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Minimally invasive posterior cervical foraminotomy for treatment of radiculopathy

An effective, time-tested, and cost-efficient motion-preservation technique

Minimal-invasive posteriore zervikale Foraminotomie zur Behandlung der Radikulopathie

Eine wirksame, bewährte und preiswerte „Non-fusion“-Technik

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A Correction to this article was published on 21 December 2017

This article has been updated

Abstract

Objective

To relieve foraminal root impingement due to lateral soft disc fragments, bony spurs, or other rarer causes.

Indications

Soft disc fragment whose bulk is >2/3 lateral to the lateral border of the thecal sac. Intraforaminal dorsal bony narrowing of the root canal. Intraforaminal synovial cyst, extra/intradural tumor.

Contraindications

Paramedian and median soft/hard disc protrusions. Kyphosis of the index level.

Surgical technique

Patient prone in reverse Trendelenburg position with the head fixed in a Mayfield clamp. Cervical spine horizontal and approximately 10 cm above the heart. Microscope from skin to skin. Skin incision: 25 mm, about 10 mm off the midline. Microsurgical blunt splitting of the muscle layers along the fiber direction. An expandable tubular retractor or a miniaturized speculum counter retractor, table anchored, is centered on the target lamino-facet junction as confirmed by fluoroscopy. Drilling of the keyhole. The axilla of the root is exposed while preserving most of the facet complex. Epidural exploration until an extruded or subligamentous disc fragment(s) is removed. If needed, removal of the dorsal bone overlying the root exiting in the foramen. The adequacy of decompression is assessed by palpating the root along its course with a small nerve hook. Closure by layers. No drain.

Postoperative management

Same day mobilization. No external brace.

Results

Minimally invasive posterior cervical foraminotomy (MI-PCF) was used to treat 103 patients for unilateral cervical radiculopathy. Mean follow-up was 32 months. Despite 1 cerebrospinal fluid leak, 1 wound hematoma, and 1 radiculitis during the early postoperative period, no patients required revision surgery. Visual analog scale (VAS) scores for neck/shoulder and arm improved significantly in the early postoperative period (3 months) and were maintained with time (p < 0.001). Neck Disability Index (NDI) improved significantly postoperatively but worsened slightly during follow-up (p < 0.001). Anterior decompression and fusion (ACDF) was required at the index level by 3 patients (mean: 55 months later) and at the adjacent level by 4 patients (mean: 27 months later).

Zusammenfassung

Operationsziel

Dekompression der intraforaminalen Nervenwurzel bei lateralen Bandscheibenfragmenten, Spondylophyten oder selteneren Ursachen.

Indikationen

Sequestrierter Bandscheibenvorfall, dessen Masse sich >2/3 lateral des Duralsacks befindet. Intraforaminale dorsale Spondylophyten. Intraforaminale Synovialzyste, extra-/intraduraler Tumor.

Kontraindikationen

Paramediane und mediane „soft/hard discs“. Kyphose des Index-Segments.

Operationstechnik

Patient in Bauchlage mit leicht flektierten Knien und Kopf in Mayfield-Klemme fixiert. Halswirbelsäule (HWS) horizontal und etwa 10 cm über Herzniveau. Mikroskop von Haut zu Haut. Hautinzision 25 mm lang, ca. 10 mm paramedian. Stumpfes Spalten der Muskelschichten entlang Faserrichtung und Faszien. Zentrieren eines spreizbaren Röhrchens oder miniaturisierten Spekulumretraktors, am Selbsthaltearm fixiert, am Übergang zwischen medialer Gelenkfacette und Halbbogen. Bestätigen der korrekten Höhe durch seitliche Bildwandlerkontrolle. Ausfräsen des „key-hole“ mit größtmöglicher Erhaltung der Gelenkfacette und Darstellen des Nervenwurzelabgangs. Epidurale Exploration und Entfernen von freien/subligamentären Bandscheibenfragmenten. Bei ausgedehnter Perforation des Faserrings kann das Bandscheibenfach partiell ausgeräumt werden. Mögliche Einengung der Nervenwurzel durch dorsale Knochensporne wird behoben. Das Austasten der Nervenwurzel mit einem kleinen Nervenhäkchen im Kanal sollte unbeeinträchtigt sein. Schichtweiser Wundverschluss. Keine Drainage.

Postoperative Weiterbehandlung

Unmittelbare postoperative Mobilisation ohne Orthese.

Ergebnisse

Wegen einseitiger zervikaler Radikulopathie unterzogen sich 103 Patienten einer minimal-invasiven posterioren zervikalen Foraminotomie. Das durchschnittliche Follow-up betrug 32 Monate. Eine Duraläsion, ein Wundhämatom und eine Nervenwurzelschwellung traten unmittelbar postoperativ auf, blieben jedoch ohne operative Revision. Auf der visuellen analogen Schmerzskala (VAS) besserten sich Nacken‑/Schulter‑/Armschmerzen in den ersten 3 postoperativen Monaten deutlich und blieben unverändert gut (p < 0,001). Der Neck Disability Index (NDI) besserte sich postoperativ, verschlechterte sich aber geringfügig im Follow-up (p < 0,001). Die HWS-Stellung blieb unverändert zu präoperativ. Eine ventrale Dekompression und Fusion wurde nach 55 Monaten bei 3 Patienten im Index-Segment und nach 27 Monaten bei 4 Patienten im Nachbarsegment erforderlich.

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Change history

  • 21 December 2017

    Correction to:

References

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Authors and Affiliations

  1. Clinic for Spine Surgery, Schön Klinik Hamburg Eilbek, Dehnhaide 120, 22081, Hamburg, Germany

    L. Papavero & R. Kothe

Authors
  1. L. Papavero
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  2. R. Kothe
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Correspondence to L. Papavero.

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Conflict of interest

L. Papavero is a consultant for Medicon e. G., Tuttlingen, Germany. R. Kothe declares that he has no competing interests.

This article does not contain any studies with human participants or animals performed by any of the authors.

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Editor

M. Mayer, München

Illustrator

R. Himmelhan, Mannheim

A correction to this article is available online at https://doi.org/10.1007/s00064-017-0526-4.

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Papavero, L., Kothe, R. Minimally invasive posterior cervical foraminotomy for treatment of radiculopathy. Oper Orthop Traumatol 30, 36–45 (2018). https://doi.org/10.1007/s00064-017-0516-6

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  • DOI: https://doi.org/10.1007/s00064-017-0516-6

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