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Minimally invasive cervical foraminotomy remains preferred radiculopathy procedure
The first long-term analysis found radicular symptoms returned to 11% of patients and 32% had onset of some radicular or neck pain.
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The first long-term clinical outcome analysis of minimally invasive cervical foraminotomy for treating radiculopathy found that 32% of patients experienced new radiculopathy or neck pain after prior successful relief of symptoms.
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Additionally, of the 32% with new symptoms, only one-third (18% overall) had a return of their original symptoms to index level radiculopathy, and 12% of patients ultimately required anterior cervical discectomy and fusion.
Although published series of minimally invasive cervical foraminotomy (MICF) have shown a short-term 85% to 98% relief of cervical radiculopathy, no long-term clinical series exist to show the stability of the early results over time, according to the researchers at the University of California Los Angeles (UCLA) and University of Chicago.
Minimally invasive approach
Larry T. Khoo, MD, of the UCLA Comprehensive Spine Center presented the results of the multi-center retrospective chart review of 73 MICF patients at the 2005 Annual Congress of the Spine Society of Europe (EuroSpine 2005). Some patients were part of a one-year study published in Neurosurgery in 2002 that initially showed a 92% to 93% relief in radiculopathy.
“The technique is the classical technique of posterior cervical foraminal decompression and discetomy, but modified with a minimally invasive muscle-sparing approach,” Khoo said. “A tubular dilator is used to approach the cervical neuroforamen ... In some cases, the patients were done sitting for endoscopic access, whereas the majority are now in a semiprone position with the use of an operating microscope.”
Khoo said the minimally invasive technique using tubular access allows surgeons to effectively decompress the nerve root with decrease muscle injury, minimal blood loss and preservation of motion by avoiding fusion at the target level on an outpatient basis.
Over four years, researchers recorded specific radiculopathy and neck pain symptoms, and collected outcome measures from clinic records, operative records and phone surveys. “Specifically, our indications were only posterior lateral disc herniation and radiculopathy with a minimum of stenosis and a minimum of axial neck pain initially,” Khoo said.
Return radiculopathy
At three months, 70 patients (96%) reported radicular pain relief, compared to preop. But, over the four-year period, “32% [of patients] had return of some degree of radiculopathy with neck pain overall in the cohort,” Khoo said. “However, of these, only 18% had symptoms at the original level and only 13% ultimately required a repeat surgery at that same level.”
At 40 months follow-up, 15 patients reported cervical radiculopathy symptoms — eight with recurrent same-level radicular symptoms and the other seven with a new radicular pattern. Of the seven with a new radicular pattern, researchers found that six patients had preop evidence of radiographic abnormality in the same level.
“What we discovered is that about a third of patients began to manifest new radicular symptoms over a course of about 30 months and of those, only approximately half had recurrence attributable to the original operated level,” Khoo said.
“Over the same time period, approximately 12% of patients also began to complain of significant axial neck pain that was not present preoperatively. Whether or not this represents progression of the natural disease process or a result of surgery remains unclear,” he added.
After MICF, researchers found the 15 patients underwent additional cervical surgery as follows:
- Three underwent MICF at the same level;
- Two underwent MICF at a different level;
- Seven underwent anterior cervical discectomy and fusion (ACDF) at the same level (six had good outcomes); and
- Three underwent ACDF at a different level.
MICF the preferred procedure
The researchers found that 10 patients (13%) required an ACDF after the four-year follow-up period. thus 64 patients were spared fusion from the original cohort by utilizing MIPCF. Based on a study by Brand et al., which cites a 2.5% per year incidence of adjacent level fusion, they calculated that another six to eight patients would have required an additional fusion had all patients been treated with ACDF initially.
Approximately 70 to 72 spinal fusions were ultimately avoided in this cohort over the four year study period. This is particularly attractive as anterior spinal fusion and instrumentation carries with attendant costs, surgical complications, nonunion and hardware failure rates, Khoo said.
“As such, from an economic and medical perspective, as well as our own personal bias, minimally invasive cervical foraminotomy continues to be our procedure of choice for properly selected patients with cervical radiculopathy,” he said.
For more information:
Lam S, Khoo, LT, Cannestra A, et al. A long-term clinical outcome analysis of minimally invasive cervical foraminotomy for the treatment of cervical radiculopathy. #4. Presented at EuroSpine 2005. Sept. 21-24, 2005. Barcelona, Spain.
Fessler RG, Khoo LT. Minimally invasive cervical microendoscopic foraminotomy: an initial clinical experience. Neurosurgery. 2002; 51(5) SUPPLEMENT 2:S2-37-S2-45.
Brand AS, Carlson GD, Palumbo MA, et al. Radiculopathy and myelopathy at segments adjacent to the site of a previous anterior cervical arthrodesis. J Bone Joint Surg Am. 1999;81:519-528.