Laminoforaminotomy

In 1946, Scoville presented the so-called keyhole foraminotomy technique at the annual Harvey Cushing Meeting. This was followed in 1951 by his report on 115 patients treated using this technique.¹ Despite its being developed several years before the now more common anterior cervical discectomy and fusion operations (Cloward^2,3 and Smith-Robinson types⁴), there are clear indications for and advantages to this approach.

The ideal patient for a posterior laminoforaminotomy is a patient with a single-level radicular syndrome, corresponding neurologic findings, and a concordant preoperative imaging study demonstrating foraminal stenosis. The nature of the foraminal stenosis can be adequately determined using a combination of plain radiographs, CT, and MRI. It can be due to a single or a combination of factors. The nerve root may be impinged by a soft disc herniation, typically seen as an extruded fragment that is hyperintense on T2-weighted imaging. This is usually the case in younger individuals. In older patients, the foramen is typically compromised by a disc-osteophyte complex that is a combination of disc material and uncovertebral osteophytes (hard disc). Foraminal stenosis, due to loss of disc height at the same level and osteophytes arising from the facet joint, may also coexist.

The keyhole foraminotomy typically provides a 3- to 5-mm exposure of the sensory root, which can then be retracted rostrally, thus facilitating the removal of the soft disc through the root’s axilla.⁵ It is difficult and risky to attempt removal of anterior uncovertebral osteophytes through this approach. In addition, this approach does not directly address foraminal stenosis due to a collapse of the disc space. However, as discussed later, numerous studies have shown excellent results in patients with hard discs. Webb et al. have described removing the superomedial aspect of the inferior pedicle using a drill to increase the foraminal volume in selected cases.⁶

The laminoforaminotomy has several advantages over the anterior discectomy and fusion. It preserves motion of the segment and therefore avoids the potential pitfalls associated with arthrodesis, namely, hardware complications, pseudarthrosis, graft subsidence, graft harvest complications, and the theoretical increased chance of accelerated adjacent-level degeneration. There are no issues with postoperative dysphagia or hoarseness and the decompression may be easily performed at multiple levels and bilaterally.

Because of the procedure’s motion-sparing advantage, spondylotic changes may continue and further surgery may be necessary for recurrent or new symptoms at the same level. Clarke et al. calculated the 5- and 10-year risk rates for development of same-segment disease as 3.2% and 5.0%, respectively.⁷ As previously mentioned, many patients have nerve root compromise as a result of bony growth into the foramen from the uncovertebral joint. The laminoforaminotomy allows an indirect decompression of the root but does not allow a direct decompression with removal of the anteriorly situated osteophytes, as would an anterior approach. Midline or collapsed disc pathology, kyphotic deformity, and disc herniation associated with unstable or traumatic cervical spine injury and the presence of significant axial neck pain are better treated with an anterior approach. The incision is typically more painful than a ventral approach for several days to weeks, and uses a midline approach and subperiosteal dissection of the paraspinal cervical musculature and lateral retraction. This may be improved with a paramedian muscle-splitting tubular approach.^8,9 No more than 50% of the facet should be resected to prevent instability and kyphosis.^10–18 Preoperative kyphosis at the symptomatic level, therefore, is a contraindication to this procedure.

A review of the recent literature is provided in Table 157-1. Typically, at least 80% to 90% of patients have good to excellent results. In the largest study, Henderson et al. reported resolution of radicular symptoms in 96% of 846 procedures performed in 736 patients, with 91.5% reporting good or excellent results.¹⁹ Jagannathan et al. recently published their experience in 162 patients who underwent a unilateral, single-level posterior cervical foraminotomy with a minimum 5-year clinical and radiographic follow-up.²⁰ Resolution of radiculopathy and improvement in the Neck Disability Index occurred in 95% and 93% of patients, respectively. There were no statistically significant changes in focal or overall cervical kyphosis with time. Thirty patients (20%) experienced postoperative loss of lordosis (defined as a Cobb angle <10 degrees measured from C2 to C7). Factors found to be associated with worsening sagittal alignment included age greater than 60 years, the presence of a preoperative cervical lordosis of less than 10 degrees, and the need for posterior surgery after the initial foraminotomy.

TABLE 157-1 Summary of Recent Literature on Posterior Cervical Laminoforaminotomy

ACDF, anterior cervical discectomy and fusion; NDI, Neck Disability Index; pts, patients; VAS, visual analogue score; yr, years.

Ventrolateral Foraminotomy

In 1996, Jho described a modified ventrolateral approach to the cervical foramen (ventral foraminotomy) to treat radiculopathy.²¹ It was based on the previously described and more extensive lateral approach of Verbiest²² and the transuncodiscal approach of Hakuba.²³ The key step in the procedure described by Jho is drilling and removal of the lateral uncovertebral joint (measuring approximately 5 to 8 mm transversely by 7 to 10 mm vertically) to expose the exiting nerve root as it passes under the vertebral artery. The surgical technique emphasizes preservation of the intervertebral disc as a functioning motion segment, while allowing direct access to the offending lesion (posterolateral disc herniation or uncovertebral osteophyte). Others, however, appear to have been using a similar technique before Jho’s publication.²⁴ As in the posterior laminoforaminotomy, the ideal patient is one with one or more ipsilateral radiculopathies due to disc herniation or uncovertebral osteophytes. It cannot address foraminal stenosis due to loss of disc space height and would achieve only an indirect decompression of the root if the stenosis was due to facet arthropathy.

The ventrolateral approach has not found widespread acceptance among spine surgeons, with most publications coming from Europe and few centers in the United States. The reasons for this include fear of unnecessarily injuring the vertebral artery and sympathetic chain (Horner syndrome), inability to address bilateral symptoms, and the widespread use and teaching of the more common anterior (fusion and now arthroplasty) and posterior (laminoforaminotomy) approaches. Furthermore, a cadaveric study demonstrated a significant alteration in the mobility of the segment after unilateral uncoforaminotomy, with an increase in the range of motion in lateral bending and axial rotation.²⁵ The clinical implication is that with time this may lead to further disc degeneration and its sequelae (disc collapse, reherniation, development of osteophytes), requiring a reoperation. For example, a recent study by Yi et al. comparing 15 patients who underwent a total disc replacement with 13 patients who had an anterior foraminotomy found good clinical results in both groups, but the anterior cervical foraminotomy caused a significant loss of disc height after surgery.²⁶ Hacker and Miller found an unacceptably high revision rate of 30% (7 patients) in their series of 23 patients, with good or better outcomes using Odom’s criteria in only 52% (12 patients).²⁷ The revisions were performed between 2 weeks and 14 months from the index procedure and there were two patterns of failure that led to reoperation: recurrent radiculopathy or intractable neck pain. Six patients underwent anterior cervical discectomy and fusion, and one patient required a corpectomy. Nonetheless, multiple publications have indicated that anterior foraminotomy improves radicular symptoms and neck pain, with good or better outcomes using Odom’s criteria in more than 80% of patients.²⁸ Some of this literature is summarized in Table 157-2. One of the largest series, by Jho et al., was published in 2002.²⁹ Of the more than 400 surgeries performed by the author and his team, 104 met the inclusion criteria for their study. Six weeks after surgery, 83 patients (79.8%) demonstrated excellent results, 20 patients (19.2%) demonstrated good results, and 1 patient (1%) experienced a fair outcome. No patient experienced a poor outcome or unchanged status. One patient required a reoperation to remove a persistent disc fragment, one patient developed discitis and had a spontaneous fusion with a slightly kyphotic angulation, one patient developed hemiparesis that resolved after 6 weeks (which the author believed was due to extended neck posture during surgery), and two patients developed transient Horner syndrome that resolved within 6 weeks. Dynamic cervical radiographs were obtained in 59 patients and all showed preservation of the motion segment.

TABLE 157-2 Summary of Literature on Anterior Foraminotomy

mo, months; NDI, Neck Disability Index; pts, patients; VAS, visual analogue score; wk, weeks; yr, years.

A few surgeons, including Jho, have expanded the indications for the approach by treating myelopathic patients with partial oblique corpectomies while still preserving much of the disc space.^30–35 These results are not reviewed here, but good outcomes have been reported and a sheep cadaveric model has shown that the ventral oblique corpectomy does not result in instability.³⁶

Laminectomy

Historically, cervical laminectomy has been a valuable motion-sparing, nonimplant surgery performed for the management of congenital or acquired multilevel cervical spinal stenosis associated with spondylosis, ossification of the posterior longitudinal ligament, and ossification or hypertrophy of the ligamentum flavum. The key factors in determining the optimal surgical candidate are the extent and nature of compression and the overall sagittal balance of the cervical spine.

Upright and dynamic (flexion-extension) MRI and CT are often recommended as preoperative imaging studies. The normal anteroposterior (AP) diameter of the spinal canal is approximately 17 mm. Stenosis is defined as a sagittal diameter of less than 12 to 13 mm. Congenital stenosis usually affects multiple levels and is readily apparent on a sagittal T2-weighted MRI. The Torg or Pavlov ratio, which is the AP diameter of the spinal canal divided by the AP diameter of the vertebral body at the same level, can be used as a guide in diagnosing congenital stenosis.³⁷ Stenosis is usually present if the ratio is less than 0.8. Another quick method to determine the presence of congenital stenosis is by assessment of plain lateral radiographs. If minimal space is present between the spinolaminar line and a line connecting the dorsal margin of the facet joints, significant canal stenosis is present.

Static and dynamic radiographs may provide information regarding instability. Concerning features, according to White and Panjabi,³⁸ include sagittal plane listhesis of greater than 3.5 mm on resting or dynamic radiographs, a sagittal plane rotation of greater than 20 degrees on flexion-extension radiographs, and a relative sagittal plane angulation of greater than 11 degrees on resting radiographs. It is critical to assess the overall sagittal balance of the cervical spine. Optimally, there should be approximately 14 degrees of lordosis from C2 to C7.

The optimal patient is one with single-level or multilevel circumferential central stenosis (i.e., congenital stenosis), or primarily dorsal impingement with preserved cervical lordosis. Preservation of lordosis is critical because maximal dorsal migration of the spinal cord takes place if the patient has an adequate cervical lordosis, typically 10 or more degrees, and 7 mm or less of ventral compression.³⁹ Those patients with a straight cervical spine or, of more concern, those with a kyphotic curve, may not be adequately decompressed through the dorsal approach and are at higher risk for development of a kyphotic deformity postoperatively. Decompression should be carried past the areas of focal stenosis to ensure that the transition areas from nonstenotic to stenotic regions do not themselves become compressed as the cord migrates dorsally. For example, if there is stenosis from C3 to C6, then the lamina of C2 should be undercut and the top of the C7 lamina should be resected.

Many reports since the 1970s have demonstrated the efficacy of laminectomy for the treatment of myelopathy. Ryken et al. recently provided an exhaustive review of this literature.⁴⁰ The surgery has numerous advantages; it can be performed relatively quickly and can address multiple levels, and it avoids the risks associated with anterior approaches, namely, hoarseness and dysphagia, which are significant risks in patients with advanced age and multilevel disease. There are disadvantages, however. The already compromised spinal cord may be damaged if instruments are placed under the midline lamina too aggressively. This has led some to recommend starting the decompression bilaterally at the laminofacet junction and then removing the central dorsal elements en bloc.⁴¹ Postoperative C5 palsy is a complication associated with multilevel dorsal decompressive surgery (laminectomy or laminoplasty), occurring with a frequency of about 5% to 10%.⁴² Its etiology continues to be a mystery and intraoperative monitoring has not been shown to prevent it.^43,44 Many believe that it may be due to the dorsal shift of the spinal cord, which is often maximal at the C5 level because it is usually at the midpoint in the laminectomy, causing tethering of the already short, less oblique C5 roots.^45,46 Some have advocated prophylactically performing foraminotomies at C4-5.^47,48 Recently, Sieh et al. have found that an average Pavlov ratio of less than 0.65 and compression at the C3-4 segment on preoperative MRI were reliable preoperative predictors for the development of this problem.⁴⁹

The development of postlaminectomy spinal instability manifested by kyphosis is a concern that has garnered much attention and has led to the development of laminoplasty as an alternative technique (see next section). In their review, Ryken et al. found the risk ranged from 14% to 47%.⁴⁰ However, as stated by the authors, no study has clearly demonstrated a relationship between postlaminectomy kyphosis and deterioration in the patient’s quality of life.

The trigger for the development of postoperative kyphosis is the denervation and weakening of the paraspinal musculature as a result of tissue dissection and bone removal. This alone may be enough to lead to kyphosis, such as in patients who already have a kyphotic cervical sagittal balance. On the other hand, in other patients, such as those with less cervical lordosis or straight spines, it may require the cumulative effect of other risk factors in addition to weakened muscles and lack of a bony scaffold to give rise to the kyphotic deformity. Not much can be done during surgery to limit the damage to the paraspinal musculature (other than possibly reducing the amount of electrocautery used and time under retraction), so it is the avoidance or limitation of other, more controllable factors that is of utmost importance in preventing this complication. One cannot overstress the importance of careful study of preoperative imaging, focusing on the presence of underlying instability and overall sagittal balance. The width and length of the laminectomy are important. If done for the treatment or prevention of myelopathy, the laminectomy should be taken to the lateral extent of the dural sac, which corresponds to the laminofacet junction. If further resection of the facets is required for decompression of the sac or individual nerve roots, this should be limited to 25% to 50% because numerous clinical, cadaveric, and finite element model studies have demonstrated that progressive facet resection produces increases in angular rotation and intervertebral disc stresses, leading to segmental hypermobility.^10–18 Laminectomies should be avoided at C2 and C7 because these laminae have been found to be relatively high load-bearing structures compared with C3 to C6, and the spinous process of C2 needs to be preserved because it is the insertion site of several key erector spinae muscles that are an integral part of the dorsal tension band.

The risk of postoperative kyphosis is greater in children for a number of anatomic reasons.⁵⁰ The child’s cervical spine is hypermobile because the muscles and supporting ligamentous structures are less well developed, the orientation of the facets is more horizontal, the vertebral bodies are wedge shaped, and the head is disproportionately larger compared with the spine.⁵¹

Laminoplasty

Laminoplasty techniques arose as a result of concern over deterioration from the long-term effects of segmental instability and kyphosis that were being seen with laminectomy, as described in detail in the previous section. The first laminoplasty technique was described in the early 1970s, and this has spawned many different variations such as the “open-door,” “French-door,” and Z-plasty techniques, the technical details of which are beyond the scope of this chapter. Despite the multitude of different laminoplasty procedures, all share in the principles of enlarging the volume of the spinal canal while maintaining the bony neural arch and thus the reattachment site for the paraspinal muscles, and preserving segmental motion.

The indications for laminoplasty are the same as those for laminectomy. Laminoplasty has all the advantages of the laminectomy and has been shown to be as effective in ameliorating myelopathic symptoms as arthrodesis and other ventral approaches (e.g., discectomies, corpectomies).⁵² Radiculopathy may be addressed by adding foraminotomies to the laminoplasty. As with laminectomy, laminoplasty allows indirect decompression of the cord by dorsal migration if there is ventral compression (e.g., disc-osteophyte complexes, ossification of the posterior longitudinal ligament) and direct decompression if there is dorsal compression (e.g., hypertrophied or calcified ligamentum flavum, shingling of the lamina, congenital stenosis). Dorsal migration depends on the presence of a neutral to lordotic sagittal alignment. Because laminectomy ideally should be reserved for patients with preserved cervical lordosis because of the risk for postlaminectomy kyphosis, laminoplasty offers the surgeon a greater degree of flexibility in that it may be performed on patients with a decreased lordotic to neutral cervical spinal curvature, but should also be avoided in patients with baseline kyphosis in the region that requires decompression. Again, careful analysis of preoperative imaging is required, as described in the laminectomy section.

Matz et al. have recently provided a comprehensive review of outcomes with the laminoplasty techniques.⁵³ Using the common Japanese Orthopedic Association scale for myelopathy, they found that the average recovery for patients was 55% to 65% and that this recovery was maintained in some studies for 5 years^54,55 and 10 years.^56–58 Despite the advantage of preserving segmental motion, many patients do experience a decrease in their range of motion and persistent axial neck pain.^53,59 A recent study did not show any benefit to preserving the muscles that attach to the spinous process of C7 in preventing or reducing postoperative neck pain.⁶⁰ As with laminectomy, C5 palsy can occur with this procedure, with the risk usually ranging from 5% to 10%. In some studies, it has been observed in up to 20%.^49,53,61 The incidence of kyphosis has been shown to be significantly less with laminoplasty (0% to 10%) than with laminectomy.^53,59,61 Unlike the situation with laminectomy, there is some evidence to support worse long-term neurologic outcomes if a kyphosis occurs following laminoplasty.^62,63

Lumbar Discectomy

Lumbar discectomy is a motion-preserving operation that relieves lumbar radicular pain in 80% to 90% of patients.^1–4 The operation was popularized by Mixter and Barr in 1934.⁵ The advent of the operating microscope in the 1970s has proved to be the main technologic advancement for this procedure over the past 75 years. Because the operation has otherwise not changed significantly over the past 40 years, very-long-term outcomes of the operation are relevant to patients currently being treated. A 90% patient satisfaction rate has been reported in a retrospective study of 201 patients with minimum 25-year follow-up.³

In most patients with lumbar disc herniations, instability is not present. Therefore, in most instances, fusion does not usually accompany discectomy, and segmental motion is preserved. Despite the excellent outcomes of discectomy, some authors have still questioned whether there may be a subgroup of patients who would benefit from fusion along with discectomy. Although fusion for lumbar disc herniation is rarely indicated, some studies suggest there are subgroups of patients that may have better outcomes with fusion than with motion preservation. Eie⁶ reviewed a series of patients treated with surgery for a herniated disc. In this study, 119 patients underwent discectomy and 69 underwent discectomy with noninstrumented posterolateral fusion. The two groups had equivalent outcomes 6 months after surgery. At 6-year follow-up, 76% of the discectomy-alone patients reported satisfaction, whereas 85% with discectomy and fusion reported satisfaction. Twenty-seven percent of the discectomy patients had pain recurrence versus 15% in the discectomy and fusion group, a statistically significant difference. On further analysis, patients working as manual laborers with preexisting back pain were especially likely to report pain recurrence when undergoing discectomy without fusion. Resnick et al.⁷ concluded that this study provides “Class III medical evidence in support of the use of fusion at the time of discectomy, especially in manual laborers or those with significant pre-operative back pain.”

Another study also favors fusion over motion preservation for a subgroup of patients undergoing surgery for a herniated lumbar disc. Matsunaga et al.⁸ reviewed a series of 80 manual laborers and athletes treated with surgery for a lumbar herniated disc. Fifty-one underwent discectomy and 29 underwent discectomy with fusion. At 1-year follow-up, 89% of the discectomy and fusion patients were back to work or athletic activities, versus only 54% in the discectomy group. The authors concluded that fusion may lead to a higher chance of return to work or preoperative level of athletic ability in manual laborers and athletes. Resnick et al.⁷ have commented that “this paper is considered to provide Class III medical evidence in support of the use of posterolateral fusion at the time of discectomy for patients involved in heavy labor and athletics.”

Motion-preserving lumbar discectomy is usually advocated for recurrent disc herniation and frequently yields excellent results. Fusion for recurrent disc herniation seems most intuitively appropriate when the patient has radiographic evidence of segmental instability. During an 18-year study of 520 patients, Cauchoix et al.⁹ found that 5.9% developed symptomatic instability after discectomy and required a subsequent fusion operation. Padua et al.¹⁰ reported similar findings; with a minimum 10-year follow-up, 6% of their patients experienced symptomatic segmental instability after discectomy.

Many surgeons advocate fusion for a third recurrent disc herniation. Some experts believe that multiple disc reherniations could be a sign of a dysfunctional motion segment and that future disc herniations are likely to occur without a fusion. Furthermore, successful outcomes after discectomy are increasingly less likely after multiple revisions.¹¹ Because of these factors, discectomy and fusion is certainly a treatment option in this scenario, but there is no definitive (class I) evidence that it is the treatment of choice.

Lumbar Laminectomy

Motion-sparing lumbar laminectomy is most commonly used in the treatment of neurogenic claudication secondary to spinal stenosis. Studies have shown this operation benefits 64% to 100% of patients.^12,13 Laminectomy without fusion has several advantages over laminectomy with instrumented fusion, including less exposure and therefore less bleeding and shorter operative time. Although it has not been definitively demonstrated in the literature, many experts believe that as a motion-preserving operation it offers less chance of future adjacent-segment disease compared with laminectomy with fusion. It also avoids the costs and risks of implant insertion.

Laminectomy without fusion also has several advantages over interspinous process spacer implants. Although both preserve motion, the long-term outcomes of laminectomy are excellent and well documented. Long-term outcomes for interspinous process spacers are not well known and no study has compared this operation with lumbar laminectomy. In addition, interspinous process spacer application places the spine into a more kyphotic posture. The long-term effect of this is unknown, but it may accelerate degeneration at adjacent segments. In contrast, lumbar laminectomy does not alter the patient’s sagittal balance. Interspinous process spacers also no longer function if a spinous process fracture occurs during or after surgery; this is not a consideration with lumbar laminectomy. Finally, lumbar laminectomy does not involve the placement of a costly implant.

Several studies support lumbar laminectomy without fusion as the treatment of choice for symptomatic lumbar stenosis in the absence of spondylolisthesis, deformity, or instability. One study randomized 45 patients with symptomatic lumbar stenosis without preoperative instability or spondylolisthesis into three groups: decompression alone, decompression and single-segment fusion, and decompression and multilevel fusion.¹⁴ All three groups reported significant improvements in their pain after surgery. There were no differences among the three groups in terms of patient satisfaction at the final follow-up. Blood loss and operative duration were greater in the groups that underwent fusion than in the group that underwent decompression alone. Rompe et al.¹⁵ performed a retrospective review of 117 patients who underwent surgery for symptomatic lumbar stenosis. Twenty-seven patients underwent decompression and fusion, whereas 90 patients underwent decompression alone. Both groups reported postoperative improvement in pain. There was no statistically significant difference in outcomes between the two groups.

Resnick et al.¹⁶ performed an extensive literature review of the role of fusion after decompression for lumbar stenosis. They concluded that “there does not appear to be evidence to support the hypothesis that fusion (with or without instrumentation) provides any benefit over decompression alone in the treatment of lumbar stenosis in patients in whom there is no evidence of preoperative deformity or instability.” This statement supports motion-sparing lumbar laminectomy as the treatment of choice for this group of patients.

Other subgroups of patients with lumbar stenosis may not be best served by this motion-sparing operative strategy. Fusion should be considered for patients with evidence of preoperative instability, spondylolisthesis, or deformity. This is supported by several studies. In 1991, Herkowitz and Kurz¹⁷ reported on 50 patients who underwent surgery for lumbar stenosis with degenerative spondylolisthesis. Twenty-five patients were assigned to decompression alone and the other 25 underwent decompression with noninstrumented posterolateral fusion. Ninety-six percent of the patients in the decompression/fusion group reported an excellent or good outcome with a mean follow-up of 3 years. Only 44% reported an excellent or good outcome in the decompression-alone group.

Another study¹⁸ placed patients with lumbar stenosis and degenerative spondylolisthesis into three groups. One group underwent decompression with facetectomy, the second group underwent decompression without facetectomy, and the third group underwent decompression with posterolateral fusion. The group that underwent decompression with fusion had 90% good/excellent results, whereas the decompression without facetectomy group had 80% good/excellent results. The decompression with facetectomy group reported only 33% good/excellent results. This study supports fusion accompanying decompression in patients with lumbar stenosis and spondylolisthesis.

After an extensive literature review that included both of these studies, Resnick et al.¹⁹ concluded “the performance of a lumbar posterolateral fusion is recommended for patients with lumbar stenosis and associated degenerative spondylolisthesis who require decompression.” They also conclude that “in situ lumbar posterolateral fusion is recommended as a treatment option in addition to decompression in patients with lumbar stenosis without deformity in whom there is evidence of spinal instability.”¹⁶

Conclusions

Discectomies, foraminotomies, and laminectomies are “tried and true” motion-preserving, nonimplant operations with high rates of success when applied to the proper patient population. These decompressive operations should be strongly considered as reasonable treatment options in patients with nerve root compression in the absence of spinal instability, spondylolisthesis, or deformity.