Original Article

Anterior Endoscopic Assisted Cervical Microdecompression of Disc and Foramen

J Chiu, M Reuter

Citation

J Chiu, M Reuter. Anterior Endoscopic Assisted Cervical Microdecompression of Disc and Foramen. The Internet Journal of Minimally Invasive Spinal Technology. 2006 Volume 1 Number 2.

Abstract

The anterior endoscopic assisted cervical microdecompression (AECM) of disc and foramen with added application of nonablative lower holmium laser energy for disc shrinkage (laser thermodiskoplasty) has proven to be safe, less traumatic, easier, and more efficacious than conventional methods with significant economic savings. It preserves spinal motion and provides a channel for spinal arthroplasty. It is an effective alternative or replacement for conventional open cervical spinal surgery for discectomy, and can decompress spinal stenosis and degenerative spine conditions.

 

Introduction

In neurosurgical and orthopedic patients, herniated or protruded cervical intravertebral discs are frequently encountered. Since the 1950s, the standard treatment for cervical disc protrusions and foraminal stenosis has been the anterior cervical microdecompression of disc and foramen with or without bony fusion.1,2,3,4,5 These open operations are associated with significant local morbidity, such as graft collapse, graft extrusion, hardware failure, non-fusion with resultant instability, infections, esophageal perforation with infection, and chronic pain, peripheral nerve injury, or infection at the graft donor site.6,7 Anterior cervical fusion (ACF) is associated with a 15% or greater chance of junctional disc herniation or adjacent segment disease at interspaces adjacent to fused levels.8,9 Anterior endoscopic cervical microdecompression (AECM) minimally invasive surgery does not cause hypermobility of adjacent vertebral segments and is associated with much lower rates of morbidity.8,9,10

Often ACF is an unattractive treatment for the symptomatic multiple-level discs in a patient, but AECM can be safely used for the treatment of these cases. The trend of evolution in spinal surgery is toward less invasive techniques.9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38 Advancements in micro-instrumentation, fiber optics, improved fluoroscopic imaging, and high-resolution digital video-imaging endoscopy—along with the accumulation of experience in percutaneous lumbar discectomy and spinal laser applications—have facilitated the development of AECM and foraminal decompression.9,14,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36

A holmium laser at nonablative, low levels of energy has been added to our standard protocol since 1995 for microdecompressive minimally invasive spinal discectomies.9,12,14,31,36,37,38,39,40,41,42,43,44,45,46,47 At nonablative levels of laser energy, the contraction of tissue occurs, further reducing the protrusion and hardening the disc to prevent recurrences (due to the photocoagulation effect of laser energy).33,36,37,41,45

Multiple levels of symptomatic cervical disc disease do occur. ACF is often an unattractive treatment in the presence of symptomatic multiple-level discs in a patient, but AECM—a minimally invasive outpatient spinal surgery—can be safely used for these cases. The purpose of this chapter is to assess the method, safety and efficacy of outpatient AECM in the treatment of symptomatic cervical herniated discs and foraminal stenosis.

Materials And Methods

AECM is performed under fluoroscopic X-ray image and endoscopic image guidance for microdecompression of herniated cervical disc and foramen. It is a minimally invasive, outpatient procedure and aims to reduce tissue trauma with much less morbidity than open cervical spinal surgery, no graft donor site problems, and a significant decrease in the convalescent period and costs.9,10,12

Surgical Indications

The AECM approach is indicated in the following clinical situations:9,12,31

  1. Symptomatic herniated cervical disc and foraminal disc lesion.

  2. Subjective complaints of neck pain with radiation down the arm (radicular pain).

  3. Symptoms of tingling and numbness.

  4. Physical findings of sensory loss, muscle weakness, or decreased reflexes in the upper extremities, correlated with the level of involvement.

  5. Severe intractable cervicogenic headache associated with the cervical disc.

  6. No improvement of symptoms after a minimum of 12 weeks of conservative therapy.

  7. Imaging study with scans positive for disc herniation, consistent with dermatome of clinical symptoms. Magnetic resonance (MRI) is the imaging study of choice.

  8. Junctional disc herniation syndrome (JDHS) or adjacent segmental disease (ASD) in post-cervical fusion.

  9. Positive pre- or intra-operative discogram and pain provocation test.

  10. Positive electromyography is considered helpful.

  11. Multiple cervical discs can be treated at one sitting.

Contraindications

  1. Imaging study with severe cervical spinal canal stenosis.

  2. A significant migrated free disc fragment not located at the disc level.

  3. Advanced spondylosis (significant bone spurs) with severe disc space narrowing and with osteophytes blocking entry into the disc space.

  4. Significant ossification of the posterior longitudinal ligament.

Surgical Procedure

Anesthesia

This procedure is done under local anesthesia with monitored intravenous conscious sedation, or occasionally, general anesthesia, if indicated. Routinely, 2.0 g of Ancef (Cefazolin) and 8.0 mg of Decadron (dexamethasone) are given intravenously at the start of anesthesia. The esophagus is made more palpable by the anesthesiologist inserting an esophageal or nasogastric tube. 9,12 The pulse of the carotid artery may be augmented with the use of sympathomimetics (e.g., ephedrine) to raise systolic blood pressure to a minimum of 130 mmHg. A SNAP™ surface electroencephalogram (EEG) ( Nicolet Biomedical, Madison, WI, USA) provides added precision for anesthesia.

Patient Positioning

In a supine position, the patient is placed with the neck extended over a rolled towel under the shoulders on an adjustable radiolucent surgical table (Fig. 1). A soft strap is placed over the forehead for stability. The shoulders are distracted gently downwards with tape. Digital C-arm fluoroscopy is used in the anteroposterior (AP) and lateral planes to control the placement of all instruments throughout the operation.9,12

Figure 1
Figure 1: (A) Patient positioning, (B) skin marking and localization, (C) placement of needle and portal of entry

Figure 2

Figure 3

Fluoroscopic and Neurophysiological Monitoring

As stated, digital C-arm fluoroscopy (Fig. 1) is used in the AP and lateral planes to monitor the placement of all instruments throughout the operation.9,12 Neurophysiological monitoring with a Bispectral Index™ monitoring system surface EEG ( Aspect Medical Systems, Newton, MA, USA) provides added precision for optimal anesthesia (Fig. 2). For added safety, neurophysiological monitoring with electromyography (EMG) needles placed in areas of distribution of the nerve roots from the spinal levels being operated upon also provides continuous neurophysiologic-neuromuscular monitoring throughout the procedure. 43

Figure 4
Figure 2: (A) Simple surface EEG monitoring, (B) computerized BIS™ Monitoring System, (C) neurophysiological EMG/NCV monitoring

Figure 5

Figure 6

Surgical Equipment and Instruments

General surgical equipment and the following instruments are necessary to perform AECM (Fig. 3):9,12,39

  • Endoscopic video tower with a tri-chip digital camera system equipped with digital video monitor, DVD recorder, light source, and photo printer.

  • Cervical endoscopic discectomy set (Karl Storz, Tuttlingen, Germany), including a 4-mm, 0° endoscope.

  • Cervical discectomy sets (2.5 mm and 3.5 mm) (Blackstone Medical, Springfield, MA, USA) with short cervical discectomes.

  • 3.5-mm, 6° cervical operating endoscope.

  • Endoscopic grasping and cutting forceps.

  • Endoscopic probe, knife, rasp, and burr.

  • More aggressively toothed trephines used for spurs and spondylitic ridges at the anterior and posterior disc space.

  • Holmium:YAG laser generator (Trimedyne, Irvine, CA, USA) with a right-angle (side-firing) probe (Fig. 4).

  • Digital fluoroscopy equipment (C-arm) and monitor.

Figure 7
Figure 3: Anterior cervical endoscopic instruments and digital endoscopy tower. (A) Cervical 0° endoscopes and endoscopic instruments. (B) Discectomes, working channel sets. (C) Discectomy set forceps, trephines, and burr. (D) Tri-chip digital camera with cervical 6°endoscope and forceps. (E) Video digital endoscopic tower with DVD recorder and imaging data monitors.

Figure 8

Figure 9

Figure 10

Figure 11

Figure 12
Figure 4: Holmium YAG laser equipment for laser thermodiskoplasty. (A) Holmium YAG laser generator, (B) right angle (side firing) laser probe.

Figure 13

Operative Technique

Localization and Portal of Entry

Initial localizing AP fluoroscopic x-rays are made with a metal stylette crossing the neck horizontally at the expected level. The midline, the levels, and the point of entry (operating portal) for surgery are marked on the skin with a marking pen (Fig. 5) 8,9,12,31,44. Alternatively, using a sterile technique, the level of the disc can be accurately identified by inserting an 18-gauge needle into a disc under fluoroscopy (Fig. 5), as described in the next section.

Figure 14
Figure 5: AECM Surgical technique for needle and stylette placement into the disc with retraction of trachea/esophagus (A) frontal view illustration: with retraction of trachea/esophagus for needle placement, (B) axial view: placement of the stylette into disc space, (C) lateral view: of the stylette into disc space (D) fluoroscopic X-ray lateral view: cervical discogram with placement of the stylette.

Figure 15

Figure 16

Figure 17

Surgical Technique

The point of entry (operating portal) is at the medial border of the right sternocleidomastoid muscle, where firm pressure is applied digitally in the space between that muscle and the trachea, pointing toward the vertebral surface (Fig. 6). The larynx and trachea are displaced medially and the carotid artery laterally (Fig. 6). The anterior cervical spine is palpated with the fingertips.

A standard 18-gauge spinal needle is passed transdermally into the disc space and its position confirmed fluoroscopically (Fig. 6). If a pain provocation test and discogram have not been completed pre-operatively, they are performed now. If results are confirmatory, the operation is performed. A 3-mm skin incision is made and a narrow guide wire stylette is passed through the needle, which is then removed. A 2.5-mm or 3.5-mm internal diameter cannula/dilator is introduced over the stylette and into the disc interspace. A standard #18 guide wire replaces the narrow one.

Figure 18
Figure 6: AECM for cervical disc decompression under fluoroscopic X-ray (A) with cutting forceps (B) curette, (C) discectome, (D) trephine, (E) burr, (F) side fire laser probe

Figure 19

Figure 20

Figure 21

Figure 22

Figure 23

A trephine replaces the dilator and incises the annulus. Under fluoroscopic and endoscopic visualization, mini-curettes and forceps (Figs. 7 & 8) loosen and remove disc fragments prior to introducing the discectome through the cannula to remove the disc. The discectome employs a high-pressure irrigation-suction system and a guillotine-style cutting blade (Fig. 7). The instruments removing the disc material are moved in a “critical fan sweep maneuver” with a 25° “rocking” excursion of the cannula hub from side to side to increase the area of total disc removed up to approximately a 50° inverted cone-shaped area within the disc space (Fig. 8).9,12 All maneuvers are closely monitored by fluoroscopy and endoscopy.8,9,12,31,34 Trephines with more aggressive teeth are used to remove bone spurs or osteophytes. Very large bone spurs can be removed with a short cannula system with a burr (Fig. 9).

Figure 24
Figure 7: Endoscopic views of AECM for microdiscectomy (A) with forceps, and (B)curette

Figure 25

Figure 26
Figure 8: AECM surgical technique (A) for microdiscectomy with discectome (B) “Fan sweep maneuver” of instrument increased disc removal, and laser application for disc tissue shrinkage, and tightening, (C) laser thermodiskoplasty for disc shrinkage under endoscopy

Figure 27

Figure 28

Figure 29
Figure 9: Cervical foraminal microdecompression with (A) micro cutting forceps, (B) curette, (C) discetome, (D) trephine, (E) rasp, (F) burr

Figure 30

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The holmium:YAG laser with a right-angle (side-firing) probe further facilitates the removal of disc material. In addition, it is used at nonablative levels of laser energy (Table 1) for laser thermodiskoplasty (i.e., collagen and a disc-shrinking and tightening effect to further decompress and harden the disc). Endoscopy is used for direct visualization (Fig. 10) and confirmation of discectomy and laser thermodiskoplasty.8,9,12,31,34 Again, after using the discetome for laser disc debris removal in the disc space, the probe and cannula are removed.

For neuroforaminal decompression, the cutting and grasping forceps, microrasp, microcurette, and microtrephine are used as well as the discetome. The surgeon should be familiar with cervical discectomy before attempting neuroforaminal decompression. Extreme care is taken not to injure the cervical nerve root by close monitoring with fluoroscopy, direct endoscopic visualization, and EMG neurophysiological monitoring. Marcaine (0.25%) is infiltrated subcutaneously around the wound. The tiny incisional wound is closed with a bandage.

Postoperative Care

Postoperatively, patients are ambulatory within one hour and subsequently discharged. They may shower the following day. A soft cervical collar is used for two to three days or as needed, and an ice pack is helpful. Mild analgesics and muscle relaxants are required at times. Progressive neck exercise begins on the second postoperative day. Patients are allowed to return to work in one to two weeks, provided heavy labor and prolonged sitting are not involved. This procedure can be extremely gratifying for the patients and the surgeon. 8,9,12,31,34

Case Illustration

A 35-year-old male professional musician is unable to play his guitar, with increasing intractable neck and upper extremity pain and numbness of fingers (Fig. 10). AECM surgical treatment of the C5-C6 herniated disc and a left C5-C6 foraminal decompressive discectomy and foraminoplasty gave immediate relief of all symptoms.

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Discussion And Comment

Advantages of AECM

The advantages of AECM are the same as those of minimally invasive spinal surgery8,9,12,31,34:

  • Excellent pain relief.

  • Same-day outpatient procedure without the need of hospitalization.

  • A small incision and less scarring of the neck.

  • No dissection of muscle, bone, ligaments, or manipulation of the dural sac or nerve roots; little or no epidural bleeding.

  • Does not promote further instability of spinal segments and preserves spinal motion.

  • Early return to usual activities, including work.

  • Commonly done under local anesthesia.

  • Costs are much less than conventional discectomy and spinal fusion.

  • Multiple-level discectomy feasible and well tolerated.

  • Least challenging to medically high-risk patients and the obese.

  • Exercise programs can begin the same day as surgery.

  • Less traumatic, physically and psychologically.

Potential Surgical Complications And Their Avoidance

  1. Infection. Infection can be avoided by careful sterile techniques, using prophylactic intravenous antibiotic intraoperatively, and with the much smaller incisional area. Infection and complications secondary to a donor graft site are avoided. Aseptic discitis can be prevented by aiming the laser beam in a “bowtie” fashion to avoid damaging the endplates. 12,38,46,47

  2. Hematoma (Subcutaneous and Deep). Hematoma occurs post-ACF and may occur with minimally invasive spinal surgery but is minimized by careful techniques, not prescribing aspirin or NSAIDs within a week prior to surgery, by the application of gentle digital pressure or placing an IV bag over the operative site for the first 5 min after surgery, and the application of an ice bag thereafter.

  3. Vascular Injuries. These are extremely rare when care is taken to locate and protect the carotid artery, jugular vein, and other vascular structures including the vertebral artery (in the foramen transversarium laterally) and the inferior and superior thyroid arteries. No carotid artery injury has been reported in the United States at the time of this writing. The carotid sheath should be identified and protected under the surgeon's fingers. If carotid arterial pulsation is difficult to palpate, it can be augmented by intravenous ephedrine.12,38,46,47 No prolonged retraction of the carotid sheath and artery is required as in ACF, and hence direct trauma and embolic complications involving carotid vessels are unlikely.

  4. Neural Injuries. These are extremely rare with minimally invasive approaches. No spinal cord injuries have been reported to the best of our research. Though possible, nerve root and spinal cord injury can be avoided with continuous intraoperative neurophysiologic monitoring (EMG/NCV) and direct endoscopic visualization. Neural complications of ACF including hypoglossal, spinal accessory, phrenic, auricular, and cutaneous nerves can be prevented by careful technique. Though a recognized complication of ACF, recurrent laryngeal nerve injury is extremely rare with AECM. Postoperatively, one case with hiccups and one with hoarseness have occurred transiently out of 1200 cases of AECM.

  5. Sympathetic Nerve Injuries. These are extremely rare but can occur from injury to cervical sympathetic and stellate ganglions. One incidental transient Horner syndrome or oculosympathetic dysfunction lasting one day following AECM was noted.

  6. Excessive Sedation. This can be avoided by surface EEG monitoring, providing more precise estimation of the depth of anesthesia, reducing the amount of anesthetics, and preventing excessive or insufficient sedation.

  7. Operation on the Wrong Level. A major complication of ACF or AECM is operating at the wrong level and with improper instrumentation. Proper use of digital C-arm fluoroscopy for anatomical localization avoids complications caused by the poor placement of instruments or operating at the wrong disc level.12,38,46,47

  8. Dural Tears. To our knowledge, these have not been reported with the use of AECM.

  9. Soft Tissue Injuries. Although these may occur due to prolonged forceful retraction, as occurs in ACF operations, they are not an issue with AECM. Similarly, failure of fusion, collapse of the bone plug, migration of the bone plug, and hardware failure cannot occur.

  10. Dysphasia and Postoperative Airway Obstruction Due to Edema. These may occur but can be avoided by careful surgical procedures and identification of these organs. Esophageal and tracheal injury due to edema or perforation can be avoided by careful palpation and digital retraction at the site of needle insertion. Having the anesthesiologist place a nasogastric tube into the esophagus aids in identifying and retracting that structure by palpation.

  11. Inadequate Decompression of Disc Material. This is minimized by using multiple modalities and instruments such as forceps, trephining the posterior ligament, discectome, burr and rasp, and laser application to both vaporize tissue and to perform thermodiskoplasty.

  12. Thyroid Gland Injury. This can be avoided by approaching the gland from the posterior and not encountering the parenchyma. A large goiter requires special care because of its vascularity.

A thorough knowledge of the AECM procedure and surgical anatomy of the cervical spine and neural foramen, careful selection of patients, and pre-operative surgical planning with appropriate diagnostic evaluations facilitate AECM and prevent potential complications. All potential complications of open anterior disc surgery are possible but rare or much less frequent in AECM.12,38,46,47

Conclusions

Minimally invasive spinal surgery of the AECM of disc and foramen represents a new procedure for treating symptomatic herniated cervical discs and foraminal lesions anteriorly through an endoscope. It aims at reducing tissue trauma compared to traditional open cervical surgery.38,39 A low-energy, nonablative laser is applied for shrinkage and tightening of the disc (laser thermodiskoplasty). With appropriate endoscopic spinal surgical training, thorough knowledge of the surgical anatomy of the cervical spine, meticulous preoperative planning, and minimally invasive surgical experience, AECM is a safe and efficacious procedure.24,25,26,27,28,29,30,31,32,33,34,35 This minimally invasive and less traumatic outpatient cervical spinal procedure results in less morbidity, faster recovery, and significant economic savings.

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Correspondence to

John C. Chiu, M.D., D.Sc., F.R.C.S Department of Neurospine Surgery California Center for Minimally Invasive Spine Surgery California Spine Institute Medical Center 1001 Newbury Road Thousand Oaks, CA 91320 USA Telephone: (805) 375-7900 Fax: (805) 375-7906 Email: chiu@spinecenter.com

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Author Information

John C. Chiu, M.D., D.Sc., FRCS
California Spine Institute

Merrill W. Reuter, M.D., Ph.D., FACS
Advanced Orthopaedics of South Florida

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