Anterior percutaneous endoscopic cervical discectomy

Anterior percutaneous endoscopic cervical discectomy

Since the early 2000s, increasingly practical PECD techniques have been introduced because of advancements in working channel endoscope and surgical instrument technology 1) 2) 3) 4).

Anterior percutaneous endoscopic cervical discectomy (PECD) is an effective minimally invasive surgery for soft cervical disc herniation in properly selected cases 5) 6).

The PECD prototype is fluoroscopically guided percutaneous cervical disc decompression without endoscopic visualization, such as automated nucleotomy 7) 8).

Randomized controlled trials

Ahn et al. compared the surgical results of PECD and ACDF. Data from patients treated with single-level PECD (n = 51) or ACDF (n = 64) were analyzed. Patients were prospectively entered into the clinical database and their records were retrospectively reviewed. Perioperative data and clinical outcomes were evaluated using the visual analogue scale (VAS), Neck Disability Index (NDI), and modified Macnab criteriaVAS and NDI results significantly improved in both groups. The rates of excellent or good results were 88.24% and 90.63% in the PECD and ACDF group, respectively. The revision rates were 3.92% and 1.56% in the PECD and ACDF group, respectively. Operative time, hospital stay, and time to return to work were reduced in the PECD group compared to the ACDF group (p < 0.001). The five-year outcomes of PECD were comparable to those of conventional ACDF. PECD provided the typical benefits of minimally invasive surgery and may be an effective alternative for treating soft cervical disc herniation 9).


A total of 103 patients with ACDF or FACD were followed up for two years. In addition to general parameters specific measuring instruments were used. Postoperatively 85.9% of the patients no longer had arm pain, and 10.1% had occasional pain. There were no significant clinical differences between the decompression with or without fusion. The full-endoscopic technique afforded advantages in operation technique, rehabilitation and soft tissue injury. The recorded results show that FACD is a sufficient and safe alternative to conventional procedures when the indication criteria are fulfilled. At the same time, it offers the advantages of a minimally invasive intervention 10).

References

1)

Chiu, J.C.; Clifford, T.J.; Greenspan, M.; Richley, R.C.; Lohman, G.; Sison, R.B. Percutaneous microdecompressive endoscopic cervical discectomy with laser thermodiskoplasty. Mt. Sinai. J. Med. 2000, 67, 278–282.
2)

Ahn, Y.; Lee, S.H.; Lee, S.C.; Shin, S.W.; Chung, S.E. Factors predicting excellent outcome of percutaneous cervical discectomy: analysis of 111 consecutive cases. Neuroradiology 2004, 46, 378–384.
3)

Ahn, Y.; Lee, S.H.; Shin, S.W. Percutaneous endoscopic cervical discectomy: clinical outcome and radiographic changes. Photomed. Laser Surg. 2005, 23, 362–368.
4)

Ahn, Y.; Lee, S.H.; Chung, S.E.; Park, H.S.; Shin, S.W. Percutaneous endoscopic cervical discectomy for discogenic cervical headache due to soft disc herniation. Neuroradiology 2005, 47, 924–930
5)

Lee, J.H.; Lee, S.H. Clinical and radiographic changes after percutaneous endoscopic cervical discectomy: a long‐term follow‐up. Photomed. Laser. Surg. 2014, 32, 663–668.
6)

Ahn, Y. Percutaneous endoscopic cervical discectomy using working channel endoscopes. Expert. Rev. Med. Devices 2016, 13, 601–610.
7)

Courtheoux, F.; Theron, J. Automated percutaneous nucleotomy in the treatment of cervicobrachial neuralgia due to disc herniation. J. Neuroradiol. 1992, 19, 211–216.
8)

Bonaldi, G.; Minonzio, G.; Belloni, G.; Dorizzi, A.; Fachinetti, P.; Marra, A.; Goddi, A. Percutaneous cervical diskectomy: preliminary experience. Neuroradiology 1994, 36, 483–486.
9)

Ahn Y, Keum HJ, Shin SH. Percutaneous Endoscopic Cervical Discectomy Versus Anterior Cervical Discectomy and Fusion: A Comparative Cohort Study with a Five-Year Follow-Up. J Clin Med. 2020 Jan 29;9(2). pii: E371. doi: 10.3390/jcm9020371. PubMed PMID: 32013206.
10)

Ruetten S, Komp M, Merk H, Godolias G. Full-endoscopic anterior decompression versus conventional anterior decompression and fusion in cervical disc herniations. Int Orthop. 2009 Dec;33(6):1677-82. doi: 10.1007/s00264-008-0684-y. Epub 2008 Nov 18. PubMed PMID: 19015851; PubMed Central PMCID: PMC2899164.

Degenerative cervical myelopathy

Degenerative cervical myelopathy

The assessment, diagnosis, operative and nonoperative management of degenerative cervical myelopathy (DCM) have evolved rapidly over the last 20 years. A clearer understanding of the pathobiology of DCM has led to attempts to develop objective measurements of the severity of myelopathy, including technology such as multiparametric magnetic resonance imaging, biomarkers, and ancillary clinical testing. New pharmacological treatments have the potential to alter the course of surgical outcomes, and greater innovation in surgical techniques have made surgery safer, more effective and less invasive. Future developments for the treatment of DCM will seek to improve the diagnostic accuracy of imaging, improve the objectivity of clinical assessment, and increase the use of surgical techniques to ensure the best outcome is achieved for each individual patient 1).

Goel was troubled by the fact that his several PubMed and MEDLINE indexed articles on the subject published in leading journals dedicated to the study of the spine have not found any place in the huge reference list of 137 articles 2)

Definition

Epidemiology

Etiology

Pathophysiology

A review of Tetreault et al. summarizes current knowledge of the pathophysiology of DCM and describes the cascade of events that occur after compression of the spinal cord, including ischemia, destruction of the blood-spinal cord barrier, demyelination, and neuronal apoptosis. Important features of the diagnosis of DCM are discussed in detail, and relevant clinical and imaging findings are highlighted. Furthermore, this review outlines valuable assessment tools for evaluating functional status and quality of life in these patients and summarizes the advantages and disadvantages of each. Other topics of this review include epidemiology, the prevalence of degenerative changes in the asymptomatic population, the natural history and rates of progression, risk factors of diagnosis (clinical, imaging and genetic), and management strategies 3).

Clinical features

Patients may initially experience minimal symptoms 4) 5) but subsequently often develop pain, sensory deficits especially affecting their hands and feet, spasticity, imbalance, bladder symptoms, and experience frequent falls 6).

Diagnosing DCSM has traditionally relied on presence of clinical symptoms, including clumsy hands, paralysis of the lower extremities, gait disturbances, urinary/bowel incontinence and severe neurological dysfunction disturbances, urinary/bowel incontinence, and severe neurological dysfunction 7) 8).

Many people with cervical spondylosis or CSM are asymptomatic. However, patients with CSM are at higher risk of spinal cord injury (SCI) following minor injury.

Only a small percentage of people with spondylosis go on to develop symptoms consistent with cervical spondylotic myelopathy (CSM), which can cause significant and disabling neurological deficits, leading to loss of function, morbidity, and mortality.

In addition, diabetes mellitus (DM) is a frequent comorbidity for people of this age and may impact the severity of CCM.

Scales

European myelopathy score.

As a widespread used scale, the Modified Japanese Orthopaedic Association scale (mJOA) should be translated and culturally adapted 9).

see Cervical spine stenosis scales

Diagnosis

Treatment

Outcome

Randomized, controlled trials

A National Institutes of Health-funded (1R13AR065834-01) investigator meeting was held before the initiation of the trial to bring multiple stakeholders together to finalize the study protocol. Study investigators, coordinators, and major stakeholders were able to attend and discuss strengths of, limitations of, and concerns about the study. The final protocol was approved for funding by the Patient-Centered Outcomes Research Institute (CE-1304-6173). The trial began enrollment on April 1, 2014 10).

Case series

References

1)

Wilson JRF, Badhiwala JH, Moghaddamjou A, Martin AR, Fehlings MG. Degenerative Cervical Myelopathy; A Review of the Latest Advances and Future Directions in Management. Neurospine. 2019 Sep;16(3):494-505. doi: 10.14245/ns.1938314.157. Epub 2019 Aug 26. PubMed PMID: 31476852; PubMed Central PMCID: PMC6790745.
2)

Goel A. Degenerative Cervical Myelopathy. Neurospine. 2019 Dec;16(4):793-795. doi: 10.14245/ns.1938384.192. Epub 2019 Dec 31. PubMed PMID: 31905465.
3)

Tetreault L, Goldstein CL, Arnold P, Harrop J, Hilibrand A, Nouri A, Fehlings MG. Degenerative Cervical Myelopathy: A Spectrum of Related Disorders Affecting the Aging Spine. Neurosurgery. 2015 Oct;77 Suppl 4:S51-67. doi: 10.1227/NEU.0000000000000951. PubMed PMID: 26378358.
4)

Kovalova I, Kerkovsky M, Kadanka Z, Kadanka Z Jr, Nemec M, Jurova B, Dusek L, Jarkovsky J, Bednarik J. Prevalence and Imaging Characteristics of Nonmyelopathic and Myelopathic Spondylotic Cervical Cord Compression. Spine (Phila Pa 1976). 2016 Dec 15;41(24):1908-1916. PubMed PMID: 27509189.
5)

Martin AR, De Leener B, Cohen-Adad J, Cadotte DW, Nouri A, Wilson JR, Tetreault L, Crawley AP, Mikulis DJ, Ginsberg H, Fehlings MG. Can microstructural MRI detect subclinical tissue injury in subjects with asymptomatic cervical spinal cord compression? A prospective cohort study. BMJ Open. 2018 Apr 13;8(4):e019809. doi: 10.1136/bmjopen-2017-019809. PubMed PMID: 29654015; PubMed Central PMCID: PMC5905727.
6)

Davies BM, Mowforth OD, Smith EK, Kotter MR. Degenerative cervical myelopathy. BMJ. 2018 Feb 22;360:k186. doi: 10.1136/bmj.k186. Review. PubMed PMID: 29472200; PubMed Central PMCID: PMC6074604.
7)

Guan L, Chen X, Hai Y, et al. High-resolution diffusion tensor imaging in cervical spondylotic myelopathy: A preliminary follow-up study. NMR Biomed. 2017
8)

Sampath P, Bendebba M, Davis JD, et al. Outcome of patients treated for cervical myelopathy. A prospective, multicenter study with independent clinical review. Spine (Phila Pa 1976) 2000;25(6):670–76.
9)

Augusto MT, Diniz JM, Rolemberg Dantas FL, Fernandes de Oliveira M, Rotta JM, Botelho RV. Development of the Portuguese version of the modified Japanese Orthopaedic Association Score: cross-cultural adaptation, reliability, validity and responsiveness. World Neurosurg. 2018 Jun 1. pii: S1878-8750(18)31127-6. doi: 10.1016/j.wneu.2018.05.173. [Epub ahead of print] PubMed PMID: 29864576.
10)

Ghogawala Z, Benzel EC, Heary RF, Riew KD, Albert TJ, Butler WE, Barker FG 2nd, Heller JG, McCormick PC, Whitmore RG, Freund KM, Schwartz JS. Cervical Spondylotic Myelopathy Surgical Trial: Randomized, Controlled Trial Design and Rationale. Neurosurgery. 2014 Oct;75(4):334-346. PubMed PMID: 24991714.

Anterior cervical pseudarthrosis

Anterior cervical pseudarthrosis

Pseudarthrosis may occur with or without supplemental anterior cervical plating.

Incidence

Difficult to assess because of lack of validated criteria. Estimate: 2–20%. Higher with dowel technique (Cloward) than with the keystone technique of Bailey & Badgley or with the interbody method of Smith-Robinson (10%) or with non-fusion advocated by Hirsch. One criterion: motion>2mm between the tips of the spinous processes on lateral flexion/extension X-rays.

Other criteria that are specific but not sensitive: lucencies around the screws of an anterior plate, toggling of the screws on flexion/extension X-rays.

Clinical

Not uniformly associated with symptoms or problems. Some patients may have chronic or recurrent neck pain, some may present with radicular symptoms. (NB: when DePalma’s data is analyzed with patients reclassified as failures if the neck and/or arm symptoms persist, the success rate of surgery is lower with pseudarthrosis)

Diagnosis

More than 2 mm movement between spinous processes on dynamic (flexion-extension) cervical spine X-rays is recommended as a criterion for pseudarthrosis (Level B Class II); this measurement is unreliable when performed by the treating surgeon (Level C Class II).

Visualization of bone trabeculation across the fusion on static films is a less reliable marker for fusion (Level D Class III) (2D reformatted CT increases the accuracy (Level D Class III)).

see Cervical fusion criteria.

Treatment

No treatment is required for asymptomatic pseudarthrosis. Options for symptomatic patients include re-resection of the bone graft with repeat fusion (some recommend using autologous bone if allograft was used; a plate may be considered if one was not used previously), cervical corpectomy with fusion, or posterior cervical fusion.


Revision of symptomatic pseudarthrosis should be considered (Level D Class III). Postrior approaches may be associated with higher fusion rates on revision than anterior approaches (Level D Class III).

Outcome

In 1- and 2-level ACDF with plating involving the same number of fusion levels, there was no statistically significant difference in the pseudarthrosis rate, revision surgery rate, subsidence, and lordosis loss between PEEK cages and structural allograft 1).


Common interbody graft options for anterior cervical discectomy and fusion (ACDF) include structural allograft and polyetheretherketone (PEEK). PEEK has gained popularity due to its radiolucency and its elastic modulus, which is similar to that of bone.

A study sought to compare the rates of pseudarthrosis, a lack of solid bone growth across the disc space, and the need for revision surgery with the use of grafts made of allogeneic bone versus PEEK.

127 cases in which patients had undergone a 1-level ACDF followed by at least 1 year of radiographic follow-up. Data on age, sex, body mass indextobacco use, pseudarthrosis, and the reoperation rate for pseudarthrosis were collected. These data were analyzed by performing a Pearson’s chi-squared test.

Of 127 patients, 56 had received PEEK implants and 71 had received allografts. Forty-six of the PEEK implants (82%) were stand-alone devices. There were no significant differences between the 2 treatment groups with respect to patient age, sex, or body mass index. Twenty-nine (52%) of 56 patients with PEEK implants demonstrated radiographic evidence of pseudarthrosis, compared to 7 (10%) of 71 patients with structural allografts (p < 0.001, OR 9.82; 95% CI 3.836-25.139). Seven patients with PEEK implants required reoperation for pseudarthrosis, compared to 1 patient with an allograft (p = 0.01, OR 10.00; 95% CI 1.192-83.884). There was no significant difference in tobacco use between the PEEK and allograft groups (p = 0.586).

The results of this study demonstrate that the use of PEEK devices in 1-level ACDF is associated with a significantly higher rate of radiographically demonstrated pseudarthrosis and need for revision surgery compared with the use of allografts. Surgeons should be aware of this when deciding on interbody graft options, and reimbursement policies should reflect these discrepancies 2).


The objective of a systematic review done by Kaiser et al. from the Department of Neurological Surgery, Columbia University, New York, USA, was to use evidence-based medicine to identify the best methodology for diagnosis and treatment of anterior pseudarthrosis.

The National Library of Medicine and Cochrane Database were queried using MeSH headings and key words relevant to pseudarthrosis and cervical spine surgery. Abstracts were reviewed, after which studies meeting inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I-III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons.

Evaluation for pseudarthrosis is warranted, as there may be an association between clinical outcome and pseudarthrosis. The strength of this association cannot be accurately determined because of the variable incidence of symptomatic and asymptomatic pseudarthroses (Class III). Revision of a symptomatic pseudarthrosis may be considered because arthrodesis is associated with improved clinical outcome (Class III). Both posterior and anterior approaches have proven successful for surgical correction of an anterior pseudarthrosis. Posterior approaches may be associated with higher fusion rates following repair of an anterior pseudarthrosis (Class III).

If suspected, pseudarthrosis should be investigated because there may be an association between arthrodesis and outcome. However, the strength of this association cannot be accurately determined. Anterior and posterior approaches have been successful 3).

References

1)

Wang M, Chou D, Chang CC, Hirpara A, Liu Y, Chan AK, Pennicooke B, Mummaneni PV. Anterior cervical discectomy and fusion performed using structural allograft or polyetheretherketone: pseudarthrosis and revision surgery rates with minimum 2-year follow-up. J Neurosurg Spine. 2019 Dec 13:1-8. doi: 10.3171/2019.9.SPINE19879. [Epub ahead of print] PubMed PMID: 31835252.
2)

Fivefold higher rate of pseudarthrosis with polyetheretherketone interbody device than with structural allograft used for 1-level anterior cervical discectomy and fusion. J Neurosurg Spine. 2018 Oct 1:1-6. doi: 10.3171/2018.7.SPINE18531. [Epub ahead of print] PubMed PMID: 30485200.
3)

Kaiser MG, Mummaneni PV, Matz PG, Anderson PA, Groff MW, Heary RF, Holly LT, Ryken TC, Choudhri TF, Vresilovic EJ, Resnick DK; Joint Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons and Congress of Neurological Surgeons. Management of anterior cervical pseudarthrosis. J Neurosurg Spine. 2009 Aug;11(2):228-37. doi: 10.3171/2009.2.SPINE08729. PubMed PMID: 19769502.

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