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.

Percutaneous trigeminal rhizotomy

Percutaneous trigeminal rhizotomy

Percutaneous trigeminal rhizotomy are invasive percutaneous techniques for trigeminal neuralgia that remain safe, simple, and effective for achieving good pain control while minimizing procedural risk 1).

It has been associated with serious complications related to the cannulation of the foramen ovale. Some of these complications, such as internal carotid artery injury, are potentially lethal.

Neuronavigation was proposed as a method to increase the procedure’s safety. All of the techniques described so far rely on pre- or intraoperative computed tomography scanning. Lepski et al. present a simple method based on magnetic resonance imaging (MRI) (radiation free) used to target the foramen ovale under navigation guidance.

This method proved to be safe and effective, and it is especially recommended for young, inexperienced neurosurgeons. 2).

Types

Percutaneous radiofrequency trigeminal rhizotomy

Percutaneous balloon compression trigeminal rhizotomy

Percutaneous glycerol trigeminal rhizotomy.

Although all 3 techniques are generally safe, efficient, and effective, a clear consensus has not been reached regarding their specific indications and degree of efficacy 3).

They differ in method and specificity of nerve injury. BC selectively injures larger pain fibers while sparing small fibers and does not require an awake, cooperative patient. Pain control rates up to 91% at 6 months and 66% at 3 years have been reported. RF allows somatotopic nerve mapping and selective division lesioning and provides pain relief in up to 97% of patients initially and 58% at 5 years. Multiple treatments improve outcomes but carry significant morbidity risk. GR offers similar pain-free outcomes of 90% at 6 months and 54% at 3 years but with higher complication rates (25% vs 16%) compared with BC. Advantages of percutaneous techniques include shorter procedure duration, minimal anesthesia risk, and in the case of GR and RF, immediate patient feedback 4).

In a systematic review and meta-analysis Percutaneous radiofrequency trigeminal rhizotomy is associated with statistically significant higher odds for immediate pain relief and anesthesia and lower risk for post-operative herpes eruption as compared to Percutaneous glycerol trigeminal rhizotomy. Patients in the Percutaneous balloon compression trigeminal rhizotomy group had a statistically significant higher risk to develop post-operative mastication weakness and diplopia when compared to Percutaneous glycerol trigeminal rhizotomy 5).

Training

A real-time augmented reality simulator for percutaneous trigeminal rhizotomy was developed using the ImmersiveTouch platform. Ninety-two neurosurgery residents tested the simulator at American Association of Neurological Surgeons Top Gun 2014. Postgraduate year (PGY), number of fluoroscopy shots, the distance from the ideal entry point, and the distance from the ideal target were recorded by the system during each simulation session. Final performance score was calculated considering the number of fluoroscopy shots and distances from entry and target points (a lower score is better). The impact of PGY level on residents’ performance was analyzed.

Seventy-one residents provided their PGY-level and simulator performance data; 38% were senior residents and 62% were junior residents. The mean distance from the entry point (9.4 mm vs 12.6 mm, P = .01), the distance from the target (12.0 mm vs 15.2 mm, P = .16), and final score (31.1 vs 37.7, P = .02) were lower in senior than in junior residents. The mean number of fluoroscopy shots (9.8 vs 10.0, P = .88) was similar in these 2 groups. Linear regression analysis showed that increasing PGY level is significantly associated with a decreased distance from the ideal entry point (P = .001), a shorter distance from target (P = .05), a better final score (P = .007), but not number of fluoroscopy shots (P = .52).

Because technical performance of percutaneous rhizotomy increases with training, we proposed that the skills in performing the procedure in our virtual reality model would also increase with PGY level, if our simulator models the actual procedure. Our results confirm this hypothesis and demonstrate construct validity 6).

References

1)

Cheng JS, Lim DA, Chang EF, Barbaro NM. A review of percutaneous treatments for trigeminal neuralgia. Neurosurgery. 2014 Mar;10 Suppl 1:25-33; discussion 33. doi: 10.1227/NEU.00000000000001687. Review. Erratum in: Neurosurgery. 2014 Jun; 10 Suppl 2:372. PubMed PMID: 24509496.
2)

Lepski G, Filho PM, Ramina K, Bisdas S, Ernemann U, Tatagiba M, Morgalla M, Feigl G. MRI-Based Radiation-Free Method for Navigated Percutaneous Radiofrequency Trigeminal Rhizotomy. J Neurol Surg A Cent Eur Neurosurg. 2015 Jan 16. [Epub ahead of print] PubMed PMID: 25594821.
3)

Missios S, Mohammadi AM, Barnett GH. Percutaneous treatments for trigeminal neuralgia. Neurosurg Clin N Am. 2014 Oct;25(4):751-62. doi: 10.1016/j.nec.2014.06.008. Epub 2014 Aug 3. PubMed PMID: 25240662.
4)

Cheng JS, Lim DA, Chang EF, Barbaro NM. A Review of Percutaneous Treatments for Trigeminal Neuralgia. Neurosurgery. 2013 Sep 23. [Epub ahead of print] PubMed PMID: 24064481.
5)

Texakalidis P, Xenos D, Tora MS, Wetzel JS, Boulis NM. Comparative safety and efficacy of percutaneous approaches for the treatment of trigeminal neuralgia: A systematic review and meta-analysis. Clin Neurol Neurosurg. 2019 May 14;182:112-122. doi: 10.1016/j.clineuro.2019.05.011. [Epub ahead of print] Review. PubMed PMID: 31121470.
6)

Shakur SF, Luciano CJ, Kania P, Roitberg BZ, Banerjee PP, Slavin KV, Sorenson J, Charbel FT, Alaraj A. Usefulness of a Virtual Reality Percutaneous Trigeminal Rhizotomy Simulator in Neurosurgical Training. Neurosurgery. 2015 Sep;11 Suppl 3:420-5; discussion 425. doi: 10.1227/NEU.0000000000000853. PubMed PMID: 26103444.

Percutaneous balloon compression trigeminal rhizotomy for multiple sclerosis related trigeminal neuralgia

Percutaneous balloon compression trigeminal rhizotomy for multiple sclerosis related trigeminal neuralgia

Many patients with multiple sclerosis related trigeminal neuralgia have pain that is centrally mediated, reducing the effectiveness of procedures performed on the trigeminal roottrigeminal ganglion, or divisions 1).

Balloon compression had the highest rate of initial pain-free response (IPFR) and duration of pain-free intervals (PFIs), compared with other modalities in the initial treatment of MS-related TN 2). It could be considered a useful technique for patients whose pain recurs after other procedures 3).

Percutaneous balloon compression PBC is a treatment that can be effective for many patients with MS-TN 4).

Compared with that in non-MS patients, symptom recurrence is higher and requires multiple procedures 5).

Repeated previous surgeries is a risk factor for an unsatisfactory outcome. However, the patients with multiple surgeries had less satisfactory results already at the first procedure, indicating that a therapy resistant disease can be predicted after the first two PBCs. Postoperative sensory deficits were common but not lasting 6).


One hundred eleven procedures with Percutaneous balloon compression (PBC) performed in 66 cases of Multiple sclerosis related trigeminal neuralgia (MS-TN) were analyzed. Therapeutic effect was measured as postoperative time to pain recurrence without medication. All complications were compiled and the sensory function was evaluated in a subgroup of cases.

The initial pain free rate was 67% and the median time to pain recurrence was 8 mo. Thirty-six patients were treated with PBC only, and among them, the results were worse if treated 3 to 4 times before, compared to first treatment (P = .009-.034). Patients who had several PBCs had worse results already after the first surgery (P < .001). A significant number of patients had impaired sensation to light touch directly after surgery, which was normalized at the late follow-up. Sensimetric testing showed raised thresholds for perception and pain directly after surgery (P = .004-.03), but these were also normalized at the late follow-up.

PBC is a treatment that can be effective for many patients with MS-TN. Repeated previous surgeries is a risk factor for an unsatisfactory outcome. However, the patients with multiple surgeries had less satisfactory results already at the first procedure, indicating that a therapy resistant disease can be predicted after the first two PBCs. Postoperative sensory deficits were common but not lasting 7).


Retrospectively collected clinical data on 80 consecutive patients who underwent 144 procedures and who received PBC for TN treatment between January 2000 and January 2010 were analyzed. The cohort included 17 MS and 63 non-MS patients.

The mean age at first operation was significantly younger in the MS group compared with the non-MS group (59 years vs 72 years, respectively, p < 0.0001). After a mean follow-up of 43 months (MS group) and 25 months (non-MS group), the symptom recurrence rate following the first operation was higher in the MS group compared with that in the non-MS group (86% vs 47%, respectively, p < 0.01). During long-term follow-up, more than 70% of MS patients required multiple procedures compared with only 44% of non-MS patients. Excellent or satisfactory outcomes were not significantly different between the MS and non-MS cohorts, respectively, at 1 day postoperatively (82% vs 91%, p = 0.35), 3 months postoperatively (65% vs 81%, p = 0.16), and at last follow-up (65% vs 76%, p = 0.34). A similar incidence of postoperative complications was observed in the 2 groups.

PBC is effective in the treatment of trigeminal neuralgia in patients with MS, but, compared with that in non-MS patients, symptom recurrence is higher and requires multiple procedures 8).


During the period 2000-2012, 10 patients with medically refractory TN and ipsilateral brainstem T2 hyperintensity underwent MVD. In 5 patients, additional clinical features suspicious for MS were present, including prior optic neuritis (n = 2), multiple disseminated lesions (n = 3), and elevated immunoglobulin G index (n = 2). One patient had failed prior percutaneous surgery; 1 patient had Burchiel type 2 TN. Follow-up (median, 14 months) was censored at the time of additional surgery (n = 6) or last clinic visit (n = 4).

Neurovascular compression was confirmed at surgery from the superior cerebellar artery (SCA) plus adjacent vein (n = 4), vein alone (n = 3), SCA alone (n = 2), and SCA plus anterior inferior cerebellar artery (n = 1). Initially after MVD, 8 patients (80%) were pain-free and subsequently tapered off medications for their facial pain. Pain recurred in 6 patients at a median of 4 months (range, 1-23 months). Actuarial rates of being pain-free off medications were 50% at 3 months and 15% at 2 years. In 6 patients, additional treatments were performed, including glycerol rhizotomy (n = 4), radiosurgery (n = 2), balloon compression (n = 2), and repeat MVD (n = 1). At last contact, 5 of the 6 patients who were retreated were pain-free.

Facial pain outcomes after MVD in patients with suspected MS-related TN are poor compared with outcomes for patients with idiopathic TN. This study provides further support that many patients with MS-related TN have pain that is centrally mediated, reducing the effectiveness of procedures performed on the trigeminal root, ganglion, or divisions 9).


Seven patients had TN related to multiple sclerosis (MS). Mean follow-up was 51.81 ± 26.63 months. 81.81 % of patients reported an acute pain relief. No major complication was observed after PBC. Eight patients (36.36 %) experienced pain recurrence and underwent one (five patients) or more (three patients) PBC. At the last follow-up, we obtained an excellent outcome (BNI I-II) in 16 patients out of 22 (72.72 %) and a good outcome (BNI III) in the remaining six. No patients had an uncontrolled pain. The lack of history of MS (p = 0.0174), the pear-like shape of the balloon at the operation (p = 0.0234) and a compression time <5 min (p < 0.05) were associated to higher pain-free survival. Considering these results PBC could be considered a useful technique for patients whose pain recurs after other procedures 10).


Balloon compression had the highest rate of initial pain-free response (IPFR) and duration of pain-free intervals (PFIs), compared with other modalities in the initial treatment of MS-related TN 11).

References

1) , 9)

Ariai MS, Mallory GW, Pollock BE. Outcomes after microvascular decompression for patients with trigeminal neuralgia and suspected multiple sclerosis. World Neurosurg. 2014 Mar-Apr;81(3-4):599-603. doi: 10.1016/j.wneu.2013.09.027. Epub 2013 Sep 19. PubMed PMID: 24056218.
2) , 11)

Mohammad-Mohammadi A, Recinos PF, Lee JH, Elson P, Barnett GH. Surgical outcomes of trigeminal neuralgia in patients with multiple sclerosis. Neurosurgery. 2013 Dec;73(6):941-50; discussion 950. doi: 10.1227/NEU.0000000000000128. PubMed PMID: 23921703.
3) , 10)

Montano N, Papacci F, Cioni B, Di Bonaventura R, Meglio M. The role of percutaneous balloon compression in the treatment of trigeminal neuralgia recurring after other surgical procedures. Acta Neurol Belg. 2014 Mar;114(1):59-64. doi: 10.1007/s13760-013-0263-x. Epub 2013 Dec 12. PubMed PMID: 24338759.
4) , 6) , 7)

Asplund P, Linderoth B, Lind G, Winter J, Bergenheim AT. One hundred eleven Percutaneous Balloon Compressions for Trigeminal Neuralgia in a Cohort of 66 Patients with Multiple Sclerosis. Oper Neurosurg (Hagerstown). 2019 Jan 23. doi: 10.1093/ons/opy402. [Epub ahead of print] PubMed PMID: 30690631.
5) , 8)

Martin S, Teo M, Suttner N. The effectiveness of percutaneous balloon compression in the treatment of trigeminal neuralgia in patients with multiple sclerosis. J Neurosurg. 2015 Dec;123(6):1507-11. doi: 10.3171/2014.11.JNS14736. Epub 2015 Jun 12. PubMed PMID: 26067615.
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