Comparison of Anterior Cervical Discectomy and Fusion versus Posterior Cervical Foraminotomy in the Treatment of Cervical Radiculopathy: A Systematic Review

Preoperative Factors on Loss of Range of Motion after Posterior Cervical Foraminotomy

Background and Objectives: Posterior cervical foraminotomy (PCF) aims to resolve cervical radiculopathy while preserving range of motion (ROM). However, its effectiveness in maintaining ROM is uncertain. This study investigates the changes in ROM after PCF and identifies preoperative factors that influence ROM reduction post surgery. Materials and Methods: This retrospective cohort study included patients treated at our hospital from August 2016 to September 2021. Clinical outcomes were assessed using the visual analog scale (VAS) for neck and arm pain and the neck disability index (NDI). Radiological outcomes included the segmental angle (SA), cervical angle (CA), C2-C7 SVA, Pfirrmann grade, extent of facetectomy, foraminal stenosis, and ROM. Patients were categorized into two groups based on segmental ROM changes: decreased (Group D) and maintained (Group M). Radiological and clinical outcomes were compared between the groups. Univariate and multivariate regression analyses were performed to identify risk factors for ROM loss after PCF. Results: 76 patients were included: 34 in Group D and 42 in Group M, with no demographic differences. Preoperatively, Group D had significantly larger flexion segmental and cervical angles than Group M (segmental, p < 0.001; cervical, p = 0.001). Group D also had a higher Pfirrmann grade (p = 0.014) and more bony bridge formations (p = 0.004). While no significant differences were observed in arm pain VAS and NDI scores, Group D exhibited worse neck pain VAS at the last follow-up (p = 0.03). Univariate linear regression indicated that preoperative segmental ROM (p < 0.001, B = 0.82) and bony bridge formation (p = 0.046, B = 5.33) were significant predictors of ROM loss post PCF. Conclusions: Patients with higher preoperative flexion angles and Pfirrmann grades at the operative level are at an increased risk for ROM loss and neck pain and often exhibit bony bridge formation. Accounting for these factors can improve surgical planning and patient outcomes.

Cervical Laminoforaminotomy for Treatment of Cervical Radiculopathy: A Case Report

Cervical laminoforaminotomy (CLF) provides a safe and effective decompression procedure of nerve roots while maintaining cervical mobility and preserving stability. However, this unique technique requires appropriate patient selection and the technical ability of the surgeon to produce an excellent outcome. Furthermore, anterior cervical discectomy and fusion (ACDF) has been accepted as the "gold standard" procedure in managing cervical radiculopathy, despite posing the risk of anterior structure injuries and fusion. Here we report a case report of the surgical management of unilateral cervical radiculopathy using the CLF technique.

Application and Advantages of the Trans-Unco-Discal (TUD) Approach for Cervical Spondylotic Myelopathy and Radiculopathy: Classification and Modification of Surgical Technique Based on the Location of Spinal Cord and/or Nerve Root Compression

Purpose: We assess the application and advantages of modifying the trans-unco-discal (TUD) approach which we underwent for cervical myelo-radiculopathy. We present the surgical techniques of the modified TUD approach. Materials and Methods: The material was 180 cases where anterior cervical decompression (ACD) was performed by the modified TUD approach. We classified the material into four groups based on the location of the nerve root and/or spinal cord compression: I, compression of the root at intervertebral foramen (IVF); II, compression of the posterior margin of the vertebral body; III, compression of the IVF and posterior margin of the vertebral body; IV, compression of the bilateral IVF and posterior margin of the vertebral body. We applied the modified TUD approach to these four types. We present the surgical procedures and techniques for the modified TUD approach. The Japanese orthopedic association (JOA) score and neuroradiological alignment were examined. Results: The improvement rate of the JOA score was 78.4% at 6 months post-surgery and 77.5% in the most recent examinations. By the modified TUD approach, compressive lesions of the spinal cord and/or nerve roots were removed, and good alignment was acquired and sustained. Conclusions: ACD by the modified TUD approach safely achieved appropriate decompression for the spinal cord and/or nerve roots, and the patients had a high improvement rate and good alignment. Complications were less common than with other surgical procedures. If the TUD approach and endoscopic approaches can be combined, their application to new area is anticipated.

Porous Cage Macro-Topography Improves Early Fusion Rates in Anterior Cervical Discectomy and Fusion

Objectives

Anterior cervical discectomy and fusion (ACDF) aims to improve pain, relieve neural compression, achieve rapid solid bony arthrodesis, and restore cervical alignment. Bony fusion occurs as early as 3 months and up to 24 months after ACDF. The correlations between bony fusion and clinical outcomes after ACDF remain unclear. Macro-topographic and porous features have been introduced to interbody cage technology, aiming to improve the strength of the bone-implant interface to promote early fusion. In this study, we aimed to compare clinical outcomes and CT-evaluated fusion rates in patients undergoing ACDF using one of two different interbody cages: traditional NanoMetalene™ (NM) cages and NM cages with machined porous features (NMRT).

Methods

This was a prospective, observational, nonrandomised, cohort study of consecutive patients undergoing ACDF. The NM cage cohort was enrolled first, then the NMRT cohort second. The visual analogue scale, neck disability index, and 12-item Short Form Survey scores were evaluated preoperatively and at 6 weeks, 3 months, and 6 months. The minimum clinical follow-up period was 12 months. Plain radiographs were obtained on postoperative day 2 to assess instrumentation positioning, and computed tomography (CT) was performed at 3 and 6 months postoperatively to assess interbody fusion (Bridwell grade).

Results

Eighty-nine (52% male) patients with a mean age of 62 ± 10.5 years were included in this study. Forty-one patients received NM cages, and 48 received NMRT cages. All clinical outcomes improved significantly from baseline to 6 months. By 3 months, the NMRT group had significantly higher CT fusion rates than the NM group (79% vs 56%, p=0.02). By 6 months, there were no significant differences in fusion rates between the NMRT and NM groups (83% vs 78%, p=0.69). The mean Bridwell grade at 6 months was 1.4 ± 0.7 in the NMRT group and 1.8 ± 1.0 in the NM group (p=0.08).

Conclusions

With both NM and NMRT cages, serial improvements in postoperative clinical outcomes were associated with fusion progression on CT. NMRT cages demonstrated significantly better fusion at 3 months and a trend toward higher quality of fusion at 6 months compared with NM cages, suggesting earlier cage integration with NMRT. An early 3-month postoperative CT is adequate for fusion assessment in almost 80% of patients undergoing ACDF with an NMRT cage, permitting an earlier return to activity.

Perspective: Cervical laminoforaminotomy (CLF) is safer than anterior cervical diskectomy/fusion (ACDF) for lateral cervical disease

Background

The literature documents that laminoforaminotomy (CLF), whether performed open, minimally invasively, or microendoscopically, is safer than anterior cervical diskectomy/fusion (ACDF) for lateral cervical disease.

Methods

ACDF for lateral cervical disc disease and/or spondylosis exposes patients to multiple major surgical risk factors not encountered with CLF. These include; carotid artery or jugular vein injuries, esophageal tears, dysphagia, recurrent laryngeal nerve injuries, tracheal injuries, and dysphagia. CLF also exposes patients to lower rates of vertebral artery injury, dural tears (DT)/cerebrospinal fluid fistulas, instability warranting fusion, adjacent segment disease (ASD), plus cord and/or nerve root injuries.

Results

Further, CLF vs. ACDF for lateral cervical pathology offer reduced tissue damage, operative time, estimated blood loss (EBL), length of stay (LOS), and cost.

Conclusion

CLFs', whether performed open, minimally invasively, or microendoscopically, offer greater safety, major pros with few cons, and decreased costs vs. ACDF for lateral cervical disease.

Clinical and cost-effectiveness of PCF versus ACD in the treatment of cervical brachialgia (FORVAD trial)

BACKGROUND

Cervical radiculopathy occurs when a nerve root is compressed in the spine, if symptoms fail to resolve after 6 weeks surgery may be indicated. Anterior Cervical Discectomy (ACD) is the commonest procedure, Posterior Cervical Foraminotomy (PCF) is an alternative that avoids the risk of damage to anterior neck structures. This prospective, Phase III, UK multicentre, open, individually randomised controlled trial was performed to determine whether PCF is superior to ACD in terms of improving clinical outcome as measured by the Neck Disability Index (NDI) 52 weeks post-surgery.

METHOD

Following consent to participate and collection of baseline data, subjects with cervical brachialgia were randomised to ACD or PCF in a 1:1 ratio on the day of surgery. Clinical outcomes were assessed on day 1 and patient reported outcomes on day 1 and weeks 6, 12, 26, 39 and 52 post-operation. A total of 252 participants were planned to be randomised. Statistical analysis was limited to descriptive statistics. Health economic outcomes were also described.

RESULTS

The trial was closed early (n = 23). Compared to baseline, the median (interquartile range (IQR)) NDI score at 52 weeks reduced from 44.0 (36.0, 62.0) to 25.3 (20.0, 42.0) in the PCF group and increased from 35.6 (34.0, 44.0) to 45.0 (20.0, 57.0) in the ACD group. ACD may be associated with more swallowing, voice and other complications and was more expensive; neck and arm pain scores were similar.

CONCLUSIONS

The trial was closed early, therefore no definitive conclusions on clinical or cost-effectiveness could be made.

Narrative Review of Uniportal Posterior Endoscopic Cervical Foraminotomy

Cervical radiculopathy is a common and disabling cervical condition characterized by symptoms including axial neck pain, radicular pain, weakness, and numbness in one or both arms. Common causes include herniated discs and foraminal stenosis, often accompanied by varying degrees of degenerative disc disease and uncovertebral joint hypertrophy. In the treatment of cervical radiculopathy, there is an increasing preference for posterior foraminotomy over anterior cervical discectomy and fusion due to the avoidance of fusion-related complications. As endoscopic spine surgery techniques continue to evolve, there is a rising interest in posterior endoscopic cervical foraminotomy and posterior endoscopic cervical discectomy as effective treatments for cervical radiculopathy. Because these procedures can performed through a single subcentimeter incision with minimal soft tissue damage, they can often be carried out as ambulatory procedures. In this narrative review, we examined current literature addressing the indications, surgical techniques, outcomes, and potential complications associated with posterior cervical endoscopic approaches.

Tailor-Made Surgical Strategy for Coexistent Cervical Myelopathy and Bilateral Radiculopathy. Combined Laminoplasty, Laminectomy, and Foraminotomy: Report of Two Cases

Cervical spondylosis is a common and degenerative disease consisting of myelopathy and radiculopathy. Surgical treatment can be considered for patients with cervical spondylosis resulting in severe pain, motor weakness, ambulation difficulty, and urination disorder. As myelopathy and radiculopathy often coexist, two-staged anterior and posterior fixation/decompression surgery can be selected to resolve those two pathologies. However, due to the invasiveness of that management, posterior surgery in a single session seems favorable. In this study, we present two cases of cervical spondylosis. A 67-year-old man was complaining of pain in the neck and right upper extremity. Radiographically, cervical canal stenosis was concurrently diagnosed with the foraminal stenosis of the left C3/4 and right C6/7. Laminoplasty from C3 to C6 (left open; C3 to C5, right open; C6) and foraminotomy of the left C3/4 and right C6/7 were performed in a single session. Another 43-year-old man was bothered by pain in the neck and bilateral upper extremities resulting from cervical canal stenosis and bilateral foraminal stenosis of C6/7. Laminoplasty from C3 to C5, laminectomy of C6, and foraminotomy of bilateral C6/7 were performed in a single session. Preoperative symptoms were remitted in both cases. As described in our cases, a tailor-made combination of laminoplasty, laminectomy, and foraminotomy can effectively resolve cervical spondylosis in a single session.

Posterior cervical foraminotomy versus anterior cervical discectomy for Cervical Brachialgia: the FORVAD RCT

Background

Posterior cervical foraminotomy and anterior cervical discectomy are routinely used operations to treat cervical brachialgia, although definitive evidence supporting superiority of either is lacking.

Objective

The primary objective was to investigate whether or not posterior cervical foraminotomy is superior to anterior cervical discectomy in improving clinical outcome.

Design

This was a Phase III, unblinded, prospective, United Kingdom multicentre, parallel-group, individually randomised controlled superiority trial comparing posterior cervical foraminotomy with anterior cervical discectomy. A rapid qualitative study was conducted during the close-down phase, involving remote semistructured interviews with trial participants and health-care professionals.

Setting

National Health Service trusts.

Participants

Patients with symptomatic unilateral cervical brachialgia for at least 6 weeks.

Interventions

Participants were randomised to receive posterior cervical foraminotomy or anterior cervical discectomy. Allocation was not blinded to participants, medical staff or trial staff. Health-care use from providing the initial surgical intervention to hospital discharge was measured and valued using national cost data.

Main outcome measures

The primary outcome measure was clinical outcome, as measured by patient-reported Neck Disability Index score 52 weeks post operation. Secondary outcome measures included complications, reoperations and restricted American Spinal Injury Association score over 6 weeks post operation, and patient-reported Eating Assessment Tool-10 items, Glasgow-Edinburgh Throat Scale, Voice Handicap Index-10 items, PainDETECT and Numerical Rating Scales for neck and upper-limb pain over 52 weeks post operation.

Results

The target recruitment was 252 participants. Owing to slow accrual, the trial closed after randomising 23 participants from 11 hospitals. The qualitative substudy found that there was support and enthusiasm for the posterior cervical FORaminotomy Versus Anterior cervical Discectomy in the treatment of cervical brachialgia trial and randomised clinical trials in this area. However, clinical equipoise appears to have been an issue for sites and individual surgeons. Randomisation on the day of surgery and processes for screening and approaching participants were also crucial factors in some centres. The median Neck Disability Index scores at baseline (pre surgery) and at 52 weeks was 44.0 (interquartile range 36.0-62.0 weeks) and 25.3 weeks (interquartile range 20.0-42.0 weeks), respectively, in the posterior cervical foraminotomy group (n = 14), and 35.6 weeks (interquartile range 34.0-44.0 weeks) and 45.0 weeks (interquartile range 20.0-57.0 weeks), respectively, in the anterior cervical discectomy group (n = 9). Scores appeared to reduce (i.e. improve) in the posterior cervical foraminotomy group, but not in the anterior cervical discectomy group. The median Eating Assessment Tool-10 items score for swallowing was higher (worse) after anterior cervical discectomy (13.5) than after posterior cervical foraminotomy (0) on day 1, but not at other time points, whereas the median Glasgow-Edinburgh Throat Scale score for globus was higher (worse) after anterior cervical discectomy (15, 7, 6, 6, 2, 2.5) than after posterior cervical foraminotomy (3, 0, 0, 0.5, 0, 0) at all postoperative time points. Five postoperative complications occurred within 6 weeks of surgery, all after anterior cervical discectomy. Neck pain was more severe on day 1 following posterior cervical foraminotomy (Numerical Rating Scale - Neck Pain score 8.5) than at the same time point after anterior cervical discectomy (Numerical Rating Scale - Neck Pain score 7.0). The median health-care costs of providing initial surgical intervention were £2610 for posterior cervical foraminotomy and £4411 for anterior cervical discectomy.

Conclusions

The data suggest that posterior cervical foraminotomy is associated with better outcomes, fewer complications and lower costs, but the trial recruited slowly and closed early. Consequently, the trial is underpowered and definitive conclusions cannot be drawn. Recruitment was impaired by lack of individual equipoise and by concern about randomising on the day of surgery. A large prospective multicentre trial comparing anterior cervical discectomy and posterior cervical foraminotomy in the treatment of cervical brachialgia is still required.

Trial registration

This trial is registered as ISRCTN10133661.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 21. See the NIHR Journals Library website for further project information.

Anterior Cervical Discectomy and Fusion Versus Microendoscopic Posterior Cervical Foraminotomy for Unilateral Cervical Radiculopathy: A 1-Year Cost-Utility Analysis

BACKGROUND

Anterior cervical discectomy and fusion (ACDF) and posterior cervical foraminotomy (PCF) are the most common surgical approaches for medically refractory cervical radiculopathy. Rigorous cost-effectiveness studies comparing ACDF and PCF are lacking.

OBJECTIVE

To assess the cost-utility of ACDF vs PCF performed in the ambulatory surgery center setting for Medicare and privately insured patients at 1-year follow-up.

METHODS

A total of 323 patients who underwent 1-level ACDF (201) or PCF (122) at a single ambulatory surgery center were compared. Propensity matching generated 110 pairs (220 patients) for analysis. Demographic data, resource utilization, patient-reported outcome measures, and quality-adjusted life-years were assessed. Direct costs (1-year resource use × unit costs based on Medicare national allowable payment amounts) and indirect costs (missed workdays × average US daily wage) were recorded. Incremental cost-effectiveness ratios were calculated.

RESULTS

Perioperative safety, 90-day readmission, and 1-year reoperation rates were similar between groups. Both groups experienced significant improvements in all patient-reported outcome measures at 3 months that was maintained at 12 months. The ACDF cohort had a significantly higher preoperative Neck Disability Index and a significantly greater improvement in health-state utility (ie, quality-adjusted life-years gained) at 12 months. ACDF was associated with significantly higher total costs at 1 year for both Medicare ($11 744) and privately insured ($21 228) patients. The incremental cost-effectiveness ratio for ACDF was $184 654 and $333 774 for Medicare and privately insured patients, respectively, reflecting poor cost-utility.

CONCLUSION

Single-level ACDF may not be cost-effective in comparison with PCF for surgical management of unilateral cervical radiculopathy.

Comparison of Single-level Cervical Radiculopathy Outcomes Between Posterior Endoscopic Cervical Decompression and Anterior Cervical Discectomy and Fusion: Mid-term Results

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

To investigate the mid-term results and technical possibilities of posterior endoscopic cervical decompression (PECD) in the treatment of cervical radiculopathy.

SUMMARY OF BACKGROUND DATA

PECD has been used in the treatment of cervical radiculopathy for the past decades; there is a paucity of studies directly comparing its outcomes with anterior cervical discectomy and fusion (ACDF) for patients with single-level cervical radiculopathy.

PATIENTS AND METHODS

From January 2016 to December 2018, clinical and radiologic data of 42 patients were collected. Patients were followed for a mean of 40.6 months (range: 30-54 mo) after surgery. Changes in cervical lordosis and degeneration of adjacent segments were analyzed. Dysphagia was assessed using the Bazaz score, and clinical outcomes were analyzed using the Neck Disability Index and visual analog scoring system.

RESULTS

There were no significant differences in neurological outcomes between the two groups. Significant between-group differences in postoperative dysphagia were observed ( P < 0.05). There were significant differences in postoperative segmental Cobb angles and disc height between the two groups ( P < 0.05). Degenerative changes in the adjacent segments occurred in 5 patients in the ACDF group and 1 patient in the PECD group ( P < 0.05); no revision surgery was needed.

CONCLUSIONS

Clinical outcomes of PECD for patients with unilateral radiculopathy were satisfactory. On the premise of a strict selection of indications, we consider this technique to be a safe supplement and alternative to ACDF for patients with unilateral cervical radiculopathy. Longer follow-up periods are required to confirm these observations.

Microendoscopic Surgery for Degenerative Disorders of the Cervical and Lumbar Spine: The Influence of the Tubular Workspace on Instrument Angulation, Clinical Outcome, Complications, and Reoperation Rates

BACKGROUND

Long-term clinical outcomes with microendoscopic spine surgery (MESS) are poorly investigated. The effect of instrument angulation on clinical outcomes has yet to be assessed.

METHODS

A total of 229 consecutive patients operated on via two MESS systems were analyzed. Instrument angulation for both MESS systems, which differ from each other regarding the working space for instruments, was assessed using a computer model. Patients' charts and endoscopic video recordings were reviewed to determine clinical outcomes, complications, and revision surgery rates. At a minimum follow-up of two years, clinical outcomes were assessed employing the Neck Disability Index (NDI) and Oswestry Disability Index (ODI).

RESULTS

A total of 52 posterior cervical foraminotomies (PCF) and 177 lumbar decompression procedures were performed. The mean follow-up was six years (range 2-9 years). At the final follow-up, 69% of cervical and 76% of lumbar patients had no radicular pain. The mean NDI was 10%, and the mean ODI was 12%. PCF resulted in excellent clinical outcomes in 80% of cases and 87% of lumbar procedures. Recurrent disc herniations occurred in 7.7% of patients. The surgical time and repeated procedure rate were significantly lower for the MESS system with increased working space, whereas the clinical outcome and rate of complication were similar.

CONCLUSIONS

MESS achieves high success rates for treating degenerative spinal disorders in the long term. Increased instrument angulation improves access to the compressive pathology and lowers the surgical time and repeated procedure rate.

Morbid Obesity Increases Length of Surgery in Elective Anterior Cervical Discectomy and Fusion Procedures but Not Readmission or Reoperation Rates: A Cohort Study

BACKGROUND

As the obesity epidemic grows, the number of morbidly obese patients undergoing anterior cervical discectomy and fusion (ACDF) continues to increase. Despite the association of obesity with perioperative complications in anterior cervical surgery, the impact of morbid obesity on ACDF complications remains controversial, and studies examining morbidly obese cohorts are limited.

METHODS

A single-institution, retrospective analysis of patients undergoing ACDF from September 2010 to February 2022 was performed. Demographic, intraoperative, and postoperative data were collected via review of the electronic medical record. Patients were categorized as nonobese (body mass index [BMI] <30), obese (BMI 30-39.9), or morbidly obese (BMI ≥40). Associations of BMI class with discharge disposition, length of surgery, and length of stay were assessed using multivariable logistic regression, multivariable linear regression, and negative binomial regression, respectively.

RESULTS

The study included 670 patients undergoing single-level or multilevel ACDF: 413 (61.6%) nonobese, 226 (33.7%) obese, and 31 (4.6%) morbidly obese patients. BMI class was associated with prior history of deep venous thrombosis (P < 0.01), pulmonary thromboembolism (P < 0.05), and diabetes mellitus (P < 0.001). In bivariate analysis, there was no significant association between BMI class and reoperation or readmission rates at 30, 60, or 365 days postoperatively. In multivariable analysis, greater BMI class was associated with increased length of surgery (P = 0.03), but not length of stay or discharge disposition.

CONCLUSIONS

For patients undergoing ACDF, greater BMI class was associated with increased length of surgery, but not reoperation rate, readmission rate, length of stay, or discharge disposition.

Short-Term Neck Pain After Posterior Foraminotomy Compared with Anterior Discectomy with Fusion for Cervical Foraminal Radiculopathy: A Secondary Analysis of the FACET Randomized Controlled Trial

BACKGROUND

Short-term neck pain after posterior cervical foraminotomy (posterior surgery) compared with anterior cervical discectomy with fusion (anterior surgery) treating cervical radiculopathy has only been assessed once, retrospectively, to our knowledge. The aim of this study was to prospectively evaluate the course of neck pain for 6 weeks after both treatments.

METHODS

This is a secondary analysis of the multicenter Foraminotomy ACDF Cost-Effectiveness Trial (FACET), conducted from January 2016 to May 2020. Of 389 patients who had single-level, 1-sided cervical radiculopathy and were screened for eligibility, 265 were randomly assigned to undergo posterior surgery (n = 132) or anterior surgery (n = 133). The primary outcome of the present analysis was neck pain, assessed weekly for 6 weeks using the visual analog scale (VAS), on a scale of 0 to 100. The secondary outcomes were arm pain, neck disability, work ability, quality of life, treatment satisfaction, motor and sensory changes, and hospital length of stay. Data were analyzed with mixed model analysis in intention-to-treat samples using 2-sided 95% confidence intervals (CIs).

RESULTS

In the first postoperative week, the mean VAS for neck pain was 56.2 mm (95% CI, 51.7 to 60.8 mm) after posterior surgery and 46.7 mm (95% CI, 42.2 to 51.2 mm) after anterior surgery. The mean between-group difference was 9.5 mm (95% CI, 3.3 to 15.7 mm), which gradually decreased to 2.3 mm (95% CI, -3.6 to 8.1 mm) at postoperative week 6. As of postoperative week 5, there was no significant difference between groups. Responder analyses confirmed this result. Secondary outcomes showed small differences between groups.

CONCLUSIONS

Insight into the course of neck pain during the first 6 weeks after posterior compared with anterior surgery is provided. Despite initially more neck pain after posterior surgery, patients swiftly improved and, as of postoperative week 5, results similar to those after anterior surgery were observed. Our findings should enable improved patient counseling and enhanced shared decision-making between physicians and patients with cervical radiculopathy, where more neck pain in the first postoperative weeks should be balanced against the benefits of posterior surgery.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Combined cervical laminoplasty and foraminotomy for coexistence of cervical myelopathy and unilateral radiculopathy: case series and preliminary results

BACKGROUND

The clinical outcomes and radiographic changes of a one-stage procedure combining cervical laminoplasty and unilateral cervical foraminotomy for patients with coexisting cervical myelopathy and unilateral radiculopathy were evaluated.

METHODS

Seven patients (two females and five males) with coexisting cervical myelopathy and unilateral cervical radiculopathy were included in this study. The mean age was 58.4 years (range 45-77 years). Cervical laminoplasty and unilateral cervical foraminotomy were performed on the recruited patients in a single stage. The quantitative clinical changes between the preoperative and 6-month postoperative assessment were analyzed using the Japanese Orthopedic Association (JOA) score, the JOA Cervical Myelopathy Evaluation Questionnaire (JOA-CMEQ), visual analog scale (VAS), and Neck Disability Index (NDI). Moreover, the preoperative and 6-month postoperative radiographic changes were assessed using the C2-7 angle and range of motion (ROM) between flexion and extension angle.

RESULTS

There were significant differences in QOL in the JOA-CMEQ between the groups. Furthermore, the postoperative VAS values in the arms and hands generally improved, although not significantly, between the groups.

CONCLUSIONS

The aforementioned surgical procedure may be safe and efficient for patients with coexisting cervical myelopathy and radiculopathy.

Cervical kinematic change after posterior full-endoscopic cervical foraminotomy for disc herniation or foraminal stenosis

OBJECTIVE

Posterior full-endoscopic cervical foraminotomy (PECF) is one of minimally invasive surgical techniques for cervical radiculopathy. Because of minimal disruption of posterior cervical structures, such as facet joint, cervical kinematics was minimally changed. However, a larger resection of facet joint is required for cervical foraminal stenosis (FS) than disc herniation (DH). The objective was to compare the cervical kinematics between patients with FS and DH after PECF.

METHODS

Consecutive 52 patients (DH, 34 vs. FS, 18) who underwent PECF for single-level radiculopathy were retrospectively reviewed. Clinical parameters (neck disability index, neck pain and arm pain), and segmental, cervical and global radiological parameters were compared at postoperative 3, 6, and 12 months, and yearly thereafter. A linear mixed-effect model was used to assess interactions between groups and time. Any occurrence of significant pain during follow-up was recorded during a mean follow-up period of 45.5 months (range 24-113 months).

RESULTS

Clinical parameters improved after PECF, with no significant differences between groups. Recurrent pain occurred in 6 patients and surgery (PECF, anterior discectomy and fusion) was performed in 2 patients. Pain-free survival rate was 91% for DH and 83% for FS, with no significant difference between the groups (P = 0.29). Radiological changes were not different between groups (P > 0.05). Segmental neutral and extension curvature became more lordotic. Cervical curvature became more lordotic on neutral and extension X-rays, and the range of cervical motion increased. The mismatch between T1-slope and cervical curvature decreased. Disc height did not change, but the index level showed degeneration at postoperative 2 years.

CONCLUSION

Clinical and radiological outcomes after PECF were not different between DH and FS patients and kinematics were significantly improved. These findings may be informative in a shared decision-making process.

Incidence of complications associated with cervical spine surgery and post-operative physical therapy and implications for timing of initiation of post-operative physical therapy: a retrospective database study

PURPOSE

To describe the incidence of complications associated with cervical spine surgery and post-operative physical therapy (PT), and to identify if the timing of initiation of post-operative PT impacts the incidence rates.

METHODS

MOrtho PearlDiver database was queried using billing codes to identify patients who had undergone Anterior Cervical Discectomy and Fusion (ACDF), Posterior Cervical Fusion (PCF), or Cervical Foraminotomy and post-operative PT from 2010-2019. For each surgical procedure, patients were divided into three 12-week increments for post-operative PT (starting at post-operative weeks 2, 8, 12) and then matched based upon age, gender, and Charlson Comorbidity Index score. Each group was queried to determine complication rates and chi-square analysis with adjusted odds ratios, 95% confidence intervals, and p-values were used.

RESULTS

Following matching, 3,609 patients who underwent cervical spine surgery at one or more levels and had post-operative PT (ACDF:1784, PCF:1593, and cervical foraminotomy:232). The most frequent complications were new onset cervicalgia (2-14 weeks, 8-20 weeks, 12-24 weeks): ACDF (15.0%, 14.0%, 13.0%), PCF (18.8%, 18.0%, 19.9%), cervical foraminotomy (16.8%, 16.4%, 19.4%); revision: ADCF (7.9%, 8.2%, 7.4%), PCF (9.3%, 10.6%, 10.2%), cervical foraminotomy (11.6%, 10.8% and 13.4%); wound infection: ACDF (3.3%, 3.4%, 3.1%), PCF (8.3%, 8.0%,7.7%), cervical foraminotomy (5.2%, 6.5%, < 4.7%). None of the comparisons were statistically significant.

CONCLUSION

The most common post-operative complications included new onset cervicalgia, revision and wound infection. Complications rates were not impacted by the timing of initiation of PT whether at 2, 8, or 12 weeks post-operatively.

Ultrasound-guided cervical selective nerve block: A case series

BACKGROUND

Cervical radiculopathy is characterized by pain, numbness, tingling, and weakness, mostly in an affected extremity, reflecting compression of a nerve in the neck is compressed or irritated where it emerges from the spinal cord. Diagnosis requires a detailed anamnesis, physical examination, and imaging. Physical therapy, exercise, medical therapy, and injections are the preferred treatments, but injections into the cervical region are only indicated if conservative treatment is ineffective.

OBJECTIVE

This study explored the utility of selective cervical nerve root blocks (SNRBs) performed at various levels under ultrasound guidance (USG).

METHODS

We evaluated patients diagnosed with cervical radiculopathy via physical examination and magnetic resonance imaging from November 2019 to March 2020. We included those who did not respond to conservative treatment and therefore received SNRBs at various levels. Sixty-three patients were evaluated over 6 months in terms of pain, functional status, and complications.

RESULTS

We retrospectively evaluated patients with cervical herniated discs who received SNRBs at various levels between C4-7 under USG. Pain and functional status improved in month 1 and was maintained until at least month 6.

CONCLUSION

SNRB injections performed under USG effectively treated pain and poor functional status in selected patients. The procedure is safe (especially) for patients who do not respond to conservative treatment.

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.

Clinical Efficacy and Safety of Surgical Treatments in Patients With Pure Cervical Radiculopathy

Background

Traditionally paired meta-analysis revealed inconsistencies in the safety and effectiveness of surgical interventions. We conducted a network meta-analysis to assess various treatments' clinical efficacy and safety for pure cervical radiculopathy.

Methods

The Embase, PubMed, and Cochrane Library databases were searched for randomized controlled trials (RCTs) comparing different treatment options for patients with pure cervical radiculopathy from inception until October 23, 2021. The primary outcomes were postoperative success rates, postoperative complication rates, and postoperative reoperation rates. The pooled data were subjected to a random-effects consistency model. The protocol was published in PROSPERO (CRD42021284819).

Results

This study included 23 RCTs (n = 1,844) that evaluated various treatments for patients with pure cervical radiculopathy. There were no statistical differences between treatments in the consistency model in terms of major clinical effectiveness and safety outcomes. Postoperative success rates were higher for anterior cervical foraminotomy (ACF: probability 38%), posterior cervical foraminotomy (PCF: 24%), and anterior cervical discectomy with fusion and additional plating (ACDFP: 21%). Postoperative complication rates ranked from high to low as follows: cervical disc replacement (CDR: probability 32%), physiotherapy (25%), ACF (25%). Autologous bone graft (ABG) had better relief from arm pain (probability 71%) and neck disability (71%). Among the seven surgical interventions with a statistical difference, anterior cervical discectomy with allograft bone graft plus plating (ABGP) had the shortest surgery time.

Conclusions

According to current results, all surgical interventions can achieve satisfactory results, and there are no statistically significant differences. As a result, based on their strengths and patient-related factors, surgeons can exercise discretion in determining the appropriate surgical intervention for pure cervical radiculopathy.

Systematic Review Registration: CRD42021284819.

Limitations of minimally invasive posterior cervical foraminotomy-a decompression method of posteriorly shifting the nerve root-in cases of large anterior osteophytes in cervical radiculopathy: A retrospective multicenter cohort study

BACKGROUND

Posterior cervical foraminotomy against anterior osteophyte is an indirect decompression procedure but less invasive compared to anterior cervical discectomy and fusion. Residual compression to the nerve root may lead to poor surgical outcomes. Although clinical results of posterior cervical foraminotomy for osteophytes are not considered better than those of disk herniation, osteophyte size and the association of the decompression area with poor surgical outcomes remain unclear. This study aimed to identify the limitations of minimally invasive posterior cervical foraminotomy for cervical radiculopathy and discuss the methods to improve surgical outcomes.

METHODS

We analyzed 55 consecutive patients with degenerative cervical radiculopathy who underwent minimally invasive posterior cervical foraminotomy. Minimum postoperative follow-up duration was 1 year. We divided the patients into nonimproved and improved groups. The cutoff value between preoperative and postoperative Neck Disability Index scores was 30% improvement. Preoperative imaging data comprised disk height, local kyphosis, spinal cord compression, anterior osteophytes in the foramen, and anterior osteophytes of >50% of the intervertebral foramen diameter. Postoperative imaging data comprised craniocaudal length and lateral width of decompressed lamina, preserved superior facet width, and area of decompressed lamina.

RESULTS

Fifty-five patients were divided into two groups: nonimproved (n = 19) and improved (n = 36). The presence of osteophytes itself was not significant; however, the presence of osteophytes of >50% of the foramen diameter increased in the nonimproved group (P = 0.004). Mean lateral width and mean area of decompressed lamina after surgery significantly increased in the improved group (P = 0.001, P = 0.03).

CONCLUSION

The presence of anterior osteophytes >50% of the diameter of the foramen led to poor improvement of clinical outcomes in minimally invasive posterior cervical foraminotomy. However, the larger the lateral width and area of the decompressed lamina, the better the surgical outcome.

Off-label usage of RhBMP-2 in posterior cervical fusion is not associated with early increased complication rate and has similar clinical outcomes

BACKGROUND CONTEXT

Arthrodesis is important for the success of posterior cervical fusion (PCF), however, there exists limited data regarding the safety and efficacy of bone morphogenic protein (BMP) in PCF.

PURPOSE

The primary objective was to evaluate early postoperative complications associated with BMP in PCF and determine whether BMP leads to adverse early clinical outcomes. A secondary objective was to determine the optimal location for BMP sponge placement, within the facet joint (IF) or elsewhere, and the optimal dosage/level.

DESIGN

Retrospective, consecutive case-control study.

PATIENT SAMPLE

Seven hundred sixty-five patients who underwent PCF OUTCOME MEASURES: Patient-reported outcomes (PROs), complications, arthrodesis, optimum dose/level of BMP METHODS: Surgical data, including preoperative diagnosis, levels fused, type of bone graft, BMP dose (when used), and fusion technique were recorded. Complications were assessed by reviewing the medical record encompassing the first 6-weeks postoperative. These included medical, neurological, and wound-related complications and reoperation. Neurological complications were defined as any new weakness, radicular pain, or numbness. PROs were collected, including SF36, VAS, EQ-5D, and NDI scores. To determine the optimal dosage and location for BMP placement, a sub-analysis was performed.

RESULTS

There were no significant differences between the BMP and no BMP group with regards to wound complications, neurological complications, or reoperation. There were no differences in PROs between BMP and no BMP. Placement of BMP for IF and at a dose of 0.87 mg/level minimized wound-related complications. The BMP group had a higher fusion rate compared to the no BMP group (96% vs. 91%, p=.02) when assessed 1 year post-operatively.

CONCLUSION

BMP was not associated with a higher rate of early complications after PCF when the dose was minimized. Complications thought to be associated with BMP, such as compressive seroma, radiculitis, and wound-related complications were not seen at a higher rate. PROs at early follow-up were similar. Placement of BMP for IF and at lower doses than previously reported may minimize complications.

The first experience with fully endoscopic posterior cervical foraminotomy and discectomy for radiculopathy performed in Viet Duc University Hospital

The aim of the article is to present the first experience of applying a full-endoscopic posterior cervical foraminotomy and discectomy performed at Viet Duc University Hospital in Hanoi and describe the outcomes of such surgical intervention. This surgical series includes 20 patients underwent surgery through full-endoscopic posterior cervical foraminotomy and discectomy. The definitive diagnosis of the patients and the evidence for surgical treatment was radiculopathy due to lateral or intraforaminal disk herniation, foraminal stenosis, and lateral recess stenosis. Patients with discogenic cervical radiculopathy but with a contraindication to endoscopic posterior cervical foraminotomy and discectomy were not subject to surgical intervention. All patients underwent a CT and MRT examination of the cervical spine before and after surgery as complementary diagnostic methods. Besides radiological diagnostic methods, electroneuromyography and spondylography were performed with functional samples, i.e., with head tilts in the front and back, to eliminate segmental instability. The timing and degree of the root pain syndrome regression were assessed using a VAS scale (visual and analog scale) with a subsequent comparison of preoperative and postoperative performance. Immediately after the operation, all patients noted a complete or nearly complete regression of the pain syndrome.

Retrospective Analysis of Sagittal Balance Parameters and Clinical Efficacy After Short-Segment Anterior Cervical Spine Surgery with Different Fusion Devices

Objective

To compare the cervical sagittal balance parameters and clinical efficacy of three fusion devices after short-segment anterior cervical discectomy and fusion.

Patients and Methods

Retrospectively analyzed 516 patients with cervical spondylosis who underwent surgery at our hospital from May 2013 to May 2019. All patients had complete data and were divided into three groups according to the selected fusion cage. Neck and upper limb pain were assessed by the visual analog scale (VAS) score. Neurological function was evaluated by the modified Japanese Orthopedics Society (mJOA) score. Also, the curvature of the cervical spine and the occurrence of dysphagia were observed.

Results

There were no significant differences in the general information, thoracic inlet angle, T1 slope, or surgical data among the groups (p>0.05). There were significant differences in the scores between pre- and postoperatively in the different groups (p<0.05). There were no significant differences in the C2-C7 Cobb angle or C2-C7 sagittal vertebral axis before the operation among the groups (p>0.05). There was a significant difference in the correction and loss of correction among the groups postoperatively and on follow-up (p>0.05). Dysphagia was less likely in the Zero-P VA fusion group than in the other two groups.

Conclusion

Different fusion instruments can relieve the symptoms. In the Prodisc-C Vivo group, no significant improvement in cervical sagittal balance was achieved. A good effect on improving sagittal balance was observed in both the Zero-P VA fusion and Skyline anterior cervical titanium plate groups, but a better effect on preventing dysphagia was observed in the Zero-PVA fusion group.

Subjective and Objective Quality-of-Life Assessment of Outcome Measures in Cervical Spine Surgery for Degenerative Changes

Cervical spine diskectomy is a commonly used procedure in degenerative disease of cervical spine surgery. However, it is difficult to assess the quality of life after this widely applied and variously modified procedure. This literature review presents cervical diskectomy results, according to various scales and measures in multidirectional surgical strategies. Using relevant databases, we tried to find the best treatment options for degenerative disk disease and the best method of quality-of-life assessment, searching for modalities that may influence the outcome.

Anterior decompression of persistent vertebral artery occlusion caused by the cervical facet joint originated osteophyte

BACKGROUND

Persistent vertebral artery occlusion caused by compression of cervical facet joint originated osteophyte is exceptional rare. The authors sought to achieve adequate decompression of the vertebral artery (VA) with less stability decrease and movement restriction via the anterior approach, and to the authors' knowledge, no case of anterior decompression of this condition has been reported, and combination of intraoperative indocyanine green (ICG) angiography in the setting of VA decompression is also rare.

CASE PRESENTATION

A 77-year-old man presented continuous vertigo, unsteady gait and dysphagia with no relationship to the head movement. Preoperative computed tomography angiography (CTA) and digital substraction angiography (DSA) examination revealed the left vertebral artery was severely compressed at C_4-5 level with approximately 95% occlusion due to a left C_4-5 facet joint originated large osteophyte. Successful anterior decompression was performed without fusion and intraoperative ICG fluorescence angiography proved excellent blood flow. After surgery, vertebrobasilar insufficiency symptoms remarkably improved with no neurological deficits and no recurrence at 12 months' follow-up.

CONCLUSIONS

The authors' therapeutic strategy of anterior decompression was successful in treating VA compression due to facet joint overgrowth with adequate exposure, no stability decrease and movement restriction, and lower rates of neck pain and blood loss.

Semi-Elective Cervical Disc Replacements for Cervical Myelopathy: A Qualitative Study

Cervical disc prolapse can be accompanied by severe pain, numbness, paraesthesiae and muscle weakness. The choice lies between a conservative approach with physiotherapy and pain modulating drugs, such as gabapentin, or a more active surgical approach, ranging from nerve decompression through vertebral foraminotomy through to cervical disc replacement. We relate the experience of a medically qualified patient in having disc prolapse at three cervical levels and what it was like to experience a lonely and difficult post-surgical recovery. Despite this, the patient would still choose active surgical decompression over a non-interventional approach. The reasons for this are discussed from the patient perspective, of which there is little directly in the medical literature.

Surgical Interventions for Cervical Radiculopathy without Myelopathy: A Systematic Review and Meta-Analysis

BACKGROUND

The effectiveness of surgical interventions for cervical degenerative disorders has been investigated in multiple systematic reviews. Differences in study population (e.g., patients with myelopathy and/or radiculopathy) were often neglected. Therefore, the objective of this study was to investigate the effectiveness of surgical interventions for patients with symptoms of cervical radiculopathy without myelopathy by conducting a systematic review and meta-analysis based on randomized controlled trials (RCTs).

METHODS

A comprehensive systematic search was conducted in MEDLINE, Embase, and CENTRAL (Cochrane Central Register of Controlled Trials) to identify RCTs that investigated the effectiveness of surgical interventions using an anterior or posterior approach compared with other interventions for patients with pure cervical radiculopathy. Outcomes were success rates (Odom criteria, similar rating scales, or percentage of patients who improved), complication and reoperation rates, work status, disability (Neck Disability Index), and pain (arm and neck). The Cochrane risk-of-bias tool was used to assess the likelihood of the risk of bias. A random-effects model was used. Heterogeneity among study results (I2 ≥ 50% or p < 0.05) was explored by conducting subgroup analyses. Funnel plots were used to assess the likelihood of publication bias.

RESULTS

A total of 21 RCTs were included, comprising 1,567 patients. For all outcomes, among all surgical techniques, only 1 pooled estimate showed a significant effect on success rate, which was in favor of anterior cervical discectomy with fusion compared with anterior cervical discectomy without an intervertebral spacer (p = 0.02; risk ratio [RR] = 0.87; 95% confidence interval [CI] = 0.77 to 0.98). Complication rates were higher when autologous bone graft from the iliac crest was used as an intervertebral spacer (p < 0.01; RR = 3.40; 95% CI = 1.56 to 7.43), related to donor-site morbidity.

CONCLUSIONS

This meta-analysis demonstrated consistent results regarding clinical outcome for pure cervical radiculopathy among all studied interventions. Complication and reoperation rates were also similar, with the exception of higher complication rates in patients in whom autologous bone grafts were used. On the basis of clinical outcome and safety, there is no superior surgical intervention for pure cervical radiculopathy.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Transtubular Anterior Cervical Foraminotomy for the Treatment of Compressive Cervical Radiculopathy: Surgical Results and Complications in a Consecutive Series of Cases

Study Design

This was a retrospective review of patients with compressive cervical radiculopathy treated with a minimally invasive anterior cervical foraminotomy (ACF).

Purpose

This study aimed to evaluate the results and complication rates of ACF in a consecutive series of patients and to report our clinical results of ACF as a minimally invasive technique in a series of 45 consecutive patients treated for compressive cervical radiculopathy.

Overview of Literature

ACF is a motion-sparing procedure and an alternative to anterior cervical discectomy and fusion (ACDF) and posterior cervical foraminotomy for direct nerve root decompression in patients with compressive cervical radiculopathy.

Methods

The chart review recorded clinical and radiological features preoperatively and postoperatively and at follow-up (FU). The effect of prognostic factors was analyzed in relation to the clinical outcome.

Results

Between January 2004 and October 2019, 45 patients (15 females and 30 males) with a mean age of 55.9 years (range, 28-78 years) underwent ACF for unilateral cervical radiculopathy. The global clinical outcome according to the MacNab scale was evaluated as excellent in 64.5% of patients (n=29), good in 28.9% (n=13), fair in 4.4% (n=2), and poor in 2.2% (n=1). The radiological FU was available for 73.3% (n=33). The statistical analysis revealed no influence of age, sex, operated level, and side on the clinical outcome. Only one patient (2.2%) exhibited spontaneous bone fusion at the operated level on FU after a right-sided C6-7 ACF with no clinical consequences. No patient presented with signs of delayed segmental instability. The overall reoperation rate of this series was 4.4%.

Conclusions

ACF is a feasible and low-cost alternative to ACDF in selected patients with cervical radiculopathy. The use of tubular retractors in ACF may confer an added advantage that creates a safe corridor for direct cervical root decompression yet minimizing surrounding soft tissue retraction and avoiding unnecessary bone removal.

Percutaneous endoscopic cervical foraminotomy as a new treatment for cervical radiculopathy: A systematic review and meta-analysis

BACKGROUND

Anterior cervical discectomy and fusion (ACDF) is the gold standard treatment for this cervical radiculopathy. Posterior endoscopic cervical foraminotomy (PECF), an effective alternative to ACDF, is becoming widely used by an increasing number of surgeons. However, comparisons of the clinical outcomes of ACDF and PECF remain poorly explored. The purpose of this study was to evaluate and compare visual analog scale (VAS)-arm scores, VAS-neck scores, neck disability index (NDI) scores, reoperation, and complications in PECF and ACDF.

MATERIALS AND METHODS

We comprehensively searched electronic databases or platforms, including PubMed, Web of Science, EMBASE, and the Cochrane Controlled Trial Center, using the PRISMA guidelines. The required information, including VAS-arm scores, VAS-neck scores, NDI scores, reoperation, and complications, was extracted from qualified studies and independently tested and compared by 2 researchers. The methodological index for nonrandomized studies was used to evaluate study quality.

RESULTS

Nine studies consisting of 230 males and 256 females were included. The mean age of the included patients was 49.6 years, and the mean follow-up time was 20.6 months. The VAS-arm scores were significantly higher, and VAS-neck scores and NDI scores of PECF showed greater improvement trends for PECF than ACDF. The complication proportion of patients with PECF was lower, while the proportion of reoperation was similar between PECF and ACDF. ACDF was the most common revision surgery. The most common complication of PECF was transient paresthesia.

CONCLUSION

Compared with ACDF, PECF is safe and effective in patients with unilateral cervical radiculopathy without myelopathy, and PECF does not increase the probability of reoperation and complications.

Traction Therapy for Cervical Radicular Syndrome is Statistically Significant but not Clinically Relevant for Pain Relief. A Systematic Literature Review with Meta-Analysis and Trial Sequential Analysis

Aim: We aimed to investigate the effectiveness of traction therapy in reducing pain by performing a systematic review with meta-analysis. We also explore the best modality for administering traction to patients with cervical radicular syndrome (CRS). Methods: We searched the Medline, Physiotherapy Evidence Database (PEDro), Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) electronic databases. Two reviewers independently selected randomized controlled trials (RCTs) that compared traction in addition to other treatments versus the effectiveness of other treatments alone for pain outcome. We calculated the mean differences (MDs) and 95% confidence intervals (CIs). We used Cochrane’s tool to assess risk of bias and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to evaluate the quality of evidence and summarize the study conclusions. Results: A total of seven studies (589 patients), one with low risk of bias, were evaluated. An overall estimate of treatment modalities showed low evidence that adding traction to other treatments is statistically significant (MD −5.93 [95% CI, −11.81 to −0.04] P = 0.05 and I² = 57%) compared to other treatments alone. The subgroup analyses were still statistically significant only for mechanical and continuous modalities. Conclusions: Overall analysis showed that, compared to controls, reduction in pain intensity after traction therapy was achieved in patients with cervical radiculopathy. However, the quality of evidence was generally low and none of these effects were clinically meaningful.

Criteria for success after surgery for cervical radiculopathy-estimates for a substantial amount of improvement in core outcome measures

BACKGROUND CONTEXT

Defining clinically meaningful success criteria from patient-reported outcome measures (PROMs) is crucial for clinical audits, research and decision-making.

PURPOSE

We aimed to define criteria for a successful outcome 3 and 12 months after surgery for cervical degenerative radiculopathy on recommended PROMs.

STUDY DESIGN

Prospective cohort study with 12 months follow-up.

PATIENT SAMPLE

Patients operated at one or two levels for cervical radiculopathy included in the Norwegian Registry for Spine Surgery (NORspine) from 2011 to 2016.

OUTCOME MEASURES

Neck disability index (NDI), Numeric Rating Scale for neck pain (NRS-NP) and arm pain (NRS-AP), health-related quality-of-life EuroQol 3L (EQ-5D), general health status (EQ-VAS).

METHODS

We included 2,868 consecutive cervical degenerative radiculopathy patients operated for cervical radiculopathy in one or two levels and included in the Norwegian Registry for Spine Surgery (NORspine). External criterion to determine accuracy and optimal cut-off values for success in the PROMs was the global perceived effect scale. Success was defined as "much better" or "completely recovered." Cut-off values were assessed by analyzing the area under the receiver operating curves for follow-up scores, mean change scores, and percentage change scores.

RESULTS

All PROMs showed high accuracy in defining success and nonsuccess and only minor differences were found between 3- and 12-month scores. At 12 months, the area under the receiver operating curves for follow-up scores were 0.86 to 0.91, change scores were 0.74 to 0.87, and percentage change scores were 0.74 to 0.91. Percentage scores of NDI and NRS-AP showed the best accuracy. The optimal cut-off values for each PROM showed considerable overlap across those operated due to disc herniation and spondylotic foraminal stenosis.

CONCLUSIONS

All PROMs, especially NDI and NRS-AP, showed good to excellent discriminative ability in distinguishing between a successful and nonsuccessful outcome after surgery due to cervical radiculopathy. Percentage change scores are recommended for use in research and clinical practice.

Anterior cervical discectomy and fusion versus posterior cervical foraminotomy for the treatment of single-level unilateral cervical radiculopathy: a meta-analysis

BACKGROUND

To compare the effectiveness and safety of anterior cervical discectomy and fusion (ACDF) with posterior cervical foraminotomy (PCF) for patients diagnosed with single-level unilateral cervical radiculopathy.

METHODS

Relevant studies comparing ACDF with PCF for cervical radiculopathy were searched in an electronic database. After data extraction and quality assessment of included studies, a meta-analysis was done by using the RevMan 5.3 software. The random effects model was used if there was heterogeneity between studies; otherwise, the fixed effects model was used.

RESULTS

A total of 3 randomized controlled trials (RCT) and 12 retrospective studies including 52705 patients were included in the meta-analysis. There were no significant differences in Neck Disability Index (NDI), Visual Analog Scale (VAS), and patients' satisfaction (P > 0.05) between treatment groups. The complication rate of the PCF group was equivalent compared with the ACDF group (P = 0.60), but the reoperation rate following PCF was on the higher side (P = 0.02). Data analysis also showed that the PCF group was associated with shorter operation time (P = 0.001) and shorter length of hospital stay (P = 0.002).

CONCLUSIONS

Among patients with single-level unilateral cervical radiculopathy, PCF has comparable effectiveness and complication rate compared with ACDF. It seems that PCF is a sufficient alternative procedure with shorter operation time, shorter length of hospital stay, and less total hospital cost for the treatment of cervical radiculopathy. However, the higher reoperation rate following PCF should be also taken into consideration.

Comparative analysis of the biomechanics of the adjacent segments after minimally invasive cervical surgeries versus anterior cervical discectomy and fusion: A finite element study

Purpose

Percutaneous full-endoscopic anterior cervical discectomy (PEACD) and posterior cervical foraminotomy (PCF) as alternatives to anterior cervical discectomy and fusion (ACDF) are extensively used in the treatment of patients with cervical spondylotic radiculopathy. The possibility of avoiding the risk of accelerated degeneration of the adjacent segments caused by fusion is claimed to be the theoretical advantage of these approaches; however, there is a paucity of supportive evidence from biomechanical data. Therefore, this study investigated and compared the effects of PCF, PEACD, and ACDF on the adjacent segments and operative segments of the cervical spine from a biomechanical standpoint.

Method

A normal and intact three-dimensional finite element digital model of C4-C7 was constructed and validated, and the finite element models of PEACD, PCF, and ACDF were obtained by modifying the C4-C7 model. All models were exposed to identical conditions of load during flexion, extension, axial rotation, and lateral bending. We calculated the range of motion (ROM), intervertebral disc pressure (IDP), and facet joint contact force (FJCF) of the operative segment and the adjacent segment in different motion conditions.

Result

The conventional ACDF had a remarkable influence on the ROM and IDP of the operative segment and the adjacent segments. In the PEACD model, the change of ROM was not noticeable; the IDP of the operative segment was significantly smaller, whereas the change of IDP of the adjacent segment was insignificant. In the PCF model, the ROM and IDP of all segments remained unaffected.During extension, the facet joint contact force changed significantly after ACDF, and it changed slightly after PECAD and PCF.

Conclusion

By comparatively analyzing the biomechanical changes of the cervical spine after PCF, PEACD, and ACDF using the finite element method, we suggested that PCF and PEACD were more suitable for surgical intervention of cervical spondylotic radiculopathy than ACDF from a biomechanical point of view and PCF may outperform PEACD.

Selective nerve root block combined with posterior percutaneous cervical endoscopic discectomy for cervical spondylotic radiculopathy with double nerve root variation: A case report

RATIONALE

The aim of this report is to present the technique of selective nerve root blockage combined with posterior percutaneous cervical endoscopic discectomy (PPECD) for cervical spondylotic radiculopathy (CSR).

PATIENT CONCERNS

A 49-year-old female has pain in the skin area of the left scapular, pain in left elbow and limitation of left upper limb movement for 1.5 years.

DIAGNOSIS

She was diagnosed with CSR and C6-7 double nerve root variation.

INTERVENTIONS

We used selective nerve root block to determine the lesion segment and applied PPECD to relieve pressure on the patient's nerve roots.

OUTCOMES

The pain symptoms disappeared after the patient was treated with C6-7 nerve root block. Endoscopic displayed C6-7 double nerve root variation on the left side of the spinal cord intraoperative. The neurological function was intact postoperatively and no recurrence of cervical disc herniation during the 5 months' follow-up period. The hospitalization time was 5 days, the operation time was 68.2 minutes and the bleeding volume was 52.6 ml. There was no change in cervical curvature and cervical disc height postoperatively. Japanese Orthopaedic Association score, SF-36 score and Visual Analogue Scale score improved significantly postoperatively.

LESSONS

The application of selective nerve root blockage combined with PPECD for CSR could achieve satisfactory effect of position and decompression of the injured nerve root. Besides, we recommend that surgery be performed under general anesthesia to minimize patients' emotional stress and discomfort.

Posterior foraminotomy versus anterior decompression and fusion in patients with cervical degenerative disc disease with radiculopathy: up to 5 years of outcome from the national Swedish Spine Register

OBJECTIVE

The long-term efficacy of posterior foraminotomy compared with anterior cervical decompression and fusion (ACDF) for the treatment of degenerative disc disease with radiculopathy has not been previously investigated in a population-based cohort.

METHODS

All patients in the national Swedish Spine Register (Swespine) from January 1, 2006, until November 15, 2017, with cervical degenerative disc disease and radiculopathy were assessed. Using propensity score matching, patients treated with posterior foraminotomy were compared with those undergoing ACDF. The primary outcome measure was the Neck Disability Index (NDI), a patient-reported outcome score ranging from 0% to 100%, with higher scores indicating greater disability. A minimal clinically important difference was defined as > 15%. Secondary outcomes were assessed with additional patient-reported outcome measures (PROMs).

RESULTS

A total of 4368 patients (2136/2232 women/men) met the inclusion criteria. Posterior foraminotomy was performed in 647 patients, and 3721 patients underwent ACDF. After meticulous propensity score matching, 570 patients with a mean age of 54 years remained in each group. Both groups had substantial decreases in their NDI scores; however, after 5 years, the difference was not significant (2.3%, 95% CI -4.1% to 8.4%; p = 0.48) between the groups. There were no significant differences between the groups in EQ-5D or visual analog scale (VAS) for neck and arm scores. The secondary surgeries on the index level due to restenosis were more frequent in the foraminotomy group (6/100 patients vs 1/100), but on the adjacent segments there was no difference between groups (2/100).

CONCLUSIONS

In patients with cervical degenerative disc disease and radiculopathy, both groups demonstrated clinical improvements at the 5-year follow-up that were comparable and did not achieve a clinically important difference from one another, even though the reoperation rate favored the ACDF group. This study design obtains population-based results, which are generalizable.

Comparing the postoperative results of single-level anterior cervical discectomy and fusion, cervical disc prosthesis and minimal invasive posterior cervical disc surgery

Objective: Comparison of preoperative and postoperative clinical characteristics of patients who underwent single-level anterior cervical discectomy and fusion, cervical discectomy and prosthesis or minimal invasive posterior cervical discectomy.Methods: The preoperative and the postoperative characteristics (0-, 3-, 12- and 24-month results) of patients who had undergone anterior cervical discectomy and fusion (24 patients, 40%), cervical discectomy and prosthesis (21 patients, 35%) or minimal invasive posterior cervical discectomy (15 patients, 25%), for single-level disc hernia of the C3 to C7 region at the İstanbul Yeni Yüzyıl University Gaziosmanpaşa Hospital between February 2015 and December 2017 were evaluated postoperatively using visual pain scales, neck disability index (NDI) values and Odom's criteria.Results: Postoperative visual analog scale and NDI scores were significantly decreased immediately after surgery in all groups (p < .001). Similarly, these two values at the second year were significantly decreased compared to post-op values (p < .001). When pre-op, post-op, third month, first year and second year scores were compared between the groups, a significant difference was found between the groups (p < .001). It was observed that the minimal invasive posterior cervical discectomy surgery was significantly better than the other two surgeries in all follow-up assessments (p < .001 for all follow-up).Conclusion: The early postoperative values of the visual pain scale and neck disability indicator were found to demonstrate immediate benefits of the surgeries, in addition to the further decrease at the 2-year follow-up in this study.

Perioperative complications of inpatient and outpatient single-level posterior cervical foraminotomy: a comparative retrospective study

BACKGROUND CONTEXT

Posterior cervical foraminotomy (PCF) is a relatively safe procedure for the treatment of cervical radiculopathy. Though most often performed as an inpatient procedure, there is an increasing number of patients treated in an outpatient setting.

PURPOSE

This study aimed to compare the perioperative complication rates associated with inpatient and outpatient single-level PCF.

STUDY DESIGN/SETTING

Retrospective database study.

PATIENT SAMPLE

Patients with cervical radiculopathy who underwent inpatient or outpatient single-level PCF between 2007 to the first quarter of 2016.

OUTCOME MEASURES

Charlson Comorbidity Index (CCI) was used as a broad measure of comorbidity. Surgical complications included cervical nerve root injury, dural tear, wound complications, infection, dysphagia, cervicalgia, and revision surgery. Medical complications included pulmonary embolism and lower limb deep vein thrombosis, acute myocardial infarction, acute respiratory failure, pneumonia, sepsis, and urinary complications.

METHODS

This study was a retrospective review of patients who received single-level PCF from 2007 to the first quarter of 2016 as either outpatients or inpatients using the Humana subset of the PearlDiver Patient Record Database. The incidence of perioperative medical and surgical complications was queried using relevant International Classification of Diseases (ICD-9-CM and ICD-10-CM) and Current Procedural Terminology codes. Multivariate logistic regression analysis, adjusted for age, gender, and CCI, was performed to calculate odds ratios (ORs) of complications among inpatients relative to outpatients treated with PCF. Propensity score matching was done, and comparisons were made for postoperative complications.

RESULTS

Throughout the time period, 1,469 and 1,192 patients received inpatient and outpatient single-level PCF, respectively. The mean CCIs±standard deviation of inpatient and outpatient groups undergoing PCF were 2.83±3.11 and 1.46±2.21, respectively (p<.001). After propensity score matching, patients who received PCF in an inpatient setting showed significantly higher rates of wound complications (OR=1.53, 95% confidence interval [CI]=1.04-2.23; p=.029), infection (OR=1.91, CI=1.15-3.15; p=.012), acute respiratory failure (OR=2.50, CI=1.23-5.08; p=.011), and urinary tract infections and incontinence (OR=2.11, CI=1.32-3.38; p=.002).

CONCLUSIONS

Outpatient single-level PCF was associated with a lower rate of perioperative medical and surgical complications. The PCF in the outpatient setting can potentially be a safe procedure for the treatment of cervical radiculopathy with appropriate patient selection.

Minimally Invasive Posterior Cervical Foraminotomy as an Alternative to Anterior Cervical Discectomy and Fusion for Unilateral Cervical Radiculopathy: A Systematic Review and Meta-analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

The aim of this study was to evaluate clinical outcomes, complications, and reoperations of minimally invasive posterior cervical foraminotomy (MI-PCF) for unilateral cervical radiculopathy without myelopathy, in comparison to anterior cervical decompression and fusion (ACDF).

SUMMARY OF BACKGROUND DATA

ACDF is a standard treatment for cervical radiculopathy secondary to lateral disc herniation or foraminal stenosis. Recent studies have suggested MI-PCF to be an effective alternative to ACDF. However, concern for reoperation and whether similar improvements in clinical outcomes can be achieved has led to a debate in the literature.

METHODS

We comprehensively searched PubMed, CINAHL Plus, and SCOPUS utilizing terms related to MI-PCF. Two independent reviewers assessed potential studies and extracted data on clinical outcome scores (neck disability index [NDI], visual analog scale [VAS]-neck, and VAS-arm), reoperation proportion, and complications. Studies included were on noncentral cervical pathology, published in the last 10 years, had a sample size of >10 patients, and reported data on minimally invasive techniques for posterior cervical foraminotomy. Heterogeneity and publication bias analyses were performed. The pooled proportions of each outcome were compared to those of ACDF obtained from two previously published studies.

RESULTS

Fourteen studies were included with data of 1216 patients. The study population was 61.8% male, with a mean age of 51.57 years, and a mean follow-up of 30 months. MI-PCF resulted in a significantly greater improvement in VAS-arm scores compared to ACDF, and similar improvements in VAS-neck and NDI scores. Proportions of complications and reoperations were similar between the two cohorts. The most common complications were transient neuropraxia, wound-related, and durotomy.

CONCLUSION

Our findings suggest that MI-PCF may be utilized as a safe and effective alternative to ACDF in patients with unilateral cervical radiculopathy without myelopathy, without concern for increased reoperations or complications.

LEVEL OF EVIDENCE

3.

How Does Screw Migration or Fracture After Anterior Cervical Plate Fixation Affect the Radiographic and Clinical Outcomes?

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

The objective of this article is to assess the effect of screw migration and fracture associated with anterior cervical plating on long-term radiographic and clinical outcomes.

BACKGROUND DATA

Screw migration and breakage detected after anterior cervical discectomy/corpectomy and fusion with plating may cause various implant-related complications and reduce solid fusion rate. However, little is known about their long-term prognosis.

MATERIALS AND METHODS

Medical records and radiographic data of 248 consecutive patients who underwent anterior cervical discectomy and fusion or anterior cervical corpectomy and fusion with a dynamic plating system and were followed up for ≥2 years were retrospectively reviewed. Patients who experienced screw migration or breakage were classified as screw failure group (SF group, n=25). Patients without screw loosening or fracture until the last follow-up were defined as the nonfailure group (NF group, n=223). Visual analogue scales for neck pain, arm pain, and neck disability index were assessed. Radiologic measurements were performed to analyze solid fusion. The solid union was defined as interspinous motion ≤1 mm on flexion/extension lateral x-rays.

RESULTS

A number of levels fused was significantly associated with increased risk of screw failure (P<0.01). A total of 13 patients in the SF group achieved solid fusion at final follow-up, although fusion rates at all postoperative time points were significantly lower in the SF group than in the NF group, including at final follow-up (P<0.01). Failures in 23 (92%) screw failure patients developed at the lowermost instrumented vertebra. The SF and NF groups experienced similar degrees of neck pain, arm pain, and neck disturbance index scores. There were no cases of complete screw extrusion or related complications requiring revision surgery.

CONCLUSION

Although screw failure increased the incidence of pseudarthrosis, it did not aggravate postoperative arm pain, neck pain, or neck disability. As failed implants rarely migrate to an extent that endangers tracheoesophageal structures, immediate removal is rarely necessary.

Ninety-Day Bundled Payment Reimbursement for Patients Undergoing Anterior and Posterior Procedures for Degenerative Cervical Radiculopathy

BACKGROUND

Anterior cervical discectomy with fusion (ACDF) or posterior cervical foraminotomy (PCF) are the mainstay surgical treatment options for patients with degenerative cervical radiculopathy (DCR).

OBJECTIVE

To compare 90-d bundled payments between ACDF and PCF for DCR in a cohort study.

METHODS

Data were extracted from MarketScan database (2000-2016) using ICD-9, ICD-10, and CPT-4 codes. The bundle payments were calculated as the payments accumulated from the index hospitalization admission to 90 d postsurgery. We also analyzed the index hospitalization (physician, hospital, and total) and the postdischarge payments (hospital readmission, outpatient services, medications, and total). Surgical groups were matched based on baseline characteristics (age, sex, insurance type, and Elixhauser score).

RESULTS

A total of 100 041 patients met the inclusion criteria. 94.9% of patients (n = 95 031). Patients underwent ACDF with 5.1% (n = 5 010) treated via PCF. Overall, median 90-d costs were significantly higher for ACDF than for PCF ($31567 vs $18412; P < .0001). The median total index hospitalization ($27841 vs $15043), physician ($4572 vs $1920), and hospital payments ($14540 vs $7404) were higher for ACDF compared to PCF for both single- and multiple-level cohorts (P < .0001). There was no difference in overall 90-d postdischarge payments. Factors associated with higher 90-d payments for both cohorts included age and comorbidity scores.

CONCLUSION

ACDF is associated with greater bundle payments in patients diagnosed with DCR. No difference was noted for the total postdischarge payments. PCF may be a cost-effective surgical option in appropriately selected patients with unilateral, paracentral, and foraminal soft herniated discs.

[Surgical design and clinical application of posterior percutaneous full-endoscopic cervical foraminotomy for cervical osseous foraminal stenosis]

Objective

To design the method of posterior percutaneous full-endoscopic cervical foraminotomy (P-PECF) for treating cervical osseous foraminal stenosis and analyze its feasibility in clinical application.

Methods

The clinical data of 12 patients with cervical osseous foraminal stenosis who met the selection criteria between October 2015 and June 2017 were retrospectively analysed. There were 7 males and 5 females with an age of 52-63 years (mean, 57.6 years). The disease duration ranged from 15 days to 6 months (mean, 3.7 months). The segments included C _{4, 5} in 2 cases, C _{5, 6} in 6 cases, and C _{6, 7} in 4 cases; all showing root pain or numbness caused by nerve root compression. All patients were treated with the P-PECF technique. At preoperation, immediately after operation, and at last follow-up, visual analogue scale (VAS) scores and neck disability index (NDI) were respectively recorded to assess the patient's quality of life and the pain of neck and arm. The clinical outcomes were evaluated by the modified Macnab criteria.

Results

All operations were successful. The operation time was 71-105 minutes (mean, 82 minutes); the intraoperative blood loss was about 5 mL. The CT of the cervical spine at 1 week postoperatively showed that the cervical root canal was enlarged and the nerve root compression was relieved. The symptoms of neck and arm pain and numbness were relieved; the hospitalization time was 2-5 days (mean, 3 days). All patients were followed up 6-18 months (mean, 12.3 months). Except for 1 patient's feeling transient hypoesthesia postoperatively, there was no complication such as hematoma, nerve root injury, or incision infection. The VAS scores and NDI at immediate postoperatively and at last follow-up were significantly improved when compared with preoperative scores ( P<0.05); and the scores also improved significantly at last follow-up when compared with the scores at immediate postoperatively ( P<0.05). According to modified Macnab criteria, the results were excellent in 9 cases, good in 2 cases, and fair in 1 case, with an excellent and good rate of 91.7%.

Conclusion

The P-PECF technique can enlarge the nerve root canal and relieve nerve root compression, and obtain better effectiveness by minimally invasive methods. It is a safe and feasible procedure.