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Pobierz
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I. Pechlivanis
C. Brenke
M. Scholz
M. Engelhardt
A. Harders
K. Schmieder
Anterior Uncoforaminotomy in the Treatment of
Recurrent Radiculopathy after Anterior Cervical
Discectomy with Fusion
Abstract
Introduction
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 degenera-
tive pathology at the level of the neural foramen leaving un-
touched the inserted graft at this level. Method: Between
February 2004 and April 2005, 7 patients underwent uncofor-
aminotomy 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 per-
formed 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 sur-
gery. 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.
In the treatment of cervical disc disorders causing radiculopathy
various surgical approaches exist. Anterior cervical discectomy
(ACD) with or without fusion is a well established surgical
procedure for the treatment of cervical disc diseases [1–8].
Whereas it may well be suitable for the treatment of medial soft
disc herniations and hard bone spurs, it can have its pitfalls in the
treatment of laterally placed pathologies. Although recurrence or
persistence of radicular pain after performed ACD with fusion is
rarely reported, reoperation may be difficult.
The problem with the recurrence of a foraminal pathology in a
fused segment is the increased invasiveness necessary to treat
such lesions. Anterior uncoforaminotomy is a well established
technique in the treatment of foraminal pathologies in our
department. Good decompression of the neural foramen in
combination with the preservation of the motion segment – to
name just two – are the advantages of this technique. Therefore,
the aim of this study was to see whether it is possible to
successfully treat this patient subgroup via an anterior uncofor-
aminotomy [9–11].
323
Patients and Methods
Key words
Radicular pain anterior uncoforaminotomy ACD spine
In this retrospective study 7 patients with anterior uncoforami-
notomy after ACD with fusion were included (Table 1). Inclusion
criteria for this study were:
Affiliation
Department of Neurosurgery, Ruhr-University of Bochum, Knappschaftskrankenhaus, Bochum-Langendreer,
Germany
Correspondence
Dr. med. Ioannis Pechlivanis Department of Neurosurgery Ruhr-University of Bochum Knappschafts-
krankenhaus In der Schornau 23–25 44892 Bochum Germany Tel.: + 49/234/299 36 01
Fax: + 49/234/299 36 09 E-mail: ioannis.pechlivanis@ruhr-uni-bochum.de
Bibliography
Minim Invas Neurosurg 2006; 49: 323– 327
r
Georg Thieme Verlag KG Stuttgart New York
DOI 10.1055/s-2006-956507
ISSN 0946-7211
Table 1 Patients with ACD and fusion: localization of primary
surgery, means of fusion and time of prior surgery
Table 3 Outcome of patients with recurrent surgery with ante-
rior uncoforaminotomy
Case No.
Level
ACD
Year of ACD
operation
Case No.
Radicular pain
Nuchal pain
1
Improved
Moderate
1
C5/6
Titanium cage
2003
2
None
None
2
C5/6
Palacos fusion
1993
3
None
Mild
3
C5/6 + C6/7
Titanium cage
2003
4
None
Moderate
4
C6/7
Iliac crest and
titanium plate
2000
5
None
Mild
6
Unchanged
Unchanged
5
C5/6
Smith-Robinson
2000
7
Improved
Moderate
6
C5/6
Titanium cage
2002
7
C5/6
Titanium cage
2001
Table 2 Clinical preoperative presentation of patients with re-
current radiculopathy after ACD and fusion
Surgical results (Table 3) were graded
– as excellent: patient with complete resolution of the radicu-
lar symptoms
– as good: patient experienced relief of radiculopathy
– as fair: patient with mild/moderate residual radicular dis-
comfort
– as poor: patient continued to have significant radicular
symptoms, or as unchanged or worse.
Symptoms
Patients
Radicular pain
7
Sensory changes
6
Motor weakness
5
Neck pain
7
Results
324
– patients with recurrent monosegmental unilateral radicular
pain
– no response to conservative treatment
– ACD with fusion in the same level
– a lateral spondylotic spur or an intraforaminal location of
spondylotic changes compressing the nerve root visible in
computed tomographic (CT) imaging.
Between February 2004 and April 2005, 7 patients with a mean
age of 52 ± 12 years (range: 40–76 years) were included in this
study. Four patients were female. The duration of symptoms
ranged from 6 months to 13 years. All patients had recurrent
radicular pain and severe neck pain. Five patients had motor
weakness and six patients had sensory changes. In five patients
ACD and titanium-cage fusion had been performed 1–3 years
prior to surgery (Fig. 1). In one patient ACD and palacos fusion
had been performed (Fig. 2), and in one patient ACD and bone
fusion with an additional ventral titanium plate had been per-
formed. According to radiological criteria all segments were
fused. No pseudarthrosis was present, especially not in the
patients treated with palacos at first surgery.
All patients were evaluated neurologically (Table 2) and pre-
operative computed tomography was performed to visualize the
distance between the graft and the uncinate process.
An upper vertebral-transcorporal approach to the neural fora-
men was chosen in all cases. In this approach the far lateral
inferior portion of the upper vertebral body and the medial
portion of the transverse foramen are trimmed as Jho described
in 2003 [12].
The surgical level was C5/6 in five patients, C6/7 in one patient
and in one patient surgery in two levels (C5/6, C6/7; one fused,
one not surgically treated before) was necessary.
For detailed and additional information see publications by Jho
and Saringer [10, 13]. VA was not exposed. Furthermore, by
leaving a thin layer of cortical bone of the lateral wall of the
uncinate process the vertebral artery remained protected.
Operations were performed by 3 surgeons. Mobilization of the
patients was done immediately after surgery. No cervical collar
was used. Postoperative CT scans were done before discharge. Six
to eight weeks after surgery the patients were allowed to return
to full activity.
The patients were discharged between days 6 and 11 after
surgery (mean: 7.4 ± 1.9). Three patients had an excellent result,
three patients had a good result and one patient remained
unchanged at discharge.
Postoperative evaluation of the uncoforaminotomy showed a
satisfactory decompression. No destabilization of the segment
was detectable. At 8-weeks follow-up 4 patients showed excel-
lent results, two patients had a good result and one patient had
unchanged radicular pain (poor outcome).
Follow-up evaluations took place 6–8 weeks and six months
after surgery. Radicular and local neck pain were quantified in
the analogue pain scale.
Illustrative case
A 59-year-old woman was referred to our department in March
2005. Surgery in C5/6 and C6/7 with palacos fusion had been
Pechlivanis I et al. Anterior Uncoforaminotomy ... Minim Invas Neurosurg 2006; 49: 323–327
Fig. 1 Patient with ACD and titanium
cage fusion and recurrent radicular pain
preoperatively. a CT scan revealing foraminal
stenosis on the right side. b Postoperative
CT scan shows foraminal decompression
via anterior uncoforaminotomy beside
the titanium cage.
Fig. 2 A 48-year-old male with performed
palacos fusion in C5 in 1993. Pain-free
interval of 10 years until the patient
reported recurrent radicular pain. a CT
scan revealing foraminal stenosis on the
left side. b CT scan shows foraminal decom-
pression after uncoforaminotomy.
325
performed 4 times before, last surgery had been in 2000 (Smith-
Robinson). Although she initially reported about an improve-
ment of her radicular pain, in 2001 she had persistent severe
neck pain and radicular symptoms in C6 in her left hand. Her
symptoms were not relieved with analgesic medication, physical
therapy, or chiropractical manipulations. On admission she had
sensory changes in C6, a diminished left biceps reflex and a slight
motor weakness in the C6 innervated muscles. Magnetic reso-
nance imaging (MRI) and CT data showed a slight compression of
the nerve root. No pseudarthrosis was present in both segments.
After a probatory periradicular infiltration with local anesthesia
of the C6 nerve root on the left side the patient was pain free.
Therefore, the patient underwent a C5/6 microsurgical anterior
foraminotomy on the left side. Intraoperatively a bone spur in
the neural foramen and a thin bone layer adherent to the dura of
the nerve root were found. After surgery the radicular pain and
the nuchal pain disappeared. Minimal local pain in the left
shoulder was present at discharge after 7 days. Postoperative
CT imaging showed a good decompression of the left neural
foramen.
Discussion
In the treatment of cervical degenerative diseases, anterior cer-
vical discectomy with or without fusion is currently most fre-
quently used. Interbody fusion cages are increasingly implanted.
Anterior interbody fusion, subsequently leading to bone fusion
results in a loss of the motion segment, that could lead to
increased strain-induced mechanical stress exertion on the ad-
jacent segments. This adjacent level disease has been well de-
scribed in radiographic and MR imaging [14–17]. Hilibrand et al.
postulated, that up to 25 % of the patients who underwent
cervical fusion may require surgical treatment of the adjacent
level within 10 years [18]. The reported cure rates of ACD with or
without fusion and posterior foraminotomy are 82–96 %
[1, 15, 18–26].
Brooke et al. reported in his series about a fusion rate of 100 %
and a loss of radicular symptoms in all of his patients treated
with a carbon fiber cage at 16.7 months mean follow-up [27].
Schmieder et al. showed a fusion rate of 97 % after 6 months
using anterior interbody fusion with titanium cages. In spite of
the fusion rate, the clinical outcome at follow-up showed un-
changed radiculopathy in 9 of 96 patients [28]. Revision
was performed in two patients because of persistent foraminal
stenosis. Although there are just a few reports about revision
surgery necessary after cervical discectomy, the main reason for
the recurrent radiculopathy seemed to be reformation of spon-
At 8 weeks follow-up the patient was free of radicular symptoms,
the motor strength in her hand was back to normal, and she had
a normal range of motion in her neck. Only a slight nuchal
discomfort, treated with physical therapy was reported.
Pechlivanis I et al. Anterior Uncoforaminotomy ... Minim Invas Neurosurg 2006; 49: 323–327
and vascular or esophageal shift. No injury of vascular structures
or of the esophagus happened.
Another reason for persistent radicular pain after ACD with or
without fusion may be the incomplete decompression of the
neural foramen at first surgery. Although there are different
methods for performing ACD with fusion, removing the offend-
ing retrospondylotic spurs is essential.
Fig. 3 Schematic drawing of the uncoforaminotomy performed be-
side the cage. (A) marks the uncoforaminotomy, (B, arrow) shows the
position of the vertebral artery
Uncoforaminotomy for the treatment of monoradicular com-
pression via a ventral approach allows direct removal of the
causative degenerative changes decompressing the neural fora-
men (Fig. 3). However, patient selection is essential for the
success. Monosegmental radiculopathy caused by a confirmed
causative CT finding and in addition the pain free interval after a
probatory anesthesia of the nerve root, are important criteria.
Additionally, nuchal pain and radicular pain should be strictly
distinguished, because by this surgical method the latter is
addressed. Nuchal pain, caused by fusion-associated problems
or adjacent level syndrome may be not influenced. In our study
we demonstrated that recurrent direct nerve compression after
prior ACD with fusion can successfully be treated via anterior
uncoforaminotomy. Advantages of uncoforaminotomy are re-
duced surgical time, minimized surgery-related trauma and
direct approach of the underlying lesion. Another advantage of
this technique is the avoidance of a second approach to the spine
necessary if an additional posterior approach is chosen.
dylotic changes due to pseudarthrosis [29–33]. Pseudar-
throsis may lead to microinstability in the operated level
and can cause renewed spondylotic compression of the
neural foramen. Both techniques, anterior and posterior surgical
approaches for revision surgery are discussed, mainly con-
troversially.
Conditio sine qua non for this approach is a complete fusion of
the treated level, because performing a ventral uncoforaminot-
omy in a non-fused level after ACD may lead to an increase in
rotational instability.
The reoperation rate after ACD with fusion is reported to range
from 1.1–8.8 % [34] excluding adjacent level morbidity.
326
Using the posterior approach, Fuji et al. reported of nine patients
with anterior cervical pseudarthrosis treated at recurrent sur-
gery with interspinous wiring without bone grafting [32]. A
retrospective study comparing anterior versus posterior repair
of anterior pseudarthrosis was done by Brodsky who showed a
fusion rate of 76 % in patients with anterior repair using
autografts without plating in contrast to a 94 % fusion rate
for patients who had undergone posterior repair with in-
terspinous wiring and onlay autograft fusion [30]. Lowery
retrospectively compared three different methods of anterior
cervical pseudarthrosis revision surgery. A 94 % fusion rate in
patients treated with posterior revision in contrast to a 45 %
fusion rate in patients who underwent anterior plating was
found [35]. Coric et al. reported about a fusion rate of 100 % in
revision of anterior cervical pseudarthrosis with anterior allo-
graft fusion and plating [29]. Reasons for reoperation in cases
with pseudarthrosis were recurrent radiculopathy or intractable
neck pain. Although there are different methods for treatment
of this pathology, performed revision-operation is often very
complex.
Conclusion
Uncoforaminotomy is a sufficient method for the treatment of
recurrent radicular pain in patients with prior anterior cervical
discectomy and fusion.
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