Motion-Sparing, Nonimplant Surgery: Cervical Spine and Lumbar Spine

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Chapter 157 Motion-Sparing, Nonimplant Surgery

Cervical Spine and Lumbar Spine

Motion-Sparing, Nonimplant Surgery: Cervical Spine

The last 20 years has seen an explosive increase in cervical spinal instrumentation development and use. However, there remain a number of motion-sparing procedures that do not require the use of a spinal implant. Such strategies eliminate the risk associated with the short- and long-term consequences of implants and spine stabilization. Motion-preserving surgery offers the patient relief of his or her neurologic symptoms while theoretically lessening spondylotic changes at adjacent levels. The disadvantage associated with motion-sparing surgery is that the spondylotic process may continue at the treated level(s). Fusion and instrumentation surgery, on the contrary, treats the symptomatic level definitively (assuming fusion is achieved).

The nonimplant, motion-sparing surgeries—laminectomy, laminoplasty, posterior laminoforaminotomy, and anterior foraminotomy—are discussed in this chapter. As with all spine procedures, outcomes are directly related to patient selection. Such is emphasized here.

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 (Cloward2,3 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.1018 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

Author (Year) Summary Conclusions
Kim and Kim9 (2009) 41 pts, 19 underwent midline approach (group 1), 22 paramedian tubular approach (group 2). Odom’s criteria and VAS. 84% of group 1 and 86% of group 2 pts had good or excellent outcome using Odom’s criteria. Group 2 had improved VAS for neck pain.
Jagannathan et al.20 (2009) 162 pts followed for minimum of 5 yr. NDI and static/dynamic lateral radiographs. NDI improved in 93% of pts, radiculopathy resolved in 95%. No significant changes in focal or overall sagittal balance.
Ruetten et al.64 (2008) 86 pts underwent ACDF, 89 pts endoscopic paramedian tubular approach. No difference in outcome between surgeries: 88% (ACDF) and 89% (foraminotomy) had resolution of arm symptoms after 2 yr. Recurrence rate of 3.4% in the foraminotomy group.
Cağlar et al.65 (2007) 84 pts, 58% with soft discs and 42% with hard discs. 96% achieved resolution of radicular symptoms. Kyphosis developed in one patient (1.2%).
Hilton66 (2007) 222 pts, 63% with soft discs and 37% with hard discs. 85% had complete relief of radicular pain. Three pts had no relief and required ACDF.
Korinth et al.67 (2006) 124 pts underwent ACDF, 168 pts posterior foraminotomy. Odom’s criteria used. Excellent and good outcomes in 93.6% ACDF and 85.1% posterior foraminotomy (statistically significant). Pts with soft discs did better than pts with hard discs with both surgeries.
Fessler and Khoo8 (2002) 51 pts, 26 underwent open midline approach, 25 microendoscopic approach. Pts in both groups had 87% to 92% improvement with no difference between the groups. Endoscopic group had shorter hospital stay and less need for narcotics.

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

Author (Year) Summary Conclusions
Kotil and Bilge68 (2008) 25 pts, VAS A positive outcome at last follow-up examination was achieved in all patients. VAS pain rating was 6.36 pretreatment and 0.64 after 1 yr.
Balasubramanian et al.69 (2008) 34 pts 94% achieved good to excellent outcomes. One patient required reoperation.
Cornelius et al.70 (2007) 40 pts, average follow-up 4.3 yr.
Odom’s criteria.
85% of pts had no residual radicular pain, 94% had no more neck pain, 90% recovered their sensory deficits, and 83% recovered from their motor deficits. Good to excellent outcome in 95%. One patient had permanent Horner syndrome.
White et al.71 (2007) 21 pts, follow-up 10 to 36 mo, VAS. Mean VAS reduction in arm pain was 6.9, neck pain, 4.0. Arm strength improved 3.8, sensation by 3.8.
Lee et al.72 (2006) 13 pts, average follow-up 19 mo. All pts had resolution of their radicular pain. Motion preserved in each patient.
Koç et al.73 (2004) 19 pts, average follow-up 23 mo.
Odom’s criteria and VAS.
Good or better outcome in 89.5%. One patient had developed contralateral foraminal stenosis at the level of the surgery and had undergone anterior discectomy and fusion.
Hacker and Miller27 (2003) 23 pts, including 2 who had two-level procedures. Good or better outcome in 52%. Seven pts (30%) required revision surgery.
Saringer et al.74 (2003) 16 pts, average follow-up 18.3 mo. Endoscopic approach. NDI and VAS. Average improvement of 44% in NDI and 96% in VAS for radicular pain. Overall subjective patient satisfaction rate 87.6%; return-to-work rate after 4 wk, 81.4%
Saringer et al.75 (2002) 34 pts, average follow-up 8.2 mo. 100% relief of radicular neck pain. 97% of pts pleased with results of surgery. One patient suffered repeat herniation treated nonoperatively.
Jho et al.29 (2002) 104 pts, average follow-up 36 mo. 52% soft disc herniations, 42% spondylotic spurs, 6% both. 79.8% experienced excellent results, 19.2% experienced good results, and one patient experienced fair results. Two pts developed transient Horner syndrome, one patient developed transient hemiparesis, and one patient developed discitis, resulting in spontaneous bone fusion.
Johnson et al.76 (2000) 21 pts, follow-up 12 to 24 mo.
Oswestry Pain Scale and VAS.
91% had improved or resolved radicular symptoms. Good or better outcome using VAS in 85%. Two pts required reoperations.

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.3035 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

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