A new minimally invasive posterior approach for the treatment of cervical radiculopathy and myelopathy: surgical technique and preliminary results

Degenerative cervical disorders predominantly lead to anterior spinal cord compression (by bony spurs at the posterior margin of the vertebral body or by degenerated disc), which may be central and/or foraminal. In a smaller percentage of cases, there is encroachment of the canal mainly from posterior by bulging yellow ligaments or bony appositions, resulting in compression syndromes of roots or spinal cord. The aim of this work is to present a minimally invasive posterior approach avoiding detachment of muscles for the treatment of cervical radiculopathy and myelopathy. Thirteen patients suffering from cervical radiculopathy (four patients) or myelopathy (nine patients) were operated according to this technique. In principle, the technique secures access to the diseased spinal segment via a percutaneously placed working channel (11 mm outer diameter and 9 mm inner diameter). The cervical paraspinal muscles are not deflected, but just spread between their fibres by special dilators. All further steps are performed through this channel under control of three-dimensional vision through the operating microscope. The mean follow-up period was 17 months (one patient died 9 months postoperatively), and patients were evaluated using a modified version of the Oswestry Index, called the Neck Disability Index (NDI), and the visual analogue scale (VAS) for neck and arm pain. The mean NDI (P<0.0001) improved from 13.2 (preoperatively) to 4.8 (postoperatively). The VAS for arm pain (P<0.001) and for neck pain (P<0.001) also showed marked postoperative improvement. Complete recovery of the preoperative neurological deficit was found in four patients, while the remaining eight patients showed improvement of the neurological symptoms during the follow-up period. There were no intra-operative or postoperative complications and no re-operation. The preliminary experience with this technique, and the good clinical outcome, seem to promise that this minimally invasive technique is a valid alternative to the conventional open exposure for treatment of lateral disc prolapses, foraminal bony stenosis and central posterior ligamentous stenosis of the cervical spine.     

Removal of an anterior spinal dermoid cyst with fenestra corpectomy in Klippel-Feil syndrome: technical case report

OBJECTIVE AND IMPORTANCE: A spinal cord tumor occurring in association with Klippel-Feil syndrome is quite rare. The removal of an anteriorly located spinal cord tumor at the level of block vertebrae creates a surgical challenge. CLINICAL PRESENTATION: A case of an intradural extramedullary dermoid cyst located anterior to the spinal cord and a syringomyelic cavity at the level of block vertebrae in a 43-year-old woman with Klippel-Feil syndrome is presented. She experienced pain and numbness in both shoulders and in her neck, and she had a slight weakness in both arms before the operation. Her weakness and the clinical symptoms completely disappeared after the operation, and the resolution of the syringomyelic cavity was observed at control magnetic resonance imaging. INTERVENTION: An anterior approach creating a fenestra corpectomy to the block vertebrae was performed, and the tumor was removed totally. No fusion or fixation was performed. CONCLUSION: To our knowledge, this is the first report of an anteriorly located intradural extramedullary cervical spine tumor in association with Klippel-Feil syndrome treated with this surgical technique. A three-dimensional computed tomographic control scan obtained 1 year after the operation did not show any instability.     

Anterior floating method for cervical myelopathy caused by ossification of the posterior longitudinal ligament

Ossification of the posterior longitudinal ligament lessens the sagittal diameter of the cervical canal and compresses the spinal cord anteriorly, and may produce severe disabling myelopathy. The anterior floating method is one of the anterior decompression and reconstructions used in the treatment of cervical myelopathy caused by ossification of the posterior longitudinal ligament. This procedure consists of subtotal resection of vertebral bodies and discs, with slight thinning and release of the ossified ligament using air instrumentation. This is followed by reconstruction of the cervical spine using autogenous strut bone graft accompanied by postoperative application of a halo vest. This method is indicated for patients who present with moderate or severe myelopathies, and especially in those where the canal narrowing ratio exceeds 60%. This radical procedure causes decompression of the spinal cord and restores its function by enlarging the neural canal with anterior migration of the ossified ligament. The procedure minimizes the extent of surgical invasions and avoids damage to the neural tissue, because it does not require the removal of the ossification of the posterior longitudinal ligament. It also stops postoperative regrowth of the ossification. The operative results with long term followup indicate a 71% average recovery rate based on the criteria established by the Japan Orthopedic Association.     

Anterior approach for dumbbell type cervical neurinoma

A one-stage anterior approach was performed in four patients for total removal of dumbbell type neurinoma at the cervical level. In each case, the neurinoma compressed the spinal cord in the cervical canal, developed anteriorly through the intervertebral foramen, and compressed the vertebral artery. A conventional cervical anterior approach at the tumor site was performed, followed by confirmation of the tumor located outside the spinal canal. After identification of the vertebral artery, corpectomy was carried out and the extradural component of the tumor was resected. In cases with a portion of the tumor located also within the dura mater, the dura mater was opened for removal of the intradural tumor. We found the anterior approach to be effective for the total removal of some kinds of cervical dumbbell type neurinomas.     

Anterior cervical microforaminotomy for cervical radiculopathy--results and review

Analysis of anterior cervical microforaminotomy performed at the North Staffordshire University Hospital along with a review of literature of this minimally invasive procedure is presented. METHODS: A retrospective-prospective study was performed on 34 patients (24 males, 10 females) with cervical disc disease who had been surgically treated with anterior cervical microforaminotomy between 1999 and 2005. Age ranged from 37 to 75. MRI findings were disc prolapse in 28 and additional osteophytes in six. Microforaminotomy was performed according to the published technique. RESULTS: Single level operations were performed in 22 patients (21 unilateral, 1 bilateral) and multi-level operations were performed in 12 patients (7 unilateral and 5 bilateral). The short-term outcomes were excellent in 65% (i.e., complete resolution of all symptoms), good in 29% (relief of radiculopathy but some non-radicular discomfort persists), and fair in 6% (mild residual radiculopathy with or without non-radicular symptoms). Postoperative complications include one patient with partial C6 root damage, which was identified intraoperatively, but had excellent results at 2 months post operation. Long-term follow-up (using the cervical spine research society questionnaire) ranged from 2-48 months. The average pain score, neurological outcome and functional outcome improved after this operation. RE-OPERATION: One patient, who had 2 level bilateral surgeries, needed discectomies with fusion for new onset myelopathy 18 months later. CONCLUSION: Appropriate patient selection is cardinal in achieving good outcome in anterior microforaminotomy.     

Implant Materials for Anterior Column Reconstruction of Cervical Spine Tumor

The spine is the most common site of bone metastases. Many cancer patients will ultimately develop spinal metastatic disease with symptomatic epidural spinal cord compression. At present, the main treatment for cervical spine tumors is surgical resection combined with postoperative radiotherapy. Implant materials for cervical spine anterior column reconstruction need to meet amounts of different properties, such as biocompatibility, bioactivity and the ability to maintain long-term mechanical strength. The selection of different materials determines the surgical efficacy and prognosis of patients to a certain extent. This article provides an overview of a variety of implant materials used for anterior column reconstruction after cervical spine tumor resection, introduces and analyzes their properties, advantages, disadvantages, derivatives, and applications in clinical practice, and looks forward to the future development of implant materials.     

Custom-tailored minimally invasive partial C2-corpectomy for ventrally located intramedullary cavernous malformation

Approaches to ventrally located intramedullary lesions of the upper cervical spine can be extremely challenging. We present a custom-tailored, minimally invasive anterior approach to a ventrally located, intramedullary cavernous hemangioma with partial lateral corpectomy of C2, complete resection of the lesion and subsequent reconstruction. A 20-year-old woman presented with the history of progressive numbness of the left upper and lower extremities and some episodes of severe headaches was referred to magnetic resonance imaging: Here, an intramedullary lesion with typical radiological features for a cavernous malformation at the ventral surface of the spinal cord at the C2 level was detected. The surgical procedure was performed under general anesthesia and electrophysiological monitoring (somatosensory-evoked potentials (SEP), muscle motor-evoked potentials (MEP), and D-wave recording). Complete resection of the cavernous malformation was achieved and reconstruction of the cervical spine was performed using a custom-tailored cage. Intraoperative neuromonitoring during resection, revealed a transient MEP loss, but unchanged D-wave and SEP recordings indicated unchanged neurological outcome. Early clinical follow-up of the patient revealed no new neurological deficits. At 3-month follow-up, there was some improvement of the sensory function. This custom-tailored minimally invasive anterior approach to a ventrally located intramedullary cavernous malformation with partial C2-corpectomy describes a possible and successful approach to ventrally located intramedullary lesions of the upper cervical spinal cord. Additionally, the hereby-described approach is not related to cervical instability.     

Management of anteriorly located C1-C2 neurofibromata

The authors discuss their recent experience with anteriorly located C1-C2 neurofibromata in five patients with cervical myelopathy and magnetic resonance scans consistent with intradural extramedullary masses in this region. Surgery was performed using a posterolateral approach with microscopic intradural exploration. Gross total intradural tumor removal was achieved in all cases. Improvement in cervical myelopathy occurred in all patients. This report concludes that C1-C2 neurofibromata located anterior to the spinal cord can be totally and safely removed using a posterolateral approach. Improvement in neurologic dysfunction accompanies posterior decompression and gross total intradural tumor removal.     

Postoperative neurological complications in intradural extramedullary tumors: A 10-year experience of a single center

BackgroundIntradural extramedullary spinal cord tumors (IDEMs) cause neurological symptoms due to compression of the spinal cord and caudal nerves. The purpose of this study was to investigate the incidence of postoperative neurological complications after surgical resection of IDEM and to identify factors associated with such postoperative neurological complications.MethodsWe retrospectively analyzed 85 patients who underwent tumor resection for IDEM between 2010 and 2020. We investigated the postoperative worsening of neurological disorders. The patients were divided into two groups: those with and without postoperative neurological complications. Patient demographic characteristics, tumor level, histological type, and surgery-related factors were also compared.ResultsThe mean age at the time of surgery was 57.4 years, and histological analysis revealed 45 cases of schwannoma, 34 cases of meningioma, three cases of myxopapillary ependymoma, one case of ependymoma, one case of hemangioblastoma and one case of lipoma. There were five cases (5.8%) of postoperative neurological complications, and four patients improved within 6 months after surgery, and one patient had residual worsening. There were no statistically significant differences in age, sex, tumor location, preoperative modified McCormick Scale grade, histology, tumor occupancy, or whether fixation was performed in the presence or absence of postoperative neurological complications. All four cases of meningioma with postoperative neurological complications had preoperative neuropathy and meningiomas were located in the anterior or lateral thoracic spine.ConclusionsNeurological complications after surgical resection for IDEM occurred in 5.8% of patients. Meningiomas with postoperative neurological complications located anteriorly or laterally in the thoracic spine.     

Midline ventral intradural schwannoma of the cervical spinal cord resected via anterior corpectomy with reconstruction: technical case report and review of the literature

OBJECTIVE AND IMPORTANCE: Spinal cord schwannomas are intradural nerve sheath tumors that almost universally occupy a dorsolateral, lateral, or ventrolateral position. Therefore, resection of these lesions typically proceeds via a posterior or posterolateral approach. CLINICAL PRESENTATION: We present a case of a midline ventral intradural schwannoma of the cervical spinal cord causing myelopathy. To the best of our knowledge, no previous reports specifically discuss purely midline ventral intradural schwannomas. INTERVENTION: Resection of the tumor was performed via an anterior cervical corpectomy with spinal arthrodesis and fixation. We review possible causes for such an anomalous location for schwannoma as well as the advantages and disadvantages of various surgical strategies for removing the tumor. CONCLUSION: This case exemplifies the usefulness of anterior approaches to the cervical spine in treating unusual intradural spinal cord tumors.     

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

BackgroundPosterior 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.MethodsWe 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.ResultsFifty-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).ConclusionThe 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.     

Outcomes and technical issues of transcorporeal anterior cervical microforaminotomy in patients with cervical brachialgia

IntroductionTranscorporeal anterior cervical microforaminotomy is a motion-preserving surgery. It addresses directly to the prolapsed disc in contrast to posterior laminoforaminotomy and does not affect facet joints; in the transuncal approach, there is a chance of vertebral artery injury and it also decreases disc height; hence, may alter the motion of that segment.ObjectiveAim is to assess the outcome of surgery and its effectiveness.MethodsA total of 40 patients were observed retrospectively of which 33 were male and 7 were female. A single study of transcorporeal anterior cervical microforaminotomy was analyzed in a private hospital (Comfort Hospital), Dhaka, Bangladesh. Patients having pure brachialgia who were not relieved by conservative treatment over 6–8 weeks in cervical disc prolapse were included in the study. Patients having more than one level of disease, features of myelopathy, or instability were excluded from the study.ResultsAll patients were pain-free postoperatively, although after one to two months 2 out of 40 patients developed brachialgia and required anterior cervical discectomy and fusion.ConclusionTranscorporeal microforaminotomy for brachialgia is a safe and effective approach that is motion preserving and minimally invasive as well.     

The cervical anterior approach for the resection of superior posterior neurogenic tumor: a case report

Many approaches for resection of the superior mediastinal tumors have been reported. We introduce an approach, which we call the cervical anterior approach. This approach is only cervical and does not require a sternotomy. Merits of this approach include the ability to remove the tumor without opening the mediastinal or parietal pleura, as well as obviating draining the thoracic cavity. The tumor is also directly visible, and the surgeon can avoid injury to the great vessels. This approach is recommended when the tumor is located superior to the third thoracic vertebra level, when it borders the great vessels, and when it does not border the trunk of the brachial plexus or nerve root. This approach is easy and safe for surgical procedures.     

Modified transcorporeal anterior cervical microforaminotomy for cervical radiculopathy: a technical note and early results

A prospective analysis of the first twenty patients operated for cervical radiculopathy by a new modification of transcorporeal anterior cervical foraminotomy technique. To evaluate early results of a functional disc surgery in which decompression for the cervical radiculopathy is done by drilling a hole in the upper vertebral body and most of the disc tissue is preserved. Earlier approaches to cervical disc surgery either advocated simple discectomy or discectomy with fusion, ultimately leading to loss of motion segment. Posterior foraminotomy does not address the more common anterior lesion. Twenty patients suffering from cervical radiculopathy not responding to conservative treatment were chosen for the new technique. Upper vertebral transcorporeal foraminotomy was performed with the modified technique in all the patients. All the patients experienced immediate/early relief of symptoms. No complications of vertebral artery injury, Horner’s syndrome or recurrent laryngeal nerve palsy were noted. Modified transcorporeal anterior cervical microforaminotomy is an effective treatment for cervical radiculopathy. It avoids unnecessary violation of the disc space and much of the bony stabilizers of the cervical spine. Short-term results of this technique are quite encouraging. Longer-term analysis can help in outlining the true benefits of this technique.     

Anterior minimally invasive approaches for the cervical spine

The percutaneous endoscopic discectomy (PECD) with working channel endoscope (WSH) endoscopy set could be a safe and effective minimally invasive surgical option for non-contained cervical disc herniation in selected patients. Judicious use of the end-firing Ho: Yttrium-Aluminium-Garnet (YAG) laser for both decompressive and thermoannuloplasty effect during the percutaneous endoscopic cervical annuloplasty (PECA) is mandatory in order to prevent possible injury to spinal cord or root. Although the percutaneous cervical stabilization (PCS) using the cervical B-Twin may not completely replace the cervical arthrodesis, this minimally invasive procedure can preserve anterior structures and thereby retain segmental stability and prevent the possible kyphotic progression after fusion surgery. To our knowledge, these minimally invasive procedures for cervical spine disease may serve to minimize surgery-induced complications associated with anterior cervical discectomy and fusion (ACDF).     

Carbon fiber reinforced polysulfone implants for tumor surgery of the spine

Anterior tumor removal, cord decompression and spinal stabilization gain in significance in surgical treatment of vertebral tumors. An implant system, consisting of a basket as vertebral body replacement, plates and screws, was developed using carbon fibre reinforced polysulfone. This system allows to perform individually shaped, stable and short-distance spine fusions from an anterior approach. Moreover its radiolucence facilitates postoperative care and irradiation. Operative technique and clinical experience are demonstrated in two patients.     

Anterior approach to intramedullary hemangioblastoma: case report

OBJECTIVE AND IMPORTANCE: Intramedullary spinal cord tumors are generally operated on by using the posterior approach. However, the posterior approach may not be suitable for a tumor in the anterior part of the spinal cord. In this report, we describe a case of a cervical intramedullary tumor that was successfully removed by using the anterior approach. CLINICAL PRESENTATION: A 48-year-old woman presented with lower cranial nerve disturbance and motor weakness of the upper extremities. Magnetic resonance imaging revealed a large extensive syrinx and an intramedullary enhanced tumor at the C6 level. The tumor was located at the left of the anterior part of the spinal cord. INTERVENTION: Based on these findings, the anterior approach was used in performing a corpectomy of C5 and C6. The tumor was highly vascular and was resected without resulting in any operative deficits. The pathological diagnosis was hemangioblastoma. CONCLUSION: The present case suggests that the anterior approach is an important option among surgical approaches to the intramedullary tumor in cases in which the tumors are small in size and are located in the anterior part of the cervical cord.     

The anterior approach to anterior cervical meningiomas: review illustrated by a case

Summary Anterior cervical meningiomas have traditionally been operated on by a posterior approach. However, several reports of an anterior approach to anterior cervical meningiomas and other anterior cervical intradural lesions have documented important advantages: large bony window of access, extradural coagulation of anterior blood supply to meningiomas, visualization of the intradural pathology in front of the spinal cord, and absence of manipulation of the spinal cord during resection of the lesion.In this study, the literature about anterior approaches to anterior cervical meningiomas is systematically reviewed and the advantages and disadvantages of the technique are discussed. Furthermore, a case of complete resection of a large anterior cervical intradural extramedullary meningioma from C5–7 by a three-level corpectomy with progressive postoperative neurological recovery is illustrated, confirming the advantages of the anterior approach.