Transtubular Anterior Cervical Foraminotomy for the Treatment of Compressive Cervical Radiculopathy: Surgical Results and Complications in a Consecutive Series of Cases

Abstract

Study Design: This was a retrospective review of patients with compressive cervical radiculopathy treated with a minimally invasive anterior cervical foraminotomy (ACF).Purpose: This study aimed to evaluate the results and complication rates of ACF in a consecutive series of patients and to report our clinical results of ACF as a minimally invasive technique in a series of 45 consecutive patients treated for compressive cervical radiculopathy.Overview of Literature: ACF is a motion-sparing procedure and an alternative to anterior cervical discectomy and fusion (ACDF) and posterior cervical foraminotomy for direct nerve root decompression in patients with compressive cervical radiculopathy.Methods: The chart review recorded clinical and radiological features preoperatively and postoperatively and at follow-up (FU). The effect of prognostic factors was analyzed in relation to the clinical outcome.Results: Between January 2004 and October 2019, 45 patients (15 females and 30 males) with a mean age of 55.9 years (range, 28–78 years) underwent ACF for unilateral cervical radiculopathy. The global clinical outcome according to the MacNab scale was evaluated as excellent in 64.5% of patients (n=29), good in 28.9% (n=13), fair in 4.4% (n=2), and poor in 2.2% (n=1). The radiological FU was available for 73.3% (n=33). The statistical analysis revealed no influence of age, sex, operated level, and side on the clinical outcome. Only one patient (2.2%) exhibited spontaneous bone fusion at the operated level on FU after a right-sided C6–7 ACF with no clinical consequences. No patient presented with signs of delayed segmental instability. The overall reoperation rate of this series was 4.4%.Conclusions: ACF is a feasible and low-cost alternative to ACDF in selected patients with cervical radiculopathy. The use of tubular retractors in ACF may confer an added advantage that creates a safe corridor for direct cervical root decompression yet minimizing surrounding soft tissue retraction and avoiding unnecessary bone removal.

Cervical Radiculopathy Focus on Characteristics and Differential Diagnosis

“…Surgery is applicable to patients with intractable or persistent pain despite sufficient conservative management for at least 6 to 12 weeks or to patients with severe or progressive neurological deficits. Cervical radiculopathy is treated surgically by anterior or posterior approaches [54]. For patients with cervical kyphosis [55], anterior procedures CTS, carpal tunnel syndrome; NCS, nerve conduction study; PIN, posterior interosseus nerve.…”

Minimally invasive anterior cervical foraminotomy for unilateral radiculopathy

“…A risk of this procedure is that it is relatively unfamiliar; the aggregate published case series in the literature sum to less than 500 total cases. 2 This unfamiliarity combined with the required bone removal near the vertebral artery intuitively carries a higher risk of vertebral artery injury than alternative procedures, which has likely limited the adoption of this technique. Additionally, the greater lateral retraction or the resection of a small portion of the longus colli carries a risk of a postoperative Horner's syndrome.…”

“…Additionally, the greater lateral retraction or the resection of a small portion of the longus colli carries a risk of a postoperative Horner's syndrome. 1,2 Last, given the disc-sparing nature of this technique, recurrent disc herniation is possible. 3 The alternative procedures were not chosen for the same reasons discussed on the previous slide-we prioritized preserving the cervical disc and motion segment, avoiding hardware implantation, and minimizing tissue disruption, postoperative pain, and postoperative restrictions.…”

“…This table of the published case series reveals overall good clinical results, low adverse event rates, and low rates of reoperation at the index level or at the adjacent level. [1][2][3][6][7][8][9][10][11] No cases of vertebral artery injury were reported. Four cases of transient Horner's syndrome were reported; one author modified his longus colli dissection technique from monopolar cautery to manual blunt dissection, a change that resulted in no further cases of Horner syndrome in that series.…”

Foraminal Restenosis After Posterior Cervical Foraminotomy for the Treatment of Cervical Radiculopathy

“…Posterior cervical foraminotomy (PCF) is an effective surgical method for the treatment of cervical radiculopathy which revision rate and clinical efficacy are reported to be similar with that of anterior cervical discectomy and fusion (ACDF). [1][2][3][4] It also can avoid troublesome postoperative complications of ACDF including pseudarthrosis, adjacent segmental disease, loss of motion segments, and postoperative dysphagia. 5,6 Furthermore, recent reports have demonstrated that PCF results in shortened hospital stay and reduced blood loss or cost compared to ACDF which makes PCF a widely applied surgical option for cervical radiculopathy.…”