Locked-in syndrome following elective cervical foraminotomy: a case report.

INTRODUCTION: There are no previously reported cases of locked-in syndrome occurring following cervical spinal surgery. We describe a case of locked-in syndrome following an elective cervical foraminotomy and discuss potential etiologies and contributing factors to our patient's presentation. CASE PRESENTATION: A 54-year-old male with a history of head and neck cancer and prior anterior cervical discectomy and fusion presented with neck pain following a motor vehicle accident. The patient underwent C4-C7 left-sided cervical posterior foraminotomy with no intraoperative complications. On postoperative day 1, the patient suddenly developed rapidly progressing weakness of the extremities and soon became non-verbal. CT angiography and near-infrared spectroscopy confirmed a basilar artery occlusion and left vertebral artery dissection. On MRI, infarcts involving the bilateral pons, left cerebral hemisphere, and left cerebellar infarct were identified. CONCLUSION: The etiology of locked-in syndrome in our patient remains unclear, but it is likely multifactorial. It is possible that the patient was predisposed to vascular injury from prior radiation therapy to the head and neck. In addition, intraoperative vascular insult may have occurred from vibrational shear stress, in turn leading to a vertebral artery dissection, basilar artery occlusion, and pontine infarct, ultimately resulting in our patient's locked-in state.

Channel-assisted cervical key hole technology combined with ultrasonic bone osteotome versus posterior percutaneous endoscopic cervical foraminotomy: a clinical retrospective study.

PURPOSE: The search for more effective and safe treatment methods for cervical spondylotic radiculopathy (CSR) has led to the rapid development and increasing popularity of minimally invasive posterior cervical foraminotomy (MI-PCF). This study aims to compare two important approaches for MI-PCF surgery: the channel-assisted cervical key hole technology combined with ultrasonic bone osteotome (CKH-UBO) and posterior percutaneous endoscopic cervical foraminotomy (PPECF). METHODS: Data from patients treated with single-level CKH-UBO (n = 35) or PPECF (n = 40) were analyzed. Clinical outcomes, including visual analogue scale (VAS) scores for neck and arm pain, Neck Disability Index (NDI), and modified Macnab criteria, were assessed preoperatively, as well as at three days, three months, and one year postoperatively. RESULTS: The percentages of patients with excellent and good outcomes were 97.14% and 92.5%, respectively. The average surgical time in the CKH-UBO group was significantly shorter than in the PPECF group (p < 0.001), while the average incision length in the PPECF group was significantly smaller than in the CKH-UBO group. There were no significant differences between the two groups in terms of blood loss, hospital stay, and clinical outcomes at three days, three months, and 12 months postoperatively. CONCLUSION: CKH-UBO can achieve the same surgical outcomes as PPECF for the treatment of CSR. However, CKH-UBO saves more time but requires patients to undergo larger incisions.

Outcomes and Complications Associated With the Learning Curve for Endoscopic Cervical Foraminotomy: A Systematic Review and Meta-Analysis.

STUDY DESIGN: A systematic review and meta-analysis. OBJECTIVE: The objective of this study is to examine the impact of the learning curve for endoscopic cervical foraminotomy for clinical outcomes and patient safety. SUMMARY OF BACKGROUND DATA: Endoscopic cervical foraminotomy is a minimally invasive surgical technique emerging in the literature for surgical management of cervical radiculopathy without the use of open incision. The adoption of endoscopic cervical foraminotomy may be hindered by the learning curve, although no review and meta-analysis exists to date on the topic. MATERIALS AND METHODS: A systematic review and meta-analysis was performed using PubMed, CINAHL, and MEDLINE from database inception until July 11, 2023. Inclusion criteria were articles that examined endoscopic cervical foraminotomy, reported outcomes, and/or complications for endoscopic cervical spine surgery relevant to the learning curve and had full-text. A random effects meta-analysis was performed for outcomes and complications. RESULTS: A total of three articles (n=203 patients) were included from 792 articles initially retrieved. The learning curves from four surgeons were examined with a FWM 21 procedures until the competency phase. There was no significant difference in the postoperative hospitalization length ( P =0.669), postoperative recovery room time ( P =0.415), intraoperative blood loss ( P =0.064), and total complication rates (10.9% vs . 1.2%, P =0.139) between endoscopic cervical foraminotomy procedures performed in the learning phase as compared with the competency phase of the learning curve. There was a significant decrease in operative time from the learning phase to the competency phase ( P =0.005). CONCLUSION: Competency was achieved on the learning curve for endoscopic cervical foraminotomy after about 21 procedures. There is no significant difference in postoperative hospitalization time, postoperative recovery room time, intraoperative blood loss, and complication rates between the learning phase and the competency phase of the learning curve for endoscopic cervical foraminotomy, noting the relatively small sample size of this study that may underpower this finding.

Single-level Anterior Cervical Discectomy and Fusion Results in Lower Five-year Revisions than Posterior Cervical Foraminotomy in a Large National Cohort.

STUDY DESIGN: A retrospective cohort study using the 2010-2020 MSpine PearlDiver administrative data set. OBJECTIVE: To compare perioperative adverse events and five-year revisions for single-level anterior cervical discectomy and fusion (ACDF) versus posterior cervical foraminotomy (PCF). SUMMARY OF BACKGROUND DATA: Cervical disk disease can often be treated surgically using single-level ACDF or PCF. Prior studies have suggested that posterior approaches provide similar short-term outcomes as ACDF; however, posterior procedures may have an increased risk of revision surgery. MATERIALS AND METHODS: The database was queried for patients undergoing elective single-level ACDF or PCF (excluding cases performed for myelopathy, trauma, neoplasm, and/or infection). Outcomes, including specific complications, readmission, and reoperations, were assessed. Multivariable logistic regression was used to ascertain odds ratios (OR) of 90-day adverse events controlling for age, sex, and comorbidities. Kaplan-Meier survival analysis was performed to determine five-year rates of cervical reoperation in the ACDF and PCF cohorts. RESULTS: A total of 31,953 patients treated by ACDF (29,958, 93.76%) or PCF (1995, 6.24%) were identified. Multivariable analysis, controlling for age, sex, and comorbidities, demonstrated that PCF was associated with significantly greater odds of aggregated serious adverse events (OR 2.17, P <0.001), wound dehiscence (OR 5.89, P <0.001), surgical site infection (OR 3.66, P <0.001), and pulmonary embolism (OR 1.72, P =0.04). However, PCF was associated with significantly lower odds of readmission (OR 0.32, P <0.001), dysphagia (OR 0.44, P <0.001), and pneumonia (OR 0.50, P =0.004). At five years, PCF cases had a significantly higher cumulative revision rate compared with ACDF cases (19.0% vs. 14.8%, P <0.001). CONCLUSIONS: The current study is the largest to date to compare short-term adverse events and five-year revision rates between single-level ACDF and PCF for nonmyelopathy elective cases. Perioperative adverse events differed by procedure, and it was notable that the incidence of cumulative revisions was higher for PCF. These findings can be used in decision-making when there is clinical equipoise between ACDF and PCF.

Noninferiority of Posterior Cervical Foraminotomy vs Anterior Cervical Discectomy With Fusion for Procedural Success and Reduction in Arm Pain Among Patients With Cervical Radiculopathy at 1 Year: The FACET Randomized Clinical Trial.

Importance: The choice between posterior cervical foraminotomy (posterior surgery) and anterior cervical discectomy with fusion (anterior surgery) for cervical foraminal radiculopathy remains controversial. Objective: To investigate the noninferiority of posterior vs anterior surgery in patients with cervical foraminal radiculopathy with regard to clinical outcomes after 1 year. Design, Setting, and Participants: This multicenter investigator-blinded noninferiority randomized clinical trial was conducted from January 2016 to May 2020 with a total follow-up of 2 years. Patients were included from 9 hospitals in the Netherlands. Of 389 adult patients with 1-sided single-level cervical foraminal radiculopathy screened for eligibility, 124 declined to participate or did not meet eligibility criteria. Patients with pure axial neck pain without radicular pain were not eligible. Of 265 patients randomized (132 to posterior and 133 to anterior), 15 were lost to follow-up and 228 were included in the 1-year analysis (110 in posterior and 118 in anterior). Interventions: Patients were randomly assigned 1:1 to posterior foraminotomy or anterior cervical discectomy with fusion. Main Outcomes and Measures: Primary outcomes were proportion of success using Odom criteria and decrease in arm pain using a visual analogue scale from 0 to 100 with a noninferiority margin of 10% (assuming advantages with posterior surgery over anterior surgery that would justify a tolerable loss of efficacy of 10%). Secondary outcomes were neck pain, disability, quality of life, work status, treatment satisfaction, reoperations, and complications. Analyses were performed with 2-proportion z tests at 1-sided .05 significance levels with Bonferroni corrections. Results: Among 265 included patients, the mean (SD) age was 51.2 (8.3) years; 133 patients (50%) were female and 132 (50%) were male. Patients were randomly assigned to posterior (132) or anterior (133) surgery. The proportion of success was 0.88 (86 of 98) in the posterior surgery group and 0.76 (81 of 106) in the anterior surgery group (difference, -0.11 percentage points; 1-sided 95% CI, -0.01) and the between-group difference in arm pain was -2.8 (1-sided 95% CI, -9.4) at 1-year follow-up, indicating noninferiority of posterior surgery. Decrease in arm pain had a between-group difference of 3.4 (1-sided 95% CI, 11.8), crossing the noninferiority margin with 1.8 points. All secondary outcomes had 2-sided 95% CIs clustered around 0 with small between-group differences. Conclusions and Relevance: In this randomized clinical trial, posterior surgery was noninferior to anterior surgery for patients with cervical radiculopathy regarding success rate and arm pain at 1 year. Decrease in arm pain and secondary outcomes had small between-group differences. These results may be used to enhance shared decision-making. Trial Registration: Netherlands Trial Register Identifier: NTR5536.

Percutaneous Full-Endoscopic versus Biportal Endoscopic Posterior Cervical Foraminotomy for Unilateral Cervical Foraminal Disc Disease.

Background: The biportal endoscopic technique (BE) is a fast-growing surgical modality that can be applied to posterior cervical foraminotomy (PCF), as well as lumbar discectomy and decompressive laminectomy. It has several technical differences from the percutaneous full-endoscopic technique (PE), which has been standardized as the representative endoscopic spinal surgery technique. The purpose of this study was to compare the short-term clinical outcomes between BE-PCF and PE-PCF. Methods: A retrospective review was conducted on 66 patients who had single-level unilateral cervical foraminal disc disease (UCFD). All patients underwent PE- or BE-PCF. Clinical outcomes including visual analog scale (VAS)-arm, VAS-neck, and Neck Disability Index (NDI) were evaluated. Perioperative data including operation time, length of hospital stay (LOS), amount of surgical drain, postoperative complications, and reoperation were collected. Serum creatine phosphokinase (CPK) and C-reactive protein (CRP) levels were recorded. Results: A total of 65 patients were included in the final analysis: 32 with PE-PCF and 33 with BE-PCF. There was no statistically significant difference in demographic and preoperative data between the two groups. All patients had significant improvement in VAS-arm, VAS-neck, and NDI compared to the baseline value. The improvement of all parameters was comparable between the two groups at each point for 1 year after surgery (p > 0.05), except for the significantly lower VAS-neck at postoperative 2 days in PE-PCF (p = 0.005). The total operation time was significantly shorter in BE-PCF (p = 0.036). There were no statistically significant differences between the two groups in regard to LOS, amount of surgical drain, and serum CPK and CRP levels (p > 0.05). Reoperation and complications between the two groups were comparable (p > 0.05). Conclusions: The 1-year postoperative clinical outcomes of PE-PCF and BE-PCF for cervical pain and disability caused by UCFD were good and comparable. PE-PCF resulted in significantly less immediate postoperative neck pain, but BE-PCF required shorter total operation time.

Ambulatory Single-level Posterior Cervical Foraminotomy for Cervical Radiculopathy: A Propensity-matched Analysis of Complication Rates.

STUDY DESIGN: Retrospective cohort comparison study. OBJECTIVE: The aim was to compare perioperative complications and 30-day readmission between ambulatory and inpatient posterior cervical foraminotomy (PCF) in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. SUMMARY OF BACKGROUND DATA: Single-level PCF for cervical radiculopathy is increasingly being performed as an ambulatory procedure. Despite this increase, there is a lack of published literature documenting the safety of ambulatory PCF. MATERIALS AND METHODS: Patients who underwent PCF (through laminotomy or laminectomy) were identified in the 2005-2018 NSQIP database. Ambulatory procedures were defined as cases that had hospital length of stay=0 days. Inpatient procedures were defined as cases that had length of stay=1-4 days. Patient characteristics, comorbidities, and procedural variables (laminotomy or laminectomy performed) were compared between the 2 cohorts. Propensity score matched comparisons were then performed for postoperative complications and 30-day readmissions between the 2 groups. RESULTS: In total, 795 ambulatory and 1789 inpatient single-level PCF cases were identified. After matching, there were 795 ambulatory and 795 inpatient cases. Statistical analysis after propensity score matching revealed no significant difference in individual complications including 30-day readmission, thromboembolic events, wound complications, and reoperation, or aggregated complications between ambulatory versus matched inpatient procedures. Overall 30-day readmissions after ambulatory single-level PCF were noted for 2.46% of the study population, and the most common reasons were surgical site infections (46%) and pain control (15%). CONCLUSIONS: The perioperative outcomes assessed in this study support the conclusion that single-level PCF for cervical radiculopathy can be performed for correctly selected patients in the ambulatory setting without increased rates of 30-day perioperative complications or readmissions compared with inpatient procedures. LEVEL OF EVIDENCE: Level III.

Critical points and effectiveness of prophylactic C4/5 foraminotomy to prevent C5 palsy after posterior cervical spine surgery.

OBJECTIVE: The aim of this study was to clarify the cut-off values of the spinal canal parameters as risk factors for C5 palsy after posterior cervical spine surgery with and without foraminotomy. METHODS: One hundred three consecutive patients (67 males, 36 females; mean age = 66 years, age range = 27-87 years) with cervical myelopathy who underwent posterior cervical spine surgery at our institution were retrospectively reviewed and included in the study. The first consecutive 69 patients who underwent posterior cervical spine surgery with prophylactic bilateral C4/5 foraminotomy were designated as the F (+) group. The subsequent 34 consecutive patients who underwent posterior cervical spine surgery without prophylactic bilateral C4/5 foraminotomy were designated as the F (-) group. All patients were then divided into four subgroups. In the F (+) group, patients with C5 palsy were designated as the F (+) P (+) subgroup (n = 13), while those without C5 palsy were designated as the F (+) P (-) subgroup (n = 56). In the F (-) group, patients with C5 palsy were designated as the F (-) P (+) subgroup (n = 5), while those without C5 palsy were designated as the F (-)P(-) subgroup (n = 29). Receiver operating characteristic curves were used to investigate the cut-off values of the spinal canal parameters for the development of postoperative C5 palsy. The assessed spinal parameters were the gutter positions (GP), laminar inclination angles (LIA), and postoperative cross-sectional areas (CSA) of the dural sac. The risk ratios (RR) of the spinal canal parameters as risk factors for C5 palsy were evaluated. RESULTS: The incidence of C5 palsy was similar between the F (+) group (18.8%) and the F (-) group (14.7%). The cut-off values for each spinal canal parameter in the F (+) group (GP: 0.82-0.84, LIA: 58.9-62.4°, and CSA: 189.5-200 mm2 ) were similar to those in the F (-) group (0.81-0.89, 61.7-62.5°, and 197.5-199.5 mm2, respectively). In the RR results for C5 palsy, the LIA was highest in both groups. The F (+) P (-) subgroup had significantly larger mean CSA at C4/5 and C5/6 (202.3 mm2 and 200.9 mm2, respectively) than the F (-)P(-) subgroup (177.3 mm2 and 178.9 mm2, respectively) (P = 0.0181 and P = 0.0277, respectively). Prophylactic C4/5 foraminotomy did not specifically prevent postoperative C5 palsy due to foraminal stenosis at C4/5. CONCLUSION: C4/5 foraminotomy should not be recommended for avoidance of C5 palsy. Although the bony spinal parameters were similar between the F (+) and F (-) groups, the CSA in the F (+) group was significantly than that in the F (-) group in the patients without C5 palsy.

Effect of Dorsal Root Ganglion Retraction in Endoscopic Lumbar Decompressive Surgery for Foraminal Pathology: A Retrospective Cohort Study of Interlaminar Contralateral Endoscopic Lumbar Foraminotomy and Discectomy versus Transforaminal Endoscopic Lumbar Foraminotomy and Discectomy.

OBJECTIVE: Postoperative dysesthesia (POD) is a common complication in surgery involving foraminal diseases, including lumbar foraminal or extraforaminal herniated nucleus pulposus (HNP). Minimal dorsal root ganglion (DRG) retraction is key to preventing POD. We compared the clinical results, safety, and efficacy between the paraspinal transforaminal approach requiring DRG retraction and the interlaminar contralateral approach without DRG retraction for foraminal and extraforaminal diseases. METHODS: A retrospective cohort study was performed of 50 patients who underwent uniportal transforaminal endoscopic lumbar foraminotomy and discectomy (TELD) and 50 patients who underwent anuniportal interlaminar contralateral endoscopic lumbar foraminotomy and discectomy (ICELF) because of lumbar foraminal HNP. The operated levels, combined degenerative diseases, postoperative complications, and POD were analyzed. The visual analog scale (VAS) pain scores, modified Oswestry Disability Index, and MacNab criteria for evaluating pain disability and response were analyzed. RESULTS: In the ICELF group (total, n = 7, 14%), there were 5 (10%) and 2 (4%) patients with POD grade 1 and 2, respectively. In the TELD group (total, n = 13, 26%), there were 7 (14%), 5 (10%), and 1 (2%) patients with POD grade 1, 2, and 3, respectively. The overall occurrence rate of grade 2 and greater POD was higher in the TELD group (n = 6, 12%) than in the ICELF group (n = 2, 4%). In the ICELF group, 3 of 9 patients (33%) with combined canal structure deforming diseases had POD, of whom none had POD of grade 2 and greater. In the TELD group, 4 of 7 patients (57%) with combined canal structure deforming diseases had POD, of whom all had POD of grade 2 and greater. Two surgical groups showed favorable clinical outcomes with the visual analog scale, Oswestry Disability Index, and MacNab criteria. CONCLUSIONS: Both TELD and ICELF were found to treat foraminal or extraforaminal HNP with good clinical outcomes. ICELF might have a lower POD rate in complicated cases such as adjacent segment disease, degenerative spondylolisthesis, and isthmic spondylolisthesis. This surgical procedure could be an alternative in complicated cases or in patients with an anatomically limited L5-S1 level. However, the procedure is technically challenging to perform.

Posterior endoscopic cervical foramiotomy and discectomy: clinical and radiological computer tomography evaluation on the bony effect of decompression with 2 years follow-up.

PURPOSE: Cervical radiculopathy is a common disabling cervical spine condition. Open anterior and posterior approaches are the conventional surgical treatment approaches with good clinical outcomes. However, the soft tissue damage in these procedures can lead to increase perioperative morbidity. Endoscopic spine surgery provides more soft tissue preservation than conventional approaches. We investigate the radiological and clinical outcomes of posterior endoscopic cervical foraminotomy and discectomy. METHODS: A prospective clinical and radiological study with retrospective evaluation were done for 25 patients with 29 levels of cervical radiculopathy who underwent posterior endoscopic cervical discectomy from November 2016 to December 2018. Clinical outcomes of Visual Analogue Scale, Neck Disability Index and MacNab's score were evaluated at pre-operative, post-operative 1 week, 3 months and final follow-up. Preoperative and post-operative final follow-up flexion and extension roentgenogram were evaluated for cervical stability assessment. Pre-operative and post-operative computer tomography cervical spine evaluation of foraminal length in ventro-dorsal, cephalad-caudal dimensions, sagittal foraminal area and using 3D CT reconstruction coronal decompression area were done. RESULTS: Twenty-nine levels of cervical radiculopathy underwent posterior endoscopic cervical decompression. The mean follow-up was 29.6 months, and the most common levels affected were C5/6 and C6/7. There was a complication rate of 12% with 2 cases of neurapraxia and one case of recurrent of prolapsed disc. There was no revision surgery in our series. There was significant clinical improvement in Visual Analogue Scale and Neck Disability Index. Prospective comparative study between preoperative and final follow-up mean improvement in VAS score was 5.08 ± 1.75, and NDI was 45.1 ± 13.3. Ninety-two percent of the patients achieved good and excellent results as per MacNab's criteria. Retrospective evaluation of the radiological data showed significant increments of foraminal dimensions: (1) sagittal area increased 21.4 ± 11.2 mm2, (2) CT Cranio Caudal length increased 1.21 ± 1.30 mm and (3) CT ventro-dorsal length increased 2.09 ± 1.35 mm and (4) 3D CT scan reconstruction coronal decompression area increased 536 ± 176 mm2, p < 0.05. CONCLUSION: Uniportal posterior endoscopic cervical foraminotomy and discectomy are safe, efficient and precise choreographed set of technique in the treatment of cervical radiculopathy. It significantly improved clinical outcomes and achieved the objective of increasing in the cervical foramen size in our cohort of patients.

Can prophylactic C4/5 foraminotomy prevent C5 palsy after cervical laminoplasty with and without posterior instrumented fusion with maximal expansion?

OBJECTIVE: To prospectively examine whether laminoplasty with maximal expansion induces C5 palsy, even with prophylactic bilateral C4/5 foraminotomy. METHODS: Thirty-five consecutive patients with cervical myelopathy underwent laminoplasty (n = 19: LP group) or posterior decompression and fusion (n = 16: PDF group) with maximal expansion. Prophylactic bilateral C4/5 foraminotomy was performed alternately in consecutive five patients undergoing each type of surgery. In each type of surgery, the first and third consecutive five patients did not undergo foraminotomy (NF subgroup: 20 patients), while the second and fourth consecutive five patients underwent foraminotomy (F subgroup: 15 patients). The widths between the gutters was equivalent to the diameter of the spinal canal, and an inclination angle of the lamina of approximately 90° was created during laminoplasty. The incidence and severity of postoperative C5 palsy were investigated. Patients with a manual muscle testing score for the deltoid muscle and/or biceps brachii muscle of ≤ 2 were diagnosed with severe palsy. RESULTS: The respective incidences of C5 palsy in the F and NF subgroups were 33% and 20% in the LP group and 50% and 20% in the PDF group. Severe palsy occurred in 67% and 0% of patients who had developed palsy in F and NF subgroups, respectively, in the LP group, and in 100% of patients in the PDF group. Furthermore, 40% of the patients with severe palsy took more than 6 months to recover. CONCLUSIONS: Laminoplasty with maximal expansion induced C5 palsy in both the LP and PDF groups, even with the addition of prophylactic bilateral C4/5 foraminotomy.

Efficacy and Safety of Foraminoplasty Performed Using an Endoscopic Drill to Treat Axillary Disc Herniation.

OBJECTIVE: To evaluate the efficacy and safety of foraminoplasty using percutaneous transforaminal endoscopic discectomy (PTED) (performed with the aid of an endoscopic drill) to treat patients with axillary disc herniations. METHODS: From October 2016 to October 2018, 83 patients with single segmental axillary disc herniations diagnosed via magnetic resonance imaging who had undergone PTED were retrospectively evaluated. Of these, 38 and 45 underwent foraminoplasty using a trephine and an endoscopic drill, respectively. The 2 groups did not differ significantly in terms of age, sex, the herniated segment, the preoperative visual analog score (VAS), or the Oswestry disability index (ODI) (all P > 0.05). Foraminoplasty-related index scores were recorded. RESULTS: We found no significant between-group difference in the VAS and ODI scores at any time after surgery; in contrast, the scores improved significantly compared with those before surgery (both P < 0.05). Compared with the trephine group, the fluoroscopy time was shorter in the endoscopic drill group but the foraminoplasty and total operation times were longer. CONCLUSIONS: Foraminoplasty featuring endoscopic drilling can be used to treat axillary-type lumbar disc herniations. The radiation exposure time is less than that of the trephine approach, but the drilling approach is less efficient. The short-term clinical outcomes afforded by the 2 methods do not differ.

Cervical posterior foraminotomy: how i do it.

BACKGROUND: Cervical pathologies are addressed through a variety of anterior and posterior approaches and minimally invasive procedures have been successfully applied during the last decades. Posterior cervical foraminotomy (PCF) should be proposed with isolated foraminal stenosis. METHOD: We provide a step-by-step description of PCF through the use of tubular retractors. Its advantages and limitations were detailed. CONCLUSION: PCF performed with tubular retractors represent a safe and efficient alternative to address an isolated level disease with unilateral radiculopathy. The risk of mechanical instability is limited when only the medial third of the facet is drilled. Patients present rapid functional recovery.

Minimally invasive anterior foraminotomy for cervical radiculopathy: how I do it.

BACKGROUND: The standard treatment for cervical radiculopathy is anterior discectomy and fusion. The authors describe a minimally invasive anterior cervical foraminotomy as a surgical option for direct nerve root decompression in cervical radiculopathy. METHOD: Through a modified Smith-Robinson approach, the prevertebral fascia is mobilized laterally, displacing the sympathetic chain with it. A thumbnail size portion of the longus colli muscle is removed. A tubular retractor is placed, centered over the index uncovertebral joint. The lateral part of the joint is progressively drilled towards the foramen. After exposure of the intervertebral foramen, the perivascular ligamentous tissue is opened. Removal of disc fragments and osteophytes allows direct visualization and direct decompression of the nerve root. CONCLUSION: Anterior cervical foraminotomy is a safe "motion preserving" procedure for direct nerve decompression in selected patients with cervical radiculopathy that does not require cervical fusion.

Endoscopic posterior cervical foraminotomy via a single stab incision for contiguous two-level cervical radiculopathy.

BACKGROUND: Endoscopic posterior cervical foraminotomy (EPCF) is an effective surgical treatment method for single-level cervical radiculopathy. However, only few studies have used the technique for two-level EPCF via a single stab incision. METHOD: In this study, the minimally invasive surgical method was used for two-level cervical radiculopathy, and useful information regarding perioperative care was presented. CONCLUSION: EPCF is an alternative treatment for patients with symptoms of adjacent two-level lesions of the cervical spine, and such procedure is advantageous as it can be performed with a small access.

Incidence and Implications of Incidental Durotomy in Transforaminal Endoscopic Spine Surgery: Case Series.

OBJECTIVE: To evaluate the incidence and outcomes of incidental durotomy in transforaminal endoscopic spine surgery. METHODS: Transforaminal lumbar endoscopic procedures were performed by 2 surgeons in 907 patients over a period of 4 years from 2014 to 2018. Patient data were evaluated retrospectively in these patients with a minimum follow-up of 1 year. RESULTS: In 907 patients over 4 years there were 5 durotomies: 4 incidental and 1 intentional. The rate for incidental durotomy was therefore 0.4%. There were no adverse outcomes from the incidental durotomies, and only 1 patient noted a headache. CONCLUSIONS: Incidental durotomy is a rare complication of transforaminal lumbar endoscopic spine surgery and appears to occur more likely in patients who have undergone previous spine surgery at the site of the endoscopic procedure, not unexpectantly. Glues, patches, and bedrest were among the various methods used after durotomy. In this series there were no cases of symptomatic spinal fluid leakage or pseudomeningocele seen. Only 20% of patients who had durotomies noted a headache in the immediate postoperative period.

How I do it? Interlaminar contralateral endoscopic lumbar foraminotomy assisted with the O-arm navigation.

BACKGROUND: The interlaminar contralateral endoscopic lumbar foraminotomy (ICELF) provides access to the foraminal pathology with less violation to facet than the ipsilateral approach. However, it is technically challenging even for an experienced surgeon. METHODS: We introduce the step-by-step workflow of the interlaminar contralateral endoscopic lumbar foraminotomy assisted with O-arm navigation system. CONCLUSION: The ICELF assisted with O-arm navigation is safe, accurate, and efficient for the treatment of lumbar foraminal stenosis. The CT-based navigation reshapes the learning curve of the advanced endoscopic technique, reducing the risk of facet joint violation, and minimizes radiation exposure to surgeons.

Laser-assisted endoscopic lumbar foraminotomy for failed back surgery syndrome in elderly patients.

Elderly patients with failed back surgery syndrome (FBSS) or post-laminectomy foraminal stenosis have a higher risk of perioperative morbidity with extensive revision surgery. Thus, there is a need for safer and less invasive surgical options, such as laser-assisted endoscopic lumbar foraminotomy (ELF). A pin-point laser beam can allow precise tissue ablation and dissection in fibrotic adhesion tissues while preventing normal tissue injury. The present study aimed to describe the surgical technique of laser-assisted ELF and to evaluate the clinical outcomes of elderly patients with FBSS. Two-year follow-up data were collected from 26 consecutive patients aged 65 years or older who were treated with laser-assisted ELF for FBSS. Full-endoscopic foraminal decompression was performed using a side-firing laser and mechanical instruments. The average age of the patients was 70.2 years (range, 65-83 years). The mean visual analog pain score for leg pain improved from 8.58 at baseline to 3.35 at 6 weeks, 2.19 at 1 year, and 2.35 at 2 years after ELF (P < 0.001). The mean Oswestry disability index improved from 65.93 at baseline to 31.41 at 6 weeks, 21.77 at 1 year, and 20.64 at 2 years after ELF (P < 0.001). Based on the modified Macnab criteria, excellent or good results were obtained in 84.6% patients and symptomatic improvements were obtained in 92.3%. Extensive revision surgery in elderly patients might cause significant surgical morbidities. Laser-assisted ELF under local anesthesia could be a safe and effective surgical alternative for such patients at risk.

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.