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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 35  |  Issue : 1  |  Page : 222-225

Evaluation of posterior cervical foraminotomy in management of cervical disc disease


1 Department of Neurosurgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission11-Mar-2021
Date of Decision06-Jul-2021
Date of Acceptance11-Jul-2021
Date of Web Publication18-Apr-2022

Correspondence Address:
Tamer A Elsaadany
54 Elgomhoriah Street, Elsanta, Gharbieya
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_64_21

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  Abstract 


Objective
Assessment of the efficacy and clinical outcome of posterior cervical foraminotomy in patients suffering from cervical polyradiculopathy.
Background
Posterior cervical procedure was the first method for management of cervical disc disease, until the appearance of anterior cervical discectomy and fusion, but in recent years, posterior cervical foraminotomy has a comeback as it does not entail fusion.
Patients and methods
Thirty patients suffering from cervical polyradiculopathy were operated through posterior cervical foraminotomy at Menoufia University Hospital.
Results
A total of 30 patients were operated, the most common level affected in this series was C5/C6 presented in 23 (31.5%) cases, followed by C6/C7 level presented in 21 (28.7%) cases, 15 (20.5%) cases with C4/C5, and 14 (19.2%) cases with C3/C4 affection. In this study; 26 (86%) cases had excellent and good outcomes according to Odom's criteria of outcome grading, while four cases had a fair outcome.
Conclusion
Posterior cervical foraminotomy is a safe and effective motion-preserving approach for treatment of cervical radiculopathy in well-selected cases. It has comparable outcomes to anterior cervical discectomy and fusion approach with avoidance of possible complications associated with anterior approaches.

Keywords: cervical disc, foraminotomy, posterior cervical


How to cite this article:
Elsaadany TA, Sheha AF, Saleh EEG, Farghaly AE, Elnoamany H. Evaluation of posterior cervical foraminotomy in management of cervical disc disease. Menoufia Med J 2022;35:222-5

How to cite this URL:
Elsaadany TA, Sheha AF, Saleh EEG, Farghaly AE, Elnoamany H. Evaluation of posterior cervical foraminotomy in management of cervical disc disease. Menoufia Med J [serial online] 2022 [cited 2024 Mar 29];35:222-5. Available from: http://www.mmj.eg.net/text.asp?2022/35/1/222/343133




  Introduction Top


Cervical radiculopathy is typically characterized as pain in the anatomic distribution of a single cervical nerve root. Sensorimotor impairment of the same nerve root may or may not be simultaneously present. Not uncommonly, multiple nerve roots may be affected simultaneously, leading to multilevel radiculopathy [1].

Cervical radiculopathy is usually the result of either a soft lateral disc displacement or spondylosis with the resultant foraminal compromise caused by a calcified disc, osteophyte, or both [1].

There are clear advantages of performing a posterior cervical foraminotomy, particularly in patients with cervical radiculopathy. Posterior decompression allows better access to eccentrically located disc fragments while obviating the need for retraction on the esophagus and laryngeal nerve, which can result in postoperative dysphagia and hoarseness following anterior approaches. Additionally, pseudoarthrosis, graft subsidence, and kyphosis, which are well-reported complications of anterior cervical discectomy and fusion (ACDF), can be eliminated when a posterior foraminotomy is performed [2].

The aim of this study is assessment of the efficacy and clinical outcome of posterior cervical foraminotomy in patients suffering from cervical polyradiculopathy.


  Patients and methods Top


This is a prospective study of 30 patients suffering from cervical radiculopathy, who were operated through posterior cervical foraminotomy at Menoufia University Hospitals from January 2017 to December 2020. A written informed consent was obtained prior to using the clinical and radiological data of any patient. The approval of the ethical and scientific committee of Menoufia University Hospitals was obtained. The offending pathology was cervical disc prolapse, whether unilateral or bilateral; soft or osteophytic complexes, compromising the foramina. Patients with central disc herniations, other neurological disorders, myelopathic manifestations, or those previously operated for cervical spinal pathologies or with signs of instability were excluded from this study.

Preoperative imaging included MRI and radiograph (anteroposterior, lateral, and dynamic) and computed tomography of the cervical spine. Electrophysiological assessment was also performed to assess the offended roots. After patient positioning, a linear skin incision, just off the midline ∼4–6 cm in length, is used. In almost all patients, the spinous process of C7 or T1 inferiorly and of C2 superiorly can be palpated with an index finger. By means of these bony landmarks, the midpoint of the skin incision is cantered over the involved interspaces. With the use of monopolar cautery, the incision is deepened, until part of the spinout process is exposed. A needle is introduced and a lateral radiograph is obtained for level confirmation. Once the level has been confirmed, the posterior cervical musculature of the affected side is detached from the lateral spinous processes, lamina, and facet joints above and below the pathological disc space.

Foraminotomy: [Figure 1] the foraminotomy is performed with a variable-speed, electric drill with a 4–6-mm cutting burr, but a 3-mm burr is used when necessary for drilling the pedicle and osteophytes. During progressive bone removal, important cortical and cancellous bony landmarks appear sequentially, guiding the surgeon along the course of the nerve root [Figure 2].
Figure 1: Posterior foraminotomy marked.

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Figure 2: (a) Preoperative, (b) intraoperative, and (c) postoperative images of the left C5–C6 and C6–C7 foraminotomy.

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Patients were followed up on monthly intervals for the first 3 months, then every 3 months clinically regarding neck pain and radiculopathy with numerical score 'visual analog scale' from 1 to 10, and radiologically by doing radiograph and computed tomographic scan by the use of the software Radiant DICOM viewer 2020. The final outcome was assessed according to modified Odom's criteria for clinical outcome.

Statistical analysis

Numerical data were expressed as mean, median, SD, minimum, and maximum. Qualitative and descriptive data were expressed as frequency and percentage. χ2 test with Yates' correction and Fisher's exact test were used to examine the relation between qualitative and descriptive variables. A two-tailed P value was used, P value of less than 0.05 was considered significant.

The results were tabulated and analyzed using Microsoft Excel 2019 (Albuquerque, New Mexico, USA) and SPSS V. 25 (SPSS Inc., Chicago, Illinois, USA).


  Results Top


A total of 73 spinal levels were operated, the most common level affected in this series was C5/C6 presented in 23 (31.5%) cases, followed by C6/C7 level presented in 21 (28.7%) cases, 15 (20.5%) cases with C4/C5, and 14 (19.2%) cases with C3/C4 affection [Table 1].
Table 1: Distribution of the opera ted levels

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Three (10%) patients of the 30 cases in the series had four-level affection, 11 (36.7%) patients had three-level affection, 12 (40%) patients had double-level affection, and four (13.3%) cases had a single-level operation.

Based on the radiographic studies and confirmed by operative data:

  1. In total, 15 (48.38%) cases had foraminal stenosis due to endplate osteophytes, uncovertebral osteophytes, facet hypertrophy, or calcified disc, these cases were categorized in the 'hard disk' subgroup.
  2. In total, 10 (35.48%) cases had prolapsed sequestrated disc material directly compressing the nerve root presenting the 'soft disc' subgroup.
  3. In total, five (16.14%) cases showed a mixture between both pathologies presenting the 'mixed disc subgroup.'


Outcome: in this study; 26 (86%) cases had excellent and good outcomes according to Odom's criteria of outcome grading. In total, four (14%) cases had fair outcome. All 26 cases with excellent and good outcomes returned to their jobs or their previous degree of daily activity within 6 weeks postoperative [Table 2].
Table 2: Outcome among the study

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Among the four cases with fair outcome, three (75%) cases had previous ACDF surgeries with recurrent or residual compression, one of them had a carpal tunnel surgery as well. In total, two (50%) cases had a long history of diabetes.

Operative time in this study ranged from 45 to 120 min with a mean of 68.888 and a median of 60 min and SD ± 25.179 min.


  Discussion Top


The posterior approach was popularized by Spurling and Scoville [3], the results obtained in many of these early series were quite good, even by today's standards.

But since the description of anterior cervical discectomy by Cloward [4], the popularity of the anterior approach has grown as the technique has gradually been made safer and easier to perform, especially with technological improvement in operative magnification, lighting, and instrumentation over the following 30 years.

However, in the last 15 years, the posterior foraminotomy approach has made a strong comeback and with the trend of minimally invasive and motion-preserving spinal surgeries, and as its advantages and the disadvantages of the anterior approach have become clearer [5].

The advantages of a posterior approach include direct visualization of the involved nerve root and decompression without the need for fusion, the ability to avoid damaging of vital structures located in the anterior area of the cervical spine (trachea, esophagus, internal carotid artery, vertebral artery, and recurrent laryngeal nerve), an ability to prevent the structural and biomechanical damage to the remaining vertebral disc by preserving it, without loss of motion segment and reduced occurrence of complications associated with bone graft and pseudoarthrosis, as well as degenerative changes of the adjacent joint [6],[7].

The results of the foraminotomy approach for soft and hard disc pathologies are comparable to those of the ACDF approach in most published series [8],[9].

In our study, male-to-female ratio was 2: 1, age ranged between 35 and 53 years with an average of 44.1 ± 6.345 years. The average duration of symptoms in our series was 12 weeks–2 years, with an average of 51.4 weeks. The most common symptoms beside radicular pain were neck pain (87.1%), upper-limb numbness (61.29%), and upper-limb weakness (32.25%). The most common signs were hyporeflexia (67.7%), sensory loss (58%), motor weakness (35.48%), and a positive Spurling test (29%).

In our study, we utilized this approach for treatment of soft-disc, hard-disc, and mixed-disc pathologies. There was no statistically significant difference between soft-disc and hard-disc pathologies (P > 0.05) in relation to the patients' outcome.

In our series, no postoperative cervical kyphosis developed in any patient, including those with straight or reversed curves. However, longer follow-up and a larger number of cases may be needed to settle this issue.

In our series utilizing a minimally invasive technique and a 4–6-cm incision, operative time ranged from 45 to 120 min with a mean of 68.88 ± 25.179 min. All patients were discharged within 24–48 h after surgery, except for one patient with an anesthesia complication. All our cases needed only minimal postoperative analgesics.

We utilized a small 4–6 -cm incision just off the midline and a small Scoville or a tubular transsphenoid retractor, we never split the nuchal ligament or disrupt the facet capsule laterally.

We found that applying a vertebral spreader between the spinous processes at the desired level, slightly distracted the articular pillars and the laminate to expose the laminar 'V' allowing proper delineation between the inferior articular facet of the lamina above (noncompressing) and the superior articular facet of the lamina below (compressing) with minimal or no bone removal from the laminate and less bone removal from the facet joints. No more than 30–50% of the facet joint was removed. We only used pediculotomy in few cases.

In our study, we utilized the prone position in all cases, we found the prone position more comfortable with easier access, better visualization of the nerve root, and less muscle dissection.

There was a statistically significant association between patients with age above 50 years at surgery and a worse outcome (P = 0.0015), a worse outcome was also correlated to multiple-level operations (P = 0.0437).

We found a very statistically significant association between patients with previous ACDF and a worse outcome (P = 0.0069). However, concerning this particular issue, larger randomized studies may be needed to confirm this observation.

We found no statistically significant association between a preoperative normal and straight or kyphotic cervical curve and the outcome. Nevertheless, longer follow-up period is needed to ensure lack of development of symptomatic progression of the cervical kyphosis-affecting outcome.

The overall spectrum of posterior approach-related complications is much more limited than the anterior approach and it includes nerve root injury, including splitting of the nerve, dural tearing, spinal cord injury, and same-segment and adjacent-segment disease [10],[11].

The primary concern should be directed at limiting nerve root manipulation and avoiding any spinal cord manipulation. There is no risk of inducing segmental instability if 50% of the fact remains intact [12],[13].

The mean follow-up period in our study was 9 months, in which we have noticed no recurrences, instability, kyphosis progression, or adjacent-level disease.


  Conclusion Top


Posterior cervical foraminotomy is an effective technique in management of selected cases of cervical disc disease. Not needing to fuse the patients or applying instrumentation reduced the overall cost of the procedure. Foraminotomy had no effect on the stability.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Carette S, Fehlings MG. Clinical practice. Cervical radiculopathy. N Engl J Med 2015; 353:392–399.  Back to cited text no. 1
    
2.
Coric D, Adamson T. Minimally invasive cervical microendoscopic laminoforaminotomy. J Neurosurg Focus 2012; 25:E2.  Back to cited text no. 2
    
3.
Spurling RG, Scoville WB. Lateral rupture of the cervical intervertebral disks: a common cause of shoulder and arm pain. Surg Gynecol Obstet 1944; 78:350–358.  Back to cited text no. 3
    
4.
Cloward R. The anterior approach for the removal of ruptured cervical disks. J Neurosurg 1958; 15:602–617.  Back to cited text no. 4
    
5.
Chang JC, Park HK, Choi SK. Posterior cervical inclinatory foraminotomy for spondylotic radiculopathy preliminary. J Korean Neurosurg Soc 2011; 49:308–313.  Back to cited text no. 5
    
6.
Gala VC, O'Toole JE, Voyadzis JM. Posterior minimally invasive approaches for the cervical spine. Orthop Clin North Am 2007; 38:339–349.  Back to cited text no. 6
    
7.
Jagannathan J, Sherman J, Szabo T, Thompson JP, Pearce RH, Schechter MT, et al. The posterior cervical foraminotomy in the treatment of cervical disc/osteophyte disease: a single-surgeon experience with a minimum of 5 years' clinicaland radiographic follow-up. J Neurosurg Spine 2012; 10:347–356.  Back to cited text no. 7
    
8.
Onymus M, Destrumelle N, Gangloff S. Surgical treatment of cervical disc displacement. Anterior or posterior approach? Rev Chir Orthop Reparatrice Appar Mot 2005; 81:296–301.  Back to cited text no. 8
    
9.
Herkowitz HN, Kurz LT, Overholt DP. Surgical management of cervical soft disc herniation. A comparison between the anterior and posterior approach. Spine (Phila Pa) 1996; 15:1026–1030.  Back to cited text no. 9
    
10.
Russel SM, Benjamin V. Posterior surgical approach to the cervical neural foramen for intervertebral disc disease. Neurosurgery 2014; 54:662–666.  Back to cited text no. 10
    
11.
Ruetten J, Sherman J, Szabo T, Tomaras CR, Blacklock JB, Parker WD et al. The posterior cervical foraminotomy in the treatment of cervical disc disease: a single-surgeon experience with a minimum of 5 years' clinical and radiographic follow-up. Neurosurg Spine J 2007; 10:247–256.  Back to cited text no. 11
    
12.
Raynor RB. Anterior or posterior approach to the cervical spine: an anatomical and radiographic evaluation and comparison. Neurosurgery 2003; 12:7–13.  Back to cited text no. 12
    
13.
Robinson J, Walker M. Posterior cervical inclinatory foraminotomy and laminoforaminotomy for spondylotic radiculopathy preliminary. Can Neurosurg Soc J 1962; 49:308–313.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]



 

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