Comparative Analysis between Total Disc Replacement and Posterior Foraminotomy for Posterolateral Soft Disc Herniation with Unilateral Radiculopathy : Clinical and Biomechanical Results of a Minimum 5 Years Follow-up

Minimally invasive posterior cervical foraminotomy versus anterior cervical fusion and arthroplasty: Systematic review and updated meta-analysis

Introduction

This study is a systematic review and meta-analysis that investigates the efficacy of different surgical methods for treating cervical disc herniation or cervical foraminal stenosis.

Research question

The research aimed to compare the efficacy of Minimally Invasive Posterior Cervical Foraminotomy (MI-PCF) with anterior approaches, namely Anterior Cervical Discectomy and Fusion (ACDF) and Cervical Disc Arthroplasty (CDA).

Material and methods

The study included a comprehensive review of eight articles that compared ACDF and MI-PCF, and four articles that compared CDA to MI-PCF.

Results

The results indicated no significant difference in surgical duration, hospital stay, complication rates, and reoperation rates between MI-PCF and ACDF. However, when comparing CDA with MI-PCF, it was found that CDA had a higher complication rate, while MI-PCF had a higher reoperation rate.

Discussion and conclusion

Despite these findings, the study recommends MI-PCF as the preferred surgical method for cervical radiculopathy, owing to the advancements in minimally invasive techniques. However, these findings are preliminary, and further research with longer follow-up periods and larger sample sizes is necessary to confirm these findings and to further explore the potential advantages and disadvantages of these surgical methods.

Comparing outcomes between anterior cervical disc replacement (ACDR) and minimally invasive posterior cervical foraminotomy (MI-PCF) in the treatment of cervical radiculopathy

BACKGROUND CONTEXT

Anterior cervical disc replacement (ACDR) and minimally invasive posterior cervical foraminotomy (MI-PCF) have emerged as two increasingly popular alternatives to anterior cervical discectomy and fusion (ACDF) for the management of cervical radiculopathy. Both techniques provide advantages of segmental motion preservation and lower rates of adjacent segment degeneration (ASD) compared to ACDF.

PURPOSE

The purpose of this study was to analyze the clinical and functional outcomes of patients undergoing ACDR or MI-PCF for the treatment of unilateral cervical radiculopathy.

STUDY DESIGN/SETTING

Retrospective Cohort Review.

PATIENT SAMPLE

A total of 152 patients were included (86 ACDR and 66 MI-PCF).

OUTCOME MEASURES

(1) Patient demographics; (2) perioperative data; (3) rates of complications and revisions; (5) visual analogue scale (VAS) and Neck Disability Index (NDI) scores.

METHODS

A retrospective cohort review was performed to identify all patients at a single institution between 2012-2020 who underwent 1- or 2- level ACDR or MI-PCF from C3-C7 with a minimum follow-up of 24 months. Patient demographics, perioperative data, postoperative complications, and revisions were analyzed. Patient reported outcome measures including VAS and NDI scores were compared.

RESULTS

The ACDR group had a significantly greater mean operative time (99.8 minutes vs 79.2 minutes, p<.001), but comparable estimated blood loss and length of stay following surgical intervention (p=.899). The overall complication rate was significantly greater in the ACDR group than the MI-PCF group (24.4% vs 6.2%; p=.003) but was largely driven by approach-related dysphagia in 20.9% of ACDR patients. The MI-PCF group had significantly greater revision rates (13.6% vs 1.2%; p=.002) with an average time to revision of 20.7 months in the MI-PCF group compared to 40.3 months in the ACDR group. The ACDR cohort had significantly greater improvements in NDI scores at the final follow-up (25.0 vs 21.3, p<.001).

CONCLUSION

Our results suggest that ACDR offer clinically relevant advantages over MI-PCF in terms of long-term revision rates despite an increased approach-related risk of transient postoperative dysphagia. Additionally, patients in the ACDR cohort achieved greater mean improvements in NDI scores but these results may have limited clinical significance due to inability to reach minimally clinically important difference (MCID) thresholds.

Impact of Posterior Cervical Foraminotomy Before or After Cervical Disk Replacement: Current Evidence

STUDY DESIGN

Narrative review.

OBJECTIVES

The purpose of this study was to provide a review of the current evidence on the impact of posterior cervical foraminotomy (PCF) performed before or after cervical disk replacement (CDR).

SUMMARY OF BACKGROUND DATA

The impact of PCF on outcomes in the setting of CDR is an evolving field, given the recent widespread adoption of CDR and the relative rarity of patients who have undergone both procedures.

METHODS

A literature search was conducted using PubMed to determine current evidence regarding the indications, outcomes, and biomechanical effects of CDR and PCF when performed alone or in combination.

RESULTS

When radicular symptoms persist following PCF, a CDR can be safely performed to provide further decompression. Conversely, a PCF can be safely performed following CDR for these same indications. The biomechanical effects of these procedures in combination demonstrate maintained stability when the facetectomy is less than 50% of the facet joint. Studies demonstrate that stability is not significantly decreased by the presence, amount, or level of posterior foraminotomies in the setting of CDR.

CONCLUSIONS

A PCF can be safely performed before or after cervical disk arthroplasty for recurrent radicular symptoms.

LEVEL OF EVIDENCE

Level V.

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.

Appraising The Evidence for Conservative versus Surgical Management of Motor Deficits in Degenerative Cervical Radiculopathy

STUDY DESIGN

Systematic review.

OBJECTIVES

Understanding the prevalence and outcome of motor deficits in degenerative cervical radiculopathy is important to guide management. We compared motor radiculopathy outcomes after conservative and surgical management, a particular focus being painful vs painless radiculopathy.

METHODS

MEDLINE and EMBASE databases were searched. We stratified each study cohort into 1 of 6 groups, I-VI, based on whether radiculopathy was painful, painless or unspecified, and whether interventions were surgical or non-surgical.

RESULTS

Of 10 514 initial studies, 44 matched the selection criteria. Whilst 42 (95.5%) provided baseline motor radiculopathy data, only 22 (50.0%) provided follow-up motor outcomes. Mean baseline prevalence of motor deficits was 39.1% (9.2%-73.3%) in conservative cohorts and 60.5% (18.5%-94.1%) in surgical cohorts. Group VI, 'surgically-managed motor radiculopathy with unclear pain status' had the largest number of cohorts. Conversely, no cohorts were found in Group III, 'conservatively-managed painless motor radiculopathy'. Large disparities in data quality made direct comparison of conservative vs operative management difficult.

CONCLUSIONS

Overall pre-intervention prevalence of motor deficits in degenerative cervical radiculopathy is 56.4%. Many studies fail to report motor outcomes after intervention, meaning statistical evidence to guide optimal management of motor radiculopathy is currently lacking. Our study highlights the need for more evidence, preferably from a prospective long-term study, to allow direct comparisons of motor outcomes after conservative and surgical management.

Minimally invasive posterior cervical foraminotomy versus anterior cervical discectomy and fusion for cervical radiculopathy: a meta-analysis

With the recent development of minimally invasive techniques, minimally invasive posterior cervical foraminotomy (MIS-PCF) has become increasingly popular as a minimally invasive method to treat cervical radiculopathy. However, there are still controversies about whether MIS-PCF is superior to anterior cervical discectomy and fusion (ACDF). The purpose of this study is to evaluate the therapeutic effects of MIS-PCF and ACDF on unilateral cervical radiculopathy without myelopathy. We searched PubMed, Embase, the Cochrane Library, and Scopus comprehensively using the terms related to MIS-PCF. Two reviewers independently evaluated the potential studies, and extracted and analyzed the data of operation time, hospital stay, neck disability index (NDI) score, visual analog scale for neck pain (VAS-neck) and arm pain (VAS-arm) scores, reoperation rate, and complications. Seven studies with 1175 patients were included. The study population was 53.5% male, with a mean age of 48.9. MIS-PCF presented a significantly shorter postoperative hospitalization time compared to ACDF, while the operation time, complication/reoperation rate, and VAS-arm, VAS-neck, and NDI scores were comparable between the two cohorts. In North America, the average cost of MIS-PCF is lower than ACDF. Thus, we suggest that MIS-PCF is an alternative to ACDF for selected patients.

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.

Feasibility of Posterior Cervical Foraminotomy for Adjacent Segmental Disease after Anterior Cervical Fusion

Objective

The aim of this study is to evaluate the feasibility of posterior cervical foraminotomy (PCF) for adjacent segmental disease (ASD) after anterior cervical fusion (ACF). As ACF is accepted as the standard treatment for cervical spondylosis, many studies have been conducted to evaluate the efficacy of various surgical techniques to overcome symptomatic ASD after the previous surgery. Herein, PCF was performed for the treatment of symptomatic ASD and the feasibility of the surgery was evaluated.

Methods

Forty nine patients who underwent PCF due to symptomatic ASD from August 2008 to November 2017 were identified. For demographic and perioperative data, the sex, age, types of previous surgery, ASD levels, operation times, and bleeding amount were recorded. The clinical outcome was assessed using the visual analogue scale for the neck and arm, the modified Odom’s criteria as well as neck disability index. Radiologic evaluations were performed by measuring disc softness, disc height, the cervical 2–7 sagittal vertical axis, cervical cobb angle, and facet violation.

Results

Thirty-seven patients were enrolled in this study. The patients were divided into two groups based on the location of the pathology; paracentral (group P) or foramina (group F). Both groups showed significant clinical improvement (p<0.05). The proportion of calcified disc and facet violations was significantly larger in group F (p<0.05). The minimal disc height decrease with mild improvement on sagittal alignment and cervical lordosis was radiologically measured without statistical significance in both groups (p>0.05).

Conclusion

PCF showed satisfactory clinical and radiologic outcomes for both paracentral and foraminal pathologies of ASD after ACF. Complications related to anterior revision were also avoided. PCF can be considered a feasible and safe surgical option for ASD after ACF.

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.

Does the Neck Pain, Function, or Range of Motion Differ After Anterior Cervical Fusion, Cervical Disc Replacement, and Posterior Cervical Foraminotomy?

OBJECTIVE

To evaluate clinical and radiologic results as well as biomechanical changes after anterior cervical discectomy and fusion (ACDF), cervical disc replacement (CDR), and posterior cervical foraminotomy (PCF) and/or discectomy in individuals with unilateral single-level cervical radiculopathy.

METHODS

A total of 97 patients received surgical treatment for unilateral intolerable radiculopathy between February 2012 and August 2017. Clinical outcomes included Neck Disability Index (NDI), visual analogue scale (VAS) for neck and arm pain, and modified Odom's criteria. Range of motion (ROM) of the whole cervical (C-ROM), operated segment (S-ROM), and upper and lower adjacent segment (U-ROM and L-ROM) were measured.

RESULTS

A total of 55 ACDFs, 21 CDRs, and 21 PCFs were performed. Clinical improvement in NDI and VAS scores were significant after surgery; however, there was no statistical significance among groups. Satisfaction rate (based on Odom's criteria) of PCF (76.2%) was inferior to that of ACDF (90.9%) and CDR (90.5%) without statistical difference. S-ROM, U-ROM, and L-ROM were slightly better in the CDR and PCF groups, without statistical significance. C-ROM significantly increased in CDR group (P = 0.04) and slightly increased in PCF group (P = 0.27). In the ACDF group, C-ROM decreased (P = 0.21) and on the contrary, the U-ROM and L-ROM increased (P > 0.05).

CONCLUSIONS

ACDF, CDR, and PCF resulted in pain relief and improvement in neck function for patients with unilateral radiculopathy. Comparatively, ACDF provides the lowest reoperation rate. CDR is effective in ameliorating cervical ROMs. PCF has a greater probability of reoperation; however, ROM after surgery is better than with ACDF.

Changes in cervical motion after cervical spinal motion preservation surgery

BACKGROUND

For patients with single-level cervical radiculopathy, various types of motion preservation surgeries, such as total disc replacement (TDR), posterior cervical foraminotomy (PCF) and posterior percutaneous endoscopic foraminotomy and discectomy (PECF), are available. In addition to motion preservation, the quality of motion is an important issue. The aim of the present study was to evaluate the influence of these surgeries on cervical motion by comparing the instantaneous axis of rotation (IAR) among PECF, TDR and PCF at the index and superior/inferior adjacent segments.

METHODS

A retrospective review was performed of patients who underwent index surgery at C5-6 for cervical single-level foraminal disc herniation or foraminal stenosis. Patients with minimal degeneration at the index and other cervical spinal levels and flexion/extension cervical lateral radiographs both preoperatively and 6 months postoperatively were included (PECF, 11 patients; TDR, 11 patients; PCF, 12 patients). The IARs were calculated at the index segment and segments above and below the index segment from the flexion and extension cervical lateral radiographs, which were obtained preoperatively and 6 months postoperatively. A standardized cervical normogram was referenced to qualify shifts in the IAR.

RESULTS

Postoperatively, neck pain was significantly decreased, with no difference among the surgical methods. The IARs were not significantly changed after the PECF. Although significant inferior shift occurred at C6-7 after TDR (p = 0.02), the shift occurred within the normal range in the cervical normogram. However, significant inferior shifts in the IARs occurred after PCF at C5-6 (p = 0.02) and C6-7 (p = 0.02), and the IARs moved out of the normal range.

CONCLUSIONS

The IARs were significantly changed after PCF at either the index segment or the adjacent segment below. The shifts in IAR at the index and adjacent segments were not significant after PECF and TDR. The sample size was too small to allow definitive conclusions, but the present study showed that PECF may be another alternative to motion preservation surgeries.