Anterior cervical discectomy and fusion for cervical radiculopathy and myelopathy

Anterior cervical discectomy and fusion is indicated for the operative treatment of either cervical radiculopathy orcervical myelopathy. This article discusses the indications for the procedure, as well as the advantages of this approach, compared with foraminotomy, laminectomy, as well as laminoplasty. The operative technique is described in detail, as well as the results and complications.     

颈椎前路椎间盘切除融合术治疗神经根型颈椎病

目的 探讨颈椎前路椎间盘切除融合术（ACDF）治疗神经根型颈椎病（CSR）的临床疗效。方法 2017年6月—2019年6月,采用ACDF治疗CSR患者43例,患者病程为8~28个月,病变位于C_4,5节段12例、C_5,6节段14例、C_6,7节段11例、C₇~T₁节段6例。评估并比较术前及术后3、6个月颈椎功能障碍指数（NDI）及颈部和上肢疼痛视觉模拟量表（VAS）评分;测量并比较术前及术后3、6个月颈椎曲度（C_2-7 Cobb角）、椎间高度和颈椎活动度（ROM）,观察并发症发生情况。结果 所有患者术后颈椎曲度、NDI、颈部和上肢疼痛VAS评分均较术前改善,差异有统计学意义（P < 0.05）;椎间高度、颈椎ROM与术前相比,差异无统计学意义（P > 0.05）。发生脑脊液漏2例,术后血肿及感染2例。结论 ACDF治疗CSR可取得较好的疗效,其可改善颈椎曲度,恢复神经功能。     

前路椎间盘切除及椎间孔切开术治疗脊髓神经根型颈椎病

2002年3月-2004年7月，我们采用前路椎间盘切除及椎间孔切开术治疗脊髓神经根型颈椎病13例，效果满意，报告如下。     

微创前路经上位椎体椎间孔减压术治疗神经根型颈椎病

【摘要】 目的：探讨微创前路经上位椎体椎间孔减压术治疗神经根型颈椎病的有效性。方法：2008年7月~2010年7月12例单侧神经根型颈椎病患者在延边大学医院接受微创前路经上位椎体椎间孔减压术。其中男7例,女5例,年龄为35~68岁,平均49岁。椎间孔狭窄部位：C5/6 4例,C6/7 5例,C7/T1 3例。软性髓核突出3例,钩椎关节骨质增生7例,突出的髓核钙化2例。均行前路手术,术中采用脊柱手术专用显微镜,在病变上位椎体确定钻孔起始部位,利用高速钻石气钻磨出一约6mm直径的通路达到病变区域,减压椎间孔。观察术前及末次随访时上肢放射性疼痛的VAS评分、颈椎功能障碍指数（NDI）及病变水平椎间盘高度。结果：手术时间为56~110min,平均86±6min;术中失血量为40~120ml,平均92±8ml。无椎动脉损伤、贺纳氏综合征、喉返神经损伤等并发症。术后随访时间为12~23个月,平均15.8±1.3个月。术前上肢疼痛VAS评分为8.5±0.5分（7~10分）,末次随访时为1.4±0.2分（0~3分）,两者比较有显著性差异（P<0.05）;术前NDI为26.4±1.3分（22~31分）,末次随访时为4.2±0.6分（3~8分）,两者比较有显著性差异（P<0.05）,改善率为84.1%;术前病变水平椎间盘高度为5.4±0.7mm（4.2~6.1mm）,末次随访时为4.9±0.7mm（3.6~5.8mm）,两者比较无显著性差异（P>0.05）。术后满意度为100%。结论：微创前路经上位椎体椎间孔减压术可减少对椎间盘的损伤,是治疗单侧神经根型颈椎病的有效手术方法。     

Anterior cervical fractional interspace decompression for treatment of cervical radiculopathy. A review of the first 66 cases

Anterior cervical fractional interspace decompression (ACFID) is an anterior cervical partial discectomy that provides adequate neuroforaminal decompression but avoids segmental collapse and spontaneous fusion. Of 63 patients, 55 were followed from six to 49 months postoperatively (mean, 23 months). Good or excellent results were obtained in 64% of the patients and in 70% of the non-Workers' Compensation patients. Eighty-five percent of the patients and 91% of the non-Workers' Compensation patients were satisfied with the results of surgery. Eighty-seven percent of the patients returned to their original work status. An average of only 1 mm of disc space height was lost. Only two (4%) disc spaces spontaneously fused. ACFID is indicated for radiculopathy due to both soft and hard discs and can be particularly valuable in treating patients with disc herniation adjacent to a previous fusion or radiculopathy with multiple-level myelographic filling defects.     

Anterior discectomy, microscopic decompression, and fusion: a treatment for cervical spondylotic radiculopathy

A consecutive series of 47 patients with cervical radiculopathy secondary to spondylosis were treated with complete discectomy, root decompression accomplished by microscopic foraminotomy on the affected side(s), and iliac graft fusion at the involved interspace(s). Forty of the 47 patients were contacted with an average follow-up of 15 months. Eighty-three percent of the patients were judged as having good results. Fusion of the involved interspace(s) occurred in 87% of cases, although this did not appear to correlate with the clinical results.     

Anterior cervical discectomy with or without bone graft placement in the treatment of cervical radiculopathy. Long-term results

BACKGROUND AND PURPOSE: Anterior approach for cervical radiculopathy is a frequently performed operation in neurosurgery. The goal of this study is to evaluate the short and long-term results of anterior cervical discectomy with and without fusion. METHODS: Between 1984 and 1999, we operated on 101 patients presenting with cervical radiculopathy by an anterior approach. The operation consisted of one-level discectomy in 74 cases, two-level discectomy in 25 cases and three-level discectomy in 2 cases. Eighty-four out of 130 levels operated on were fused. Evaluation was done following a consultation with dynamic cervical X-rays and by telephone using a detailed questionnaire. Follow-up was obtained in 91 cases with a mean of 54 months in fused patients, and a mean of 45 months in the non-fused patients. RESULTS: Post-operative results were good in 95% in the 2 groups of patients. We encountered 8 complications, all in patients operated with bone graft placement. Five patients were reoperated on at an adjacent level, 4 being fused previously. CONCLUSIONS: The 2 techniques are comparable in term of goods results at short and long-term follow-up. Anterior discectomy without fusion is associated with less complications, less post-operative pain, and less operative time cost.     

Anterior uncoforaminotomy in the treatment of recurrent radiculopathy after anterior cervical discectomy with fusion.

BACKGROUND: In patients after anterior cervical discectomy (ACD) with fusion newly developed retrospondylophytes or incomplete decompression of the nerve root can cause recurrent radicular pain. Anterior cervical uncoforaminotomy (uncoforaminotomy) is an operative method which removes the causative degenerative pathology at the level of the neural foramen leaving untouched the inserted graft at this level. METHOD: Between February 2004 and April 2005, 7 patients underwent uncoforaminotomy after ACD with fusion for the treatment of recurrent cervical radiculopathy in our neurosurgical department. Prior to treatment patients received a computed tomography (CT) and a neurological examination. Anterior uncoforaminotomy was performed thereafter (for technical details see publication by Jho, 1996). A postoperative CT scan was done before discharge. Follow-up examination was performed eight weeks after surgery. FINDINGS: Five patients underwent the operation at C5/6, one patient was operated at C6/7 and one patient had the operation at two levels (C5/6 and C6/7). At discharge six patients had excellent or good results. CONCLUSION: Uncoforaminotomy is a good method for the treatment of newly acquired spondylotic spurs in the foramen or incomplete osseous decompression after ACD with fusion and recurrent radicular pain.     

后路经皮内窥镜下颈椎椎间盘切除术治疗神经根型颈椎病

目的探讨后路经皮内窥镜下颈椎椎间盘切除术(PECD)治疗神经根型颈椎病(CSR)的中期临床疗效。方法回顾性分析2016年1月-2017年12月采用后路PECD治疗的31例CSR患者的临床资料,采用疼痛视觉模拟量表(VAS)评分评估上肢及颈部疼痛情况,采用日本骨科学会(JOA)评分评估神经系统功能,记录颈椎曲度及手术节段活动度(ROM)变化。结果所有手术顺利完成,手术时间41~76(57.9±8.6)min,术中出血量12~30(19.7±4.0)mL,住院时间3~6(3.6±0.6)d,术后随访(33.9±8.1)个月。术中均无神经根损伤、硬膜囊破裂等并发症发生。术后上肢VAS评分及JOA评分均较术前明显改善,差异有统计学意义(P<0.05),术后颈椎曲度、手术节段ROM与术前相比无明显改变,差异无统计学意义(P>0.05)。结论后路PECD治疗CSR安全、有效,术中对关节突部分骨质的切除不会影响术后颈椎曲度。     

颈椎后路内窥镜下椎间盘切除术治疗单节段神经根型颈椎病

目的:探讨颈椎后路内窥镜下椎间盘切除术(microendoscopic discectomv,MED)治疗单节段神经根型颈椎病(cervical spondylotic radiculopathy,CSR)的临床疗效.方法:2010年9月～2012年8月,我科采用颈椎后路MED治疗单节段神经根型颈椎病患者16例,其中男11例,女5例;年龄31～56岁,平均41.7岁;C4/5 4例,C5/6 9例,C6/7 3例;均为一侧根性症状,CT 、MRI等影像学检查提示单节段外侧突出或/和关节突增生致椎间孔狭窄,神经受压节段与临床症状体征相符,经系统保守治疗6周以上无效,颈椎动力位X线片未见颈椎不稳.随访观察患者的颈痛VAS评分、JOA评分、颈椎生理曲度、颈椎病变节段稳定性和椎间高度的变化,并进行统计学分析.结果:平均手术时间89min (75～1 15min);术中平均出血量85ml(30～160ml);术后平均住院时间4.1d(3～7d);出院时患者神经根性症状缓解11例,明显改善5例;16例均获随访,平均随访时间12.7个月(6～25个月),VAS评分由术前的7.13±1.15分降至术后的3.00±0.63分,末次随访时为1.94±0.85分;JOA评分由术前12.63±1.09分提高至15.63±0.50分,末次随访时为16.13±0.62分;术前、术后与术次随访时两两比较均有统计学意义(P＜0.05) 颈椎生理曲度D值从术前7.66±0.99mm提高到末次随访时10.99±0.95mm,差异有统计学意义(P＜0.05) 术前和末次随访时病变节段椎间高度分别为5.56±0.54mm和5.54±0.52mm,差异无统计学意义(p＞0.05).过伸过屈位X线片未显示明显颈椎失稳结论:在严格选择适应证的前提下,颈椎后路MED治疗单节段神经根型颈椎病可取得较满意的临床疗效.     

Small keyhole transuncal foraminotomy for unilateral cervical radiculopathy

Summary Interbody fusion after anterior discectomy may lead to acceleration of degenerative changes at adjacent levels. Although the posterior approach preserves the motion segment, decompression of the nerve root is indirect if “hard disc prolaps” is the main cause. Recently, a technique of microsurgical anterior cervical foraminotomy for the treatment of radiculopathy with preservation of the segment mobility was published. In this study, we present this technique with several modifications. Thirteen patients – 5 men and 8 women with an average age of 49 years – with unilateral radiculopathy resistant to conservative treatment underwent microsurgical anterior foraminotomy via a small keyhole transuncal approach. The base of the uncinate process (UP) was directly drilled in the trajectory to the intervertebral foramen without destroying the disc tissue. The vertebral artery between the transverse process was not exposed. Furthermore, the functional anatomy of the uncovertebral joint remained largely intact. All patients experienced complete relief of radiating pain. A cervical collar was not used. Mean follow-up time was 19 months. The mobility of the operated segment was preserved in each patient. No instability of the cervical spine was seen. The microsurgical anterior foraminotomy via a small keyhole transuncal approach is safe, minimally invasive, and represents an effective method to treat unilateral cervical radiculopathy caused by disc prolaps and/or uncovertebral osteophytes. Additionally, the segment mobility is preserved and prevents the acceleration of degenerative changes at adjacent levels.     

Surgical treatment of cervical radiculopathy

Cervical radiculopathy can be a disabling condition for patients. Pain, paresthesia, and motor deficit may occur. Although there are ample treatment options for these patients, surgery may be necessary. The goal of this article is to discuss the diagnosis of cervical radiculopathy and outline surgical indications. Surgical options are discussed in detail. Anterior and posterior approaches will be reviewed along with the advantages of each. Hopefully this article enables the reader to look at cervical radiculopathy through the eyes of a surgeon and aid in determining appropriate care. Understanding the surgical anatomy may also allow a pain management specialist to focus his or her treatment directly on the offending pathology and optimize nonsurgical care, as well.     

Surgical management of cervical radiculopathy

Cervical radiculopathy presents as pain in a dermatomal distribution. Despite conservative nonoperative therapy, a large subset of patients will require surgical intervention. Indications for surgery include recalcitrant radiculopathy despite nonoperative treatment for more than 6 weeks and progressive motor deficit or disabling motor deficit (deltoid palsy, wrist drop) prior to 6 weeks. Anterior and posterior approaches have both yielded successful results in appropriately selected patients. Anterior cervical diskectomy and fusion is the generally preferred treatment for radiculopathy when there is a significant component of axial neck pain, when the disease is centrally located, or when there is any degree of segmental kyphosis. Posterior laminoforaminotomy is an acceptable choice for lateral soft disk herniations with predominant arm pain and for caudal lesions in large, short-necked individuals.     

Results of posterior cervical foraminotomy for treatment of cervical spondylitic radiculopathy

We evaluated the results of posterior cervical foraminotomy for spondylitic radiculopathy using a questionnaire sent to all 77 patients who had undergone surgery between 1990 and 1995 at our institution. Sixty-two patients (40 male) returned their questionnaires, one of whom had undergone two procedures (dealt with as separate events). Sixty patients complained of pre-operative arm pain; of these 42 (70%) had complete or > 75% resolution of their pain, 14 (23%) had < 75% improvement in their pain and four (7%) had the same or worsened pain at the time of the questionnaire. Sixteen patients (27%) reported initial improvement in symptoms with subsequent deterioration. The mean patient satisfaction score using a linear analogue scale from 0 to 10 was 7.5. Main postoperative complaints were neck pain (22%), persisting motor deficit (6%) and persisting sensory deficit (9%). One patient suffered nerve root damage at surgery. For unilateral and, in some cases, multi-level degenerative disease causing cervical radiculopathy, posterior cervical foraminotomy is a useful technique with the advantage of avoiding fusion, immobilization and the long-term risk of instability.     

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.     

An expanding cervical synovial cyst causing acute cervical radiculopathy

Synovial cysts of the cervical spine occur infrequently in the spinal canal and are most often associated with degenerative facet joints. Despite the prevalence of degenerative spinal disease, symptomatic synovial cysts are extremely uncommon. We report a rare case that showed an exacerbation of a cervical radiculopathy due to an acute expansion of the synovial cyst. Magnetic resonance (MR) images originally revealed a small cystic extradural lesion when the patient presented with neck pain and slightly numbness in the right hand. The patient's complaints subsequently subsided after administration of pain killers. However, 2 weeks after this, the patient experienced a spontaneous, sudden, severe radiating pain into the right arm without any accompanying cervical injury. MR images showed that the cyst had become markedly increased in size in the intervening 4 weeks and compressed the spinal cord laterally. Because the arm pain was so severe and neurologic examinations revealed the paralysis of the C8 nerve root, the synovial cyst was excised surgically and a good clinical outcome achieved. Thus, even if symptoms are mild and the size of the synovial cyst is small, acute expansion of the cyst might be rarely observed and careful management, including surgical consideration, is needed.