13. Minimally invasive posterior cervical foraminotomy as an alternative to anterior cervical discectomy and fusion for unilateral cervical radiculopathy

Abstract

BACKGROUND CONTEXT Unilateral cervical radiculopathy refractory to conservative treatment is one of the most common pathologies that spine surgeons treat surgically. Anterior cervical discectomy and fusion (ACDF) has long been considered standard treatment for cervical radiculopathy secondary to lateral disc herniation or foraminal stenosis. Recent studies suggest minimally-invasive posterior cervical foraminotomy (MI-PCF) to be an alternative to ACDF, but not without concern for reoperation and magnitude of patient outcome improvement. PURPOSE To compare patient outcomes, reoperation rate and complication rate of MI-PCF to those of ACDF by analyzing the current literature. STUDY DESIGN/SETTING Systematic review, meta-analysis. PATIENT SAMPLE A total of 1,216 patients who underwent MI-PCF for cervical radiculopathy from 14 previously published studies. OUTCOME MEASURES (1) Patient-reported outcome scores: Visual Analog Scale (VAS) for arm and neck pain, neck disability index (NDI), (2) reoperation rate, (3) complication rate. METHODS Three electronic databases (PubMed, CINAHL Plus, and SCOPUS) were queried using terms related to MI-PCF. Open approaches were excluded. MINORS scoring was used to assess study quality. A total of 14 studies were included in this analysis. Analyses for heterogeneity and publication bias were performed. Clinical outcome scores (NDI, VAS-neck and VAS-arm), reoperation proportion, and complications were assessed. Each outcome measure was compared to those of ACDF from two previously published studies. A random-effects model of meta-analysis was used for heterogenous groups, and a fixed-effects model was used for groups that were not. Overlap of 95% confidence intervals suggests no significant difference at the p RESULTS Fourteen studies were included in this analysis, with outcome data of 1,216 patients. The mean age of the study population was 51.57 years, who were 61.8% male and had a mean follow-up period of 30 months. The mean improvement in NDI was 20.30 (95% CI, 18.81-21.79) and 16.85 (95% CI, 14.96-19.10) for the MI-PCF and ACDF groups, respectively. The mean improvement in VAS-neck was 4.16 (95% CI, 2.70-5.61) and 2.47 (95% CI, 2.09-2.84) for the MI-PCF and ACDF groups, respectively. The mean improvement in VAS-arm was 5.31 (95% CI, 4.50-6.12) and 2.27 (95% CI, 1.82-2.70) for the MI-PCF and ACDF groups, respectively. 6% (95% CI, 3%-12%) of patients who underwent MI-PCF required a re-operation compared to 3.9% (95% CI, 2.77%-5.46%) of those who underwent ACDF. Complications were noted in 4% (95% CI, 3%-7%) of MI-PCF patients and 7.79% (95% CI, 5.54%-10.85%) of ACDF patients. The most common complications were transient neuropraxia, wound-related, and durotomy. CONCLUSIONS MI-PCF resulted in a greater improvement in VAS-arm scores compared to ACDF, supporting its effectiveness as a procedure for lateral pathology. There were no other significant differences in patient-reported clinical outcome scores, proportion of patients requiring re-operation, or complications between patients who underwent MI-PCF and those who underwent ACDF for unilateral cervical radiculopathy. Thus, MI-PCF may be utilized as a safe and effective alternative to ACDF in patients with unilateral cervical radiculopathy without myelopathy, without concern for increased reoperations or complications, and with advantages of preservation of cervical motion and quicker recovery. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.