, and a satisfactory cosmetic result. Successful cases confirm that treatment of spinal cord-limited compression by endoscopic technology is feasible.

Effective Range of Percutaneous Posterior Full-Endoscopic Paramedian Cervical Disc Herniation Discectomy and Indications for Patient Selection

The objective was to investigate the effective and safe range of paramedian CDH by percutaneous posterior full-endoscopy cervical intervertebral disc nucleus pulposus resection (PPFECD) to provide a reference for indications and patient selection. Sixteen patients with CDH satisfied the inclusion criteria. Before surgery the patients underwent cervical spine MRI, and the distance between the dural sac and herniated disc was measured. An assessment was performed by MRI immediately after surgery, measuring the distance between dural sac and medial border of discectomy (DSMD). The preoperative average distance between the dural sac and peak of the herniated disc (DSPHD) was 3.87 ± 1.32 mm; preoperative average distance between dural sac and medial border of herniated disc (DSMHD) was 6.91 ± 1.21 mm and an average distance of postoperative DSMD was 5.41 ± 1.40 mm. Postoperative VAS of neck and shoulder pain was significantly decreased but JOA was significantly increased in each time point compared with preoperative ones. In summary, the effective range of PPFECD to treat paramedian CDH was 5.41 ± 1.40 mm, indicating that DSMHD and DSPHD were within 6.91 ± 1.21 mm and 3.87 ± 1.32 mm, respectively. PPFECD surgery is, therefore, a safe and effective treatment option for patients with partial paramedian cervical disc herniation.

[The first experience with a new technique of portal endoscopic discectomy for herniated cervical discs]

Choosing the most appropriate tactics for surgical treatment of herniated cervical discs is a topical issue to be discussed. The idea of herniated disc removal using an endoscopic technique is not new. This is routine surgery for the lumbar spine. However, application of endoscopic techniques in surgery on the cervical spine was first reported only in 2014 (J. Yang, et al.).

OBJECTIVE

To master the methodology of a new technique, portal endoscopic discectomy, and define the indications for this surgery on herniated cervical discs; to compare outcomes of this surgery with outcomes of anterior microsurgical discectomy.

MATERIAL AND METHODS

The study included 25 patients who underwent portal endoscopic cervical discectomy. A comparison group consisted of 25 patients who underwent anterior microsurgical discectomy and placement of an interbody cage.

RESULTS

A comparison of the results of surgeries revealed no significant difference (p>0.05) in the degree of postoperative local and radicular pain syndrome. According to the Neck Disability Index (NDI), a significant improvement occurred in patients with endoscopic surgery. According to the Odom criterion, a significant advantage in the number of excellent and good outcomes occurred in patients of the study group. There were significant differences between groups in the duration of postoperative hospital stay. The duration was 3 days in the study group and 5 days in the control group, on average.

CONCLUSION

Portal endoscopic discectomy is highly efficient in treatment of herniated cervical discs and enables achieving clinical outcomes associated with much less surgical trauma. The study demonstrates not only the efficacy of the suggested technique but also its safety compared to that of traditional anterior microsurgical techniques that usually involve interbody fusion. This surgery surpasses other interventions in the rate of rehabilitation and social adaptation of patients as well as reduces postoperative hospital stay.

Clinical and radiological outcomes of two-level endoscopic posterior cervical foraminotomy

PURPOSE

The efficacy and safety of endoscopic posterior cervical foraminotomy (EPCF) have been demonstrated for single-level cervical radiculopathy, but no report in the medical literature has described the clinical results of two-level EPCF. The aim of this study was to assess the clinical and radiological outcomes of two-level EPCF performed in patients with cervical radiculopathy.

METHODS

Twenty-two consecutive patients (9 females and 13 males) that underwent two-level EPCF with cervical radiculopathy from January 2012 to January 2014 were included in this study. Clinical outcomes were assessed before surgery and at 1, 3, 6, 12, and 24 months postoperatively using visual analogue scale for neck and arm, neck pain and disability scale (NPDS), and neck disability index (NDI) scores. Radiological outcomes were assessed by measuring segmental lordosis (SL), C2-7 lordosis, and disc height index (DHI) before surgery and at 12 and 24 months postoperatively.

RESULTS

Mean VAS, NPDS, and NDI scores were significant improved at 1 month postoperatively versus preoperative values and these improvements were maintained at 2 years after surgery. SL and C2-7 lordosis were significantly increased after surgery, and no instability in dynamic view was observed during the 2-year follow-up period. Percentage DHIs of operated discs were also maintained without significant change at 2 years after surgery. One patient suffered from transient motor palsy due to root retraction.

CONCLUSIONS

Two-level EPCF can be safely preformed and should be considered an alternative to two-level anterior cervical discectomy and fusion or open posterior cervical foraminotomy in selected patients.

A brief history of endoscopic spine surgery

Few neurosurgeons practicing today have had training in the field of endoscopic spine surgery during residency or fellowship. Nevertheless, over the past 40 years individual spine surgeons from around the world have worked to create a subfield of minimally invasive spine surgery that takes the point of visualization away from the surgeon's eye or the lens of a microscope and puts it directly at the point of spine pathology. What follows is an attempt to describe the story of how endoscopic spine surgery developed and to credit some of those who have been the biggest contributors to its development.

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.

Anterior transcorporeal approach of percutaneous endoscopic cervical discectomy for disc herniation at the C4-C5 levels: a technical note

BACKGROUND CONTEXT

With the continuous development of the spinal endoscopic technique in recent years, percutaneous endoscopic cervical discectomy (PECD) has emerged, which bridges the gap between conservative therapy and traditional surgery and has been mainly divided into the anterior transdiscal approach and the posterior interlaminar access. Because of the relatively greater violation to the anterior nucleus pulposus, there is a higher potential of postoperative intervertebral space decrease in the anterior transdiscal approach than in the posterior interlaminar access. In addition, when the herniated lesion is migrated upward or downward behind the vertebral body, both approaches, and even anterior cervical discectomy and fusion, are impractical, and corpectomy is commonly considered as the only efficacious treatment. Anterior transcorporeal approach under endoscopy could enable an individual and adjustable trajectory within the vertebral body under different conditions of disc herniation preserving the motion of adjacent segment, especially in a migrated or sequestered lesion.

PURPOSE

This report aimed to first describe a novel anterior transcorporeal approach under endoscopy in which we addressed a migrated disc herniation at the C4-C5 levels.

STUDY DESIGN

A technical report was carried out.

PATIENT SAMPLE

A 37-year-old woman presented with posterior neck pain and weakness of extremities for 9 months. On neurologic examination, tingling sensation and numbness were not obvious. However, the power of extremities was dramatically decreased at a level of 3. Hoffmann sign was positive in the bilateral hand. Magnetic resonance imaging (MRI) showed a huge herniation of the C4-C5 disc compressing the median area of the spinal cord. Besides the C4-C5 disc herniation, preoperative computer tomography (CT) also detected that the herniated disc had partial calcification. A novel anterior transcorporeal approach of PECD, through the vertebral body of C5, was performed to address a migrated disc herniation at the C4-C5 levels.

OUTCOME MEASURES

The posterior neck pain was measured using the visual analog scale (VAS).

METHODS

A novel anterior transcorporeal approach under endoscopy was performed to address a migrated disc herniation at the C4-C5 levels.

RESULTS

This operation was accomplished in 75 minutes. Postoperatively, the drainage tube was retained into the drilling hole for 24 hours to avoid the possibility of hematoma. The patient was advised to wear a neck collar for 3 weeks. Immediately after the operation, the posterior neck pain improved from VAS 7/10 preoperatively to 3/10, and the myodynamia of extremities improved stepwise. At 12 hours postoperatively, the range of motion was also improved. In the further follow-up, the patient has completely recovered from the preoperative symptoms, whose myodynamia of extremities is normal. Besides the postoperative MRI, a total removal of the herniated disc and the transcorporeal drilling tunnel are observed in CT. At postoperative 3-month follow-up, neither disc space narrowing nor instability was observed on CT, in which the bone defect after drilling tunnelwas partially decreased, indicating bone healing. There were no surgery-related complications, such as dysphagia, Horner syndrome, recurrent laryngeal nerve palsy, vagus nerve injury, tracheoesophageal injury, or cervical hematocele.

CONCLUSIONS

As a supplement to the described surgical approach of PECD, the transcorporeal approach is a novel access for the treatment of cervical intervertebral disc herniation. Among the advantages of this approach are providing a clear visual field during microendoscopic surgery and decreasing the intraoperative iatrogenic injury to, as well as avoiding violation to the discal tissue. Theoretically, the potential of secondary decline of intervertebral height is low. However, as the limitation of one case shows, whether this transcorporeal approach is efficacious and reliable should be verified in a further comparative cohort study with a large volume of patients.

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.