A Transtubular Microsurgical Approach to Treat Lateral Cervical Disc Herniation

Comparison of clinical efficacy between retention and removal of the vertebral bony endplate in anterior cervical discectomy and fusion for the treatment of cervical spondylotic myelopathy

BACKGROUND

Anterior cervical discectomy and fusion (ACDF) have a history of more than 60 years to treat cervical spondylotic myelopathy. This study is based on the original classic surgical procedure to remove the bony endplate to expand the range of vertical decompression to analyze and compare the clinical efficacy of two different ACDF in treating cervical spondylotic myelopathy.

METHODS

The inpatients in hospital were randomly divided into two groups A and B. Patients in Group A received ACDF surgery with bony endplates preserved, and patients in group B received ACDF surgery with bony endplates removed. All patients were followed-up for three years, and then compared the clinical efficacy from the following aspects, blood loss statistics during and after the operation, Japanese Orthopedic Association's scoring (JOA) standard for cervical spondylotic myelopathy, Cervical curvature index, cervical flexion and extension range, intervertebral bone graft fusion time and fusion rate.

RESULTS

1. The operative time and intraoperative (postoperative) blood loss in group A were significantly better than that in group B, with statistical significance (P < 0.05)0.2. There was no significant difference in postoperative neurological function recovery, cervical curvature index, cervical flexion and extension activity, and Intervertebral fusion time between two groups (P > 0.05), while group A was superior to group B in terms of bone graft fusion rate (P < 0.05). 3. Four patients (6.7%) in group B suffered from dyspnea due to neck hematoma caused by drainage tube blockage, but all of them were cured immediately and no death occurred.

CONCLUSIONS

During the 3-year follow-up period after the operation, six patients in group B have subsidence and loosening of the internal fixator due to bone subsidence around the implant. Although immediate surgical treatment is not required, renovation surgery is inevitable in the long term.

Minimally Invasive Posterior Cervical Foraminotomy Versus Anterior Cervical Fusion and Arthroplasty: Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVES

Patients with lateral cervical disc and foraminal pathology can be treated with anterior and posterior approaches including anterior cervical discectomy and fusion(ACDF), cervical total disc arthroplasty(TDA), and minimally invasive posterior cervical foraminotomy(MIS-PCF). Although MIS-PCF may have some advantages over the anterior approaches, few comparative studies and meta-analyses have been done to assess superiority.

METHODS

This study includes a systematic review of the literature and meta-analysis of studies directly comparing minimally invasive posterior cervical foraminotomy to either anterior cervical discectomy and fusion or cervical total disc arthroplasty.

RESULTS

In comparing patients undergoing ACDF and MIS-PCF, operative time ranged from 68 to 97.8 minutes in the ACDF group compared to 28 to 93.9 minutes in the MIS-PCF group. Mean postoperative length of stay ranged from 33.84 to 112.8 hours in the ACDF group compared to 13.68 to 83.6 hours in the MIS-PCF group. The total complication rates were 3.72% in the ACDF group and 3.73% in the MIS-PCF group. A random-effects model meta-analysis was carried out which failed to show a statistically significant difference in the complication rate between the two procedures(OR .91; 95% CI 0.13, 6.43; P = .92, I² = 59%). The total reoperation rate was 3.5% in the ACDF group and 5.4% in the MIS-PCF group. A random-effects model meta-analysis was carried out which failed to show a statistically significant difference in the reoperation rate between the two procedures(OR .66; 95% CI 0.33, 1.33; P = .25, I² = 0). In comparing patients undergoing TDA and MIS-PCF, operative time ranged from 90.3 to 106.7 minutes in the TDA group compared to 77.4 to 93.9 minutes in the MIS-PCF group. Mean postoperative length of stay ranged from 103.2 to 165.6 hours in the TDA group and 93.6 to 98.4 hours in the MIS-PCF group. The complication rate ranged from 23.5 to 28.6% in the TDA group and 0 to 14.3% in the MIS-PCF group. The overall reoperation rates were 2.6% in the TDA group and 10.2% in the MIS-PCF group.

CONCLUSIONS

There is no clear superiority between MIS-PCF and ACDF/TDA in terms of operative time, postoperative length of stay, or rate of complications/reoperations. Further studies with increased follow-up intervals >48 months, and higher sample sizes are necessary to determine the true superiority of MIS-PCF and anterior neck approaches in treatment of lateral disc and foraminal pathology.

Case Report: A Case Series Using Natural Anatomical Gaps-Posterior Cervical Approach to Skull Base and Upper Craniocervical Meningiomas Without Bone Removal

Background: Removal of anteriorly located tumors of the upper cervical spine and craniovertebral junction (CVJ) is a particular surgical challenge. Extensive approaches are associated with pain, restricted mobility of neck and head and, in case of foramen magnum and clivus tumors, with retraction of brainstem and cerebellum.

Methods: Four symptomatic patients underwent resection of anteriorly located upper cervical and lower clivus meningiomas without laminotomy or craniotomy using a minimally invasive posterior approach. Distances of natural gaps between C0/C1, C1/C2, and C2/C3 were measured using preoperative CT scans and intraoperative lateral x-rays.

Results: In all patients, safe and complete resection was conducted by the opening of the dura between C0/C1, C1/C2, and C2/C3, respectively. There were no surgical complications. Local pain was reported as very moderate by all patients and postoperative recovery was extremely fast. All tumors had a rather soft consistency, allowing mass reduction prior to removal of the tumor capsule and were well separable from lower cranial nerves and vascular structures.

Conclusion: If tumor consistency is appropriate for careful mass reduction before removal of the tumor capsule and if tumor margins are not firmly attached to crucial structures, then upper cervical, foramen magnum, and lower clivus meningiomas can be safely and completely removed through natural gaps in the CVJ region. Both prerequisites usually become clear early during surgery. Thus, this tumor entity may be planned using this minimally invasive approach and may be extended if tumor consistency turns out to be less unfavorable for resection or if crucial structures cannot be easily separated from the tumor.

Comparison of outcomes following minimally invasive and open posterior cervical foraminotomy: description of minimally invasive technique and review of literature

Although minimally invasive posterior cervical foraminotomy (MIS-PCF) is frequently employed in the treatment of cervical radiculopathy, there are very few studies directly comparing outcomes between MIS-PCF and open posterior cervical foraminotomy and between MIS-PCF and percutaneous endoscopic (full-endoscopic) posterior cervical foraminotomy (FE-PCF). This study includes a description of technique and systematic review of literature and analysis of clinical studies comparing outcomes between MIS-PCF and open posterior cervical foraminotomy and between MIS-PCF and FE-PCF. Six comparative studies, including one randomized controlled trial were included in analysis. Average operative time ranged from 60.5 to 171 minutes in the open group and 77.65 to 115 minutes in the MIS group. Mean intraoperative blood loss ranged from 43.5 to 246 cc in the open group and 42 to 138 cc in the MIS group. Average postoperative length of stay ranged from 58.6 to 304.8 hours in the open group and 20 to 273.6 hours in the MIS group. Two studies reported significantly increased VAS-N (Neck) scores postoperatively in patients undergoing open cervical foraminotomies, however both studies reported that the differences lost statistical significance with longer follow-up. There were no significant differences in complications or reoperations between open and MIS groups. One retrospective cohort study was included in analysis that compared MIS-PCF and FE-PCF. Postoperatively at 24 months, mean NDI and VAS-N were significantly lower after FE-PCF than MIS-PCF. There was no significant change in VAS-A (Arm) between the two groups. Direct comparative studies between MIS-PCF and open cervical foraminotomy are limited in number. Although, there is a significant heterogeneity in studies comparing open and MIS-PCF there appears to be a trend of decreased hospital length of stay and postoperative analgesic usage in the minimally invasive cohort.