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.

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.

Unilateral Biportal Endoscopic Posterior Cervical Foraminotomy: An Outcome Comparison With the Full-endoscopic Posterior Cervical Foraminotomy.

STUDY DESIGN: Retrospective control study. OBJECTIVE: To compare the curative effects of unilateral biportal endoscopic posterior cervical foraminotomy (UBE-PCF) with full-endoscopic posterior cervical foraminotomy (FPCF). SUMMARY OF BACKGROUND DATA: There are few studies directly comparing outcomes between UBE-PCF and FPCF. The objective of this study was to compare outcomes between UBE-PCF and FPCF. METHODS: A retrospective control study was conducted for 69 patients of cervical radiculopathy from July 2019 to December 2021. Clinical outcomes scores, including neck disability index, visual analog scale (VAS)-arm, and VAS-neck were evaluated. Serum creatine kinase levels and the size of the operating hole were measured. RESULTS: Postoperative neck disability index, VAS-neck, and VAS-arm scores showed statistically significant improvement over preoperative scores ( P <0.01). The operating time was significantly shorter in the UBE-PCF group ( P <0.001). No significant differences were found in serum creatine kinase levels between the 2 groups ( P >0.05). The mean area of the operating hole was 1.47+0.05 cm 2 in the FPCF group and 1.79+0.11 cm 2 in the UBE-PCF group. The difference was statistically significant ( P <0.001). CONCLUSIONS: Both UBE-PCF and FPCF are safe and effective procedures for cervical radiculopathy. Predictable and sufficient decompression could be achieved by UBE-PCF in a shorter operation time. LEVEL OF EVIDENCE: Treatment Benefits Level III.

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.

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.

Outcomes and Vertebral Osteophytes and Bulging Intervertebral Discs Occupancy as a Decision-Making Tool for Surgical Success in Patients Undergoing Microendoscopic Foraminotomy for Lumbar Foraminal Stenosis.

OBJECTIVE: The objective of this study was to determine the long-term outcomes of microendoscopic foraminotomy in treating lumbar foraminal stenosis and identify the optimal extent of decompression that yields improved results and fewer complications. METHODS: A retrospective cohort study reviewed the medical records of 95 consecutive patients who underwent microendoscopic foraminotomy for lumbar foraminal stenosis. Clinical outcomes were assessed using the Japanese Orthopaedic Association scoring system and visual analog scale for low back and leg pain. Surgical success was determined by meeting significant improvement thresholds for back and leg pain at 2 years postoperatively. Multiple regression analysis identified factors associated with improved pain scores. Receiver operating characteristic curve analysis determined the cut-off values for successful surgeries. RESULTS: Significant improvements were observed in Japanese Orthopaedic Association and visual analog scale scores for back and leg pain 2 years postoperatively compared with preoperative scores (P < 0.0001) and sustained over a ≥5-year follow-up period. Reoperation rates were low and did not significantly increase over time. Multiple regression analysis identified occupancy of the vertebral osteophytes and bulging intervertebral discs (O/D complex) as surgical success predictors. A 45.0% O/D complex occupancy cutoff value was determined, displaying high sensitivity and specificity for predicting surgical success. CONCLUSIONS: This study provides evidence supporting the long-term efficacy of microendoscopic foraminotomy for lumbar foraminal stenosis and predicting surgical success. The 45.0% O/D complex occupancy cut-off value can guide patient selection and outcome prediction. These insights contribute to informed surgical decision-making and underscore the importance of evaluating the O/D complex in preoperative planning and predicting outcomes.

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.

Microendoscopic Posterior Cervical Laminoforaminotomy for C4 Radiculopathy.

OBJECTIVE: Cervical microendoscopic laminoforaminotomy (MELF) has been proven to be an effective, motion preserving procedure for the surgical treatment of cervical radiculopathy. Cervical 4 (C4) radiculopathies are often unrecognized by the initial evaluating physician and may be misdiagnosed as axial neck pain. In this study, we compare MELF to anterior cervical disk fusion (ACDF) for C4 radiculopathy in the largest series of minimally invasive foraminotomy for C4 radiculopathy to date. METHODS: This is a single-institution retrospective chart review of 42 cases for C4 radiculopathy, 21 MELF and 21 ACDF. Primary outcome measures were length of surgery, length of hospital stay, and time to return to work. Secondary outcome measures were visual analog scale (VAS) neck pain and reoperation rate. RESULTS: All patients were diagnosed with a unilateral C4 radiculopathy using magnetic resonance imaging or steroid injections. The length of surgery and length of hospital stay were significantly decreased in the MELF group compared with ACDF. VAS neck pain significantly decreased for patients in both groups, but the difference between MELF and ACDF was not statistically significant. There were no major complications. No patient underwent revision at the index level or adjacent levels in the MELF group. CONCLUSIONS: We demonstrate that C4 radiculopathy can be identified with appropriate history, physical examination, and targeted nerve root injections. When identified, these radiculopathies that fail conservative therapy can be effectively treated with cervical microendoscopic laminoforaminotomy, with comparable outcomes to ACDF. The length of surgery and length of stay are reduced when compared with ACDF.

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.

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.

Full-endoscopic foraminotomy in low-grade degenerative and isthmic spondylolisthesis: a patient-specific tailored approach.

PURPOSE: To describe the surgical technique and methodology to successfully plan and execute an endoscopic foraminotomy in patients with isthmic or degenerative spondylolisthesis, according to each patient's unique characteristics. METHODS: Thirty patients with degenerative or isthmic spondylolisthesis (SL) with radicular symptoms were included from March 2019 to September 2022. Treating physician registered patients' baseline and imaging characteristics, as well as preoperative back pain VAS, leg pain VAS and ODI. Subsequently, authors treated the included patients with an endoscopic foraminotomy according to a "patient-specific" tailored approach. RESULTS: Nineteen patients (63.33%) had isthmic SL and 11 patients (36.67%) had degenerative SL. 75.86% of the cases had a Meyerding Grade 1 listhesis. One of the transforaminal foraminotomies with lateral recess decompression in degenerative SL had to be aborted because of intense osseous bleeding. Of the remaining 29 patients, one patient experienced recurrence of the sciatica pain that required subsequent reintervention and fusion. No other intraoperative or post-operative complications were observed. None of the patients developed post-operative dysesthesia. In 86.67% of the patients, the foraminotomy was implemented using a transforaminal approach. In the remaining 13.33% of the cases, an interlaminar contralateral approach was used. Lateral recess decompression was performed in half of the cases. Mean follow-up time was 12.69 months, reaching a maximum of 40 months in some patients. Outcome variables such as VAS for leg and back pain, as well as ODI, showed statistically significant reduction since the 3-month follow-up visit. CONCLUSION: In the presented case series, endoscopic foraminotomy achieved satisfactory outcomes without sacrificing segmental stability. The proposed patient-specific "tailored" approach allowed to successfully design and execute the surgical strategy to perform an endoscopic foraminotomy through transforaminal or interlaminar contralateral approaches.

Learning curve for endoscopic posterior cervical foraminotomy.

PURPOSE: While anterior cervical discectomy and fusion as well as cervical disk arthroplasty are gold standard treatments for the surgical treatment of cervical radiculopathy, posterior endoscopic cervical foraminotomy (PECF) as a substitute procedure is gaining popularity. To date, studies investigating the number of surgeries needed to achieve proficiency in this procedure are lacking. The purpose of the study is to examine the learning curve for PECF. METHODS: The learning curve in operative time for two fellowship-trained spine surgeons at independent institutions was retrospectively assessed for 90 uniportal PECF procedures (PBD: n = 26, CPH: n = 64) performed from 2015 to 2022. Operative time was assessed across consecutive cases using a nonparametric monotone regression, and a plateau in operative time was used as a proxy to define the learning curve. Secondary outcomes assessing achievement of endoscopic prowess before and after the initial learning curve included number of fluoroscopy images, visual analog scale (VAS) for neck and arm, Neck Disability Index (NDI), and the need for reoperation. RESULTS: There was no significant difference in operative time between surgeons (p = 0.420). The start of a plateau for Surgeon 1 occurred at 9 cases and 111.6 min. The start of a plateau for Surgeon 2 occurred at 29 cases and 114.7 min. A second plateau for Surgeon 2 occurred at 49 cases and 91.8 min. Fluoroscopy use did not significantly change before and after surmounting the learning curve. The majority of patients achieved minimally clinically important differences in VAS and NDI after PECF, but postoperative VAS and NDI did not significantly differ before and after achieving the learning curve. There were no significant differences in revisions or postoperative cervical injections before and after reaching a steady state in the learning curve. CONCLUSION: PECF is an advanced endoscopic technique with an initial improvement in operative time that occurred after as few as 8 cases to as many as 28 cases in this series. A second learning curve may occur with additional cases. Patient-reported outcomes improve following surgery, and these outcomes are independent of the surgeon's position on the learning curve. Fluoroscopy use does not change significantly along the learning curve. PECF is a safe and effective technique that current and future spine surgeons should consider as part of their armamentarium.

Is navigation beneficial for transforaminal endoscopic lumbar foraminotomy? A preliminary comparison study with fluoroscopic guidance.

PURPOSE: The primary purpose of this study was to determine radiation exposure of the surgeon during transforaminal endoscopic lumbar foraminotomy (TELF). Secondary purpose of this study was to compare clinical and radiologic outcomes between TELF under C-arm fluoroscopic guidance (C-TELF) and O-arm navigation-guided TELF (O-TELF). METHODS: The author reviewed patients' medical records who underwent TELF at our institute from June 2015 to November 2022. A total of 40 patients were included (18 patients with C-TELF and 22 with O-TELF). Basic demographic data were collected. Preoperative/postoperative visual analog scale (VAS) and Oswestry Disability Index (ODI) were recorded at the outpatient clinic. Radiologic features were compared on X-rays at each follow-up. The degree of foraminal expansion was measured/compared through MRI. In the C-TELF group, the amount of exposure was calculated with a dosimeter. RESULTS: Average surgeon's effective dose in the C-TELF group was 0.036 mSv. In the case of the O-TELF group, there was no radiation exposure during operation. However, the operation time in the O-TELF group was about 37 min longer than that in the C-TELF group. There were significant improvements in VAS/ODI after operation in both groups. Complications were identified in three patients. CONCLUSION: O-TELF showed similarly favorable clinical and radiologic outcomes to C-TELF in lumbar foraminal stenosis, including complication rate. Compared to C-TELF, O-TELF has an advantage of not wearing a lead apron since the operator is not exposed to radiation. However, the operation time was longer with O-TELF due to O-arm setting time. Because there are pros and cons, the choice of surgical method depends on the surgeon's preference.

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.

Minimally Invasive Management of a C6-7 Disk Extrusion Through a Posterior Cervical Foraminotomy: 2-Dimensional Operative Video.

This operative video details treatment of a cervical disk herniation through a minimally invasive posterior cervical foraminotomy and microdiskectomy. A man in his 20s presented with unilateral C6-7 radiculopathy, and imaging findings indicated a paracentral disk herniation at C6-7. There was no evidence of spinal cord compression or cervical myelopathy and no severe spondylosis. Therefore, a posterior cervical foraminotomy was offered rather than an anterior diskectomy and fusion or arthroplasty to preserve segmental motion and limit potential implant-related complications. The patient consented to the procedure. This video reviews the nuances of this approach and the key surgical steps to ensure adequate decompression without introducing iatrogenic instability. The patient tolerated the procedure well and reported immediate relief of radicular pain after surgery. He returned to work without activity restrictions at the 2-week mark. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

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.

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.

Morphometric change in intervertebral foramen after percutaneous endoscopic lumbar foraminotomy: an in vivo radiographic study based on three-dimensional foramen reconstruction.

PURPOSE: This study aimed to perform in vivo three-dimensional (3D) quantitative measurements of morphometric changes in the foramen in patients with lumbar foraminal stenosis (LFS) undergoing percutaneous endoscopic lumbar foraminotomy (PELF) and investigate the relationship between anatomical changes in the foramen and clinical outcomes. METHODS: We retrospectively reviewed consecutive patients with LFS treated with PELF between January 2016 and September 2020 at our centre. Clinical outcomes were evaluated. Foraminal volume (FV) and foraminal minimal area (FMA) were calculated using a novel vertebral and foramen segmentation method. A comparison of the anatomical parameters of the foramen were conducted between the satisfied and unsatisfied groups divided based on the modified MacNab criteria. RESULTS: A total of 26 eligible patients with a mean follow-up of 3.6 years were enrolled. A significant increase was found in overall FV (71.5%) from 1.436 ± 0.396 to 2.464 ± 0.719 cm3 (P < 0.001) and FMA (109.5%) from 0.849 ± 0.207 to 1.780 ± 0.524 cm2. All clinical outcomes were significantly improved (P < 0.001) after PELF. No significant difference was found in changes in neither FV nor FMA between the two groups. CONCLUSION: Clinical results and foraminal dimensions improved significantly after PELF, indicating that PELF was a prominent technique suitable for LFS because of the direct decompression at impingement structures. No relationship was found between morphometric changes and clinical outcomes, revealing that full-scale endoscopic decompression is necessary and adequate for LFS, and unsatisfactory outcomes are less likely to result from decompression procedure.

Percutaneous full endoscopic foraminotomy for treatment of cervical spinal nerve compression in horses using a uniportal approach: Feasibility study.

BACKGROUND: Cervical spinal nerve insult can be a sequel of osteoarthropathy in horses due to enlargement of the articular processes (AP). OBJECTIVES: To describe the percutaneous endoscopic cervical foraminotomy procedure in horses. STUDY DESIGN: Ex vivo experimental study and clinical case report. METHODS: The technique was performed in three equine cadavers and in two clinical cases with history of forelimb lameness located in the caudal cervical region. Briefly, the horse was positioned in lateral recumbency, with the affected AP joint uppermost. Under fluoroscopic guidance, the endoscopic instruments (Ø 6.9 mm, length 207 mm, 25° angle of vision) were positioned at the dorsal bony margin of the intervertebral foramen (IVF). The bone was freed from soft tissues and removed using diamond various burrs, hence widening the IVF. The bone drilling was continued until the medial cortical surface of the caudal AP was removed. Thereafter, the endoscope was removed and the skin portal was closed. RESULTS: The average of operation time in clinical cases was 98 ± 24 min. The horses recovered smoothly from the operation. At 12-month follow-up, the clinical signs had resolved completely without recurrence. MAIN LIMITATION: Small number of clinical cases and absence of post-mortem examination or histopathology performed in the cadaver study to assess possible iatrogenic injuries. CONCLUSION: Cervical spinal nerve decompression via minimal invasive foraminotomy is feasible in horses. More research is required before this procedure can be recommended in clinical cases.

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.