1
|
Shima K, Shimizu T, Fujibayashi S, Murata K, Matsuda S, Otsuki B. Feasibility of total and partial uncinectomy during anterior cervical approach: MRI-based analysis of 176 patients regarding vertebral artery location. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:3540-3546. [PMID: 37634197 DOI: 10.1007/s00586-023-07888-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 07/12/2023] [Accepted: 08/06/2023] [Indexed: 08/29/2023]
Abstract
PURPOSE To determine the technical feasibility of uncinate process (UP) resection (uncinectomy) during anterior cervical approach with risk-avoidance of vertebral artery (VA) injury. METHODS One hundred and seventy-six magnetic resonance imaging images with cervical spondylosis were evaluated. The diameter between UP and VA (UP-VA distance), the presence of a fat plane, and the VA's anterior-posterior position relative to UP (anterior[A], middle[M], posterior[P]) at C3-4 to C6-7 segments were investigated. Subsequently, easy-to-use classifications were developed according to the feasibility of total and partial uncinectomy. Total uncinectomy: easy (distance: > 2 mm); moderate (distance: ≤ 2 and fat plane: +); advanced (no fat plane). Partial uncinectomy: easy (distance: > 2 mm and P, A, or M position); moderate (distance: ≤ 2; fat plane: + and P position), and advanced (no fat plane and P position). RESULTS UP-VA distance of C5-6 on the right side (left/right: 0.41/0.31 mm) was the smallest. The ratio of no fat plane of C5-6 (46.6%/49.4%) was the highest. C5-6 had a high rate of P position (7.4%/8.5%) while C6-7 had a high rate of A position (19.3%/18.2%). More than 90% individuals were classified as easy for partial uncinectomy at any vertebral segment (C3-7), while more than 30% were classified as advanced at C4-7 with the highest rate at C5-6 for total uncinectomy. CONCLUSION When performing uncinectomy during the anterior cervical approach, the C5-6 segment may be at the greatest risk of VA injury. Hence, preoperative MR images should be thoroughly evaluated to avoid VA injury.
Collapse
Affiliation(s)
- Koichiro Shima
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Shogoin, Kawahara-Cho 54, Sakyo-Ku, Kyoto, 606-8507, Japan.
| | - Takayoshi Shimizu
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Shogoin, Kawahara-Cho 54, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Shunsuke Fujibayashi
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Shogoin, Kawahara-Cho 54, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Koichi Murata
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Shogoin, Kawahara-Cho 54, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Shuichi Matsuda
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Shogoin, Kawahara-Cho 54, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Bungo Otsuki
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Shogoin, Kawahara-Cho 54, Sakyo-Ku, Kyoto, 606-8507, Japan
| |
Collapse
|
2
|
Yin M, Ding X, Zhu Y, Lin R, Sun Y, Xiao Y, Wang T, Yan Y, Ma J, Mo W. Safety and Efficacy of Anterior Cervical Discectomy and Fusion with Uncinate Process Resection: A Systematic Review and Meta-Analysis. Global Spine J 2022; 12:1956-1967. [PMID: 35349779 PMCID: PMC9609504 DOI: 10.1177/21925682221084969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
STUDY DESIGN This is a meta-analysis and systematic review of the available literature. OBJECTIVE In the case of severe foraminal stenosis, conducting uncinate process resection (UPR) during ACDF could achieve complete nerve root decompression and significant relief of neurological symptoms for CR. However, there is some controversy regarding its necessity and safety. This study aims to compare the safety and efficacy of ACDF with UPR and ACDF. METHODS The following electronic databases were searched: Medline, PubMed, Embase, the Cochrane Central Register of Controlled Trials, Evidence Based Medicine Reviews, VIP, and CNKI. And the following data items were considered: baseline demographics, efficacy evaluation indicators, radiographic outcome, and surgical details. RESULTS 10 studies were finally identified, including 746 patients who underwent ACDF with UPR compared to 729 patients who underwent ACDF. The group of ACDF with UPR had statistically longer intraoperative time (95% CI: 4.83, 19.77, P = .001) and more intraoperative blood loss (95% CI: 12.23, 17.76, P < .001). ACDF with UPR obtained a significantly better improvement of Arm VAS at postoperative first follow-up (95% CI: -1.85, -.14 P = .02). There was no significant difference found in improvement of Neck VAS at postoperative latest follow-up (95% CI: -.88, .27, P = .30), improvement of Arm VAS at postoperative latest follow-up (95% CI: -.59, -.01, P = .05), improvement of NDI (95% CI: -2.34, .33, P = .14), JOA (95% CI: -.24, .43, P = .56), change of C2-C7 lordosis (95% CI: -.87, 1.33, P = .68), C2-C7 SVA (95% CI: -.73, 5.08, P = .14), T1 slope (95% CI: -2.25, 1.51, P = .70), and fusion rate (95% CI: .83, 1.90 P = .29). CONCLUSION ACDF with UPR is an effective and necessary surgical method for CR patients with severe foraminal stenosis.
Collapse
Affiliation(s)
- Mengchen Yin
- Shanghai University of Traditional
Chinese Medicine, Shanghai, China,Long hua Hospital, Shanghai
University of Traditional Chinese Medicine, Shanghai, China
| | - Xing Ding
- Shanghai University of Traditional
Chinese Medicine, Shanghai, China,Long hua Hospital, Shanghai
University of Traditional Chinese Medicine, Shanghai, China
| | - Yuefeng Zhu
- Shanghai University of Traditional
Chinese Medicine, Shanghai, China
| | - Rui Lin
- Guangdong Provincial Hospital of
Chinese Medicine, Guangzhou, China
| | - Yueli Sun
- Shanghai University of Traditional
Chinese Medicine, Shanghai, China,Long hua Hospital, Shanghai
University of Traditional Chinese Medicine, Shanghai, China
| | - Yu Xiao
- Shanghai University of Traditional
Chinese Medicine, Shanghai, China,Long hua Hospital, Shanghai
University of Traditional Chinese Medicine, Shanghai, China
| | - Tao Wang
- Shanghai University of Traditional
Chinese Medicine, Shanghai, China,Long hua Hospital, Shanghai
University of Traditional Chinese Medicine, Shanghai, China
| | - Yinjie Yan
- Shanghai University of Traditional
Chinese Medicine, Shanghai, China,Long hua Hospital, Shanghai
University of Traditional Chinese Medicine, Shanghai, China
| | - Junming Ma
- Shanghai University of Traditional
Chinese Medicine, Shanghai, China,Long hua Hospital, Shanghai
University of Traditional Chinese Medicine, Shanghai, China
| | - Wen Mo
- Shanghai University of Traditional
Chinese Medicine, Shanghai, China,Long hua Hospital, Shanghai
University of Traditional Chinese Medicine, Shanghai, China
| |
Collapse
|
3
|
Cabrera J, Carelli L, Girão A, Cechin Í. Unilateral spacer distraction of the subaxial cervical facet joint for the treatment of fixed coronal malalignment of the craniovertebral junction. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2022; 13:121-126. [PMID: 35837431 PMCID: PMC9274674 DOI: 10.4103/jcvjs.jcvjs_9_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 05/08/2022] [Indexed: 11/09/2022] Open
Abstract
Introduction: The standard treatment for a fixed coronal malalignment of the craniovertebral junction is an anterior and/or posterior column osteotomy (PCO) plus instrumentation. However, the procedure is very challenging, carrying an inherently high risk of complications even in experienced hands. This case series demonstrates the usefulness of an alternative treatment that adds a unilateral spacer distraction (USD) to the subaxial cervical facet joint to promote coronal realignment and fusion. Materials and Methods: A single-center retrospective study of the patients with fixed coronal malalignment of the craniovertebral junction caused by different etiologies treated with USD in the concavity side with PCO in the convexity side of the subaxial cervical spine. Demographic characteristics and radiological parameters were collected with special emphasis on clinical and radiological measurements of coronal alignment of the cervical spine. Results: From 2012 to 2019, four patients were treated with USD of the subaxial cervical spine complementing an asymmetrical PCO at the same level. The causes of coronal imbalance were congenital, tuberculosis, posttraumatic, and ankylosing spondylitis. The level of USD was C2–C3 in three patients and C3–C4 in one patient. A substantial coronal realignment was achieved in all four. One patient had an iatrogenic vertebral artery injury during the dissection and facet distraction and developed Wallenberg's syndrome with partial recovery. Conclusions: USD of the concave side with unilateral PCO of the convexity side in the subaxial cervical spine is a promising alternative treatment for fixed coronal malalignment of the craniovertebral junction from different causes.
Collapse
|
4
|
Echt M, Mikhail C, Girdler SJ, Cho SK. Anterior Reconstruction Techniques for Cervical Spine Deformity. Neurospine 2020; 17:534-542. [PMID: 33022158 PMCID: PMC7538358 DOI: 10.14245/ns.2040380.190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/05/2020] [Accepted: 08/17/2020] [Indexed: 01/07/2023] Open
Abstract
Cervical spine deformity is an uncommon yet severely debilitating condition marked by its heterogeneity. Anterior reconstruction techniques represent a familiar approach with a range of invasiveness and correction potential-including global or focal realignment in the sagittal and coronal planes. Meticulous preoperative planning is required to improve or prevent neurologic deterioration and obtain satisfactory global spinal harmony. The ability to perform anterior only reconstruction requires mobility of the opposite column to achieve correction, unless a combined approach is planned. Anterior cervical discectomy and fusion has limited focal correction, but when applied over multiple levels there is a cumulative effect with a correction of approximately 6° per level. Partial or complete corpectomy has the ability to correct sagittal deformity as well as decompress the spinal canal when there is anterior compression behind the vertebral body. If pathoanatomy permits, a hybrid discectomy-corpectomy construct is favored over multilevel corpectomies. The anterior cervical osteotomy with bilateral complete uncinectomy may be necessary for angular correction of fixed cervical kyphosis, and is particularly useful in the midcervical spine. A detailed understanding of the patient's local anatomy, careful attention to positioning, and avoiding long periods of retraction time will help prevent complications and iatrogenic injury.
Collapse
Affiliation(s)
- Murray Echt
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Christopher Mikhail
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Steven J. Girdler
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samuel K. Cho
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| |
Collapse
|
5
|
Clifton W, Valero-Moreno F, Vlasak A, Damon A, Tubbs RS, Merrill S, Pichelmann M. Microanatomical considerations for safe uncinate removal during anterior cervical discectomy and fusion: 10-year experience. Clin Anat 2020; 33:920-926. [PMID: 32239547 DOI: 10.1002/ca.23596] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 03/25/2020] [Accepted: 03/27/2020] [Indexed: 11/09/2022]
Abstract
Cervical radiculopathy from uncovertebral joint (UVJ) hypertrophy and nerve root compression often occurs anterior and lateral within the cervical intervertebral foramen, presenting a challenge for complete decompression through anterior cervical approaches owing to the intimate association with the vertebral artery and associated venous plexus. Complete uncinatectomy during anterior cervical discectomy and fusion (ACDF) is a controversial topic, many surgeons relying on indirect nerve root decompression from restoration of disc space height. However, in cases of severe UVJ hypertrophy, indirect decompression does not adequately address the underlying pathophysiology of anterolateral foraminal stenosis. Previous reports in the literature have described techniques involving extensive dissection of the cervical transverse process and lateral uncinate process (UP) in order to identify the vertebral artery for safe removal of the UP. Recent anatomical investigations have detailed the microanatomical organization of the fibroligamentous complex surrounding the UP and neurovascular structures. The use of the natural planes formed from the encapsulation of these connective tissue layers provides a safe passage for lateral UP dissection during anterior cervical approaches. This can be performed from within the disc space during ACDF to avoid extensive lateral dissection. In this article, we present our 10-year experience using an anatomy-based microsurgical technique for safe and complete removal of the UP during ACDF for cervical radiculopathy caused by UVJ hypertrophy.
Collapse
Affiliation(s)
- William Clifton
- Department of Neurological Surgery, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Fidel Valero-Moreno
- Department of Neurological Surgery, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Alexander Vlasak
- Department of Neurological Surgery, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Aaron Damon
- Department of Neurological Surgery, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - R Shane Tubbs
- Department of Neurosurgery and Structural and Cellular Biology, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Sarah Merrill
- Mayo Clinic Alix School of Medicine, Scottsdale, Arizona, USA
| | - Mark Pichelmann
- Department of Neurosurgery, Mayo Clinic Health Systems, Eau Claire, Wisconsin, USA
| |
Collapse
|
6
|
Valero-Moreno F, Clifton W, Damon A, Pichelmann M. Total Anterior Uncinatectomy During Anterior Discectomy and Fusion for Recurrent Cervical Radiculopathy: A Two-dimensional Operative Video and Technical Report. Cureus 2020; 12:e7466. [PMID: 32351845 PMCID: PMC7188006 DOI: 10.7759/cureus.7466] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
A common cause of cervical radiculopathy from degenerative foraminal stenosis is severe uncovertebral hypertrophy. It is difficult to accomplish complete foraminal decompression in these cases with posterior techniques without the removal of a large portion of the facet joint. Total removal of the uncovertebral joint from an anterior approach allows for complete decompression of the exiting cervical nerve root and has been shown to be a safe technique. In this surgical video and technical report, we demonstrate the surgical anatomy and operative technique of a two-level anterior uncinatectomy during anterior discectomy and fusion (ACDF) for recurrent cervical radiculopathy after a previous multi-level posterior foraminotomy. The patient is a 67-year-old male with a progressive left arm and neck pain with radiographic, clinical, and electrophysiologic diagnostic evidence of active C6 and C7 radiculopathies from degenerative foraminal stenosis at the C5-6 and C6-7 levels. Posterior foraminotomies had been performed without significant improvement in his radicular pain. A repeat MRI demonstrated lateral foraminal stenosis from severe uncovertebral joint hypertrophy at the C5-6 and C6-7 levels. After acquiring informed consent from the patient, an anterior approach was performed with complete removal of the uncovertebral joints at both levels with discectomy and fusion. Postoperatively, the patient had complete resolution of his radicular pain and remained pain-free at the latest follow-up. Complete uncinatectomy and ACDF is an effective technique for complete foraminal decompression in cases of refractory radiculopathy and neck pain after unsuccessful posterior decompression.
Collapse
Affiliation(s)
| | | | - Aaron Damon
- Neurological Surgery, Mayo Clinic, Jacksonville, USA
| | | |
Collapse
|
7
|
Clifton W, Pichelmann M. Letter to the Editor. Safety in the use of a high-speed burr for total uncinectomy during ACDF. J Neurosurg Spine 2019; 32:488-489. [PMID: 31731272 DOI: 10.3171/2019.9.spine191122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|