Cervical radiculopathy remains a potentially disabling disease with a significant impact on patients’ quality of life. Despite conservative nonoperative treatment a large number of patients will end up needing surgical treatment. The most prevalent surgical options in this setting include anterior cervical discectomy and fusion (ACDF), posterior cervical foraminotomy, and cervical arthroplasty.2 Importantly, posterior cervical foraminotomy is an attractive option that may maintain cervical range of motion and minimize adjacent-segment degeneration. There are, however, no good data to guide the optimal timing of surgical treatment. Surgery is generally recommended when cervical-root–related dysfunction persists for more than 6–12 weeks despite nonsurgical treatment.12 A comparison of medical and surgical treatment published in Spine in 1999,12 showed that surgically treated patients had better outcomes with greater degrees of improvement, even though they had more neurological and nonneurological symptoms and more functional disability before treatment. In the current issue of Journal of Neurosurgery: Spine, Jagannathan et al.8 have reviewed a series of 162 cases involving patients with cervical radiculopathy who were treated with a posterior cervical foraminotomy, with a mean follow-up of 77.3 months (range 60–177). This review has addressed not only the clinical outcome but also and more importantly the long-term radiological outcome of cervical spinal alignment following posterior cervical foraminotomy. In this current series, 92% of patients showed an improvement of their Neck Disability Index scores from 18 (range 2–39) preoperatively to 8 (range 0–39) postoperatively. Ninety-five percent of patients with cervical radiculopathy experienced improvement of their symptoms. Loss of cervical lordosis (defined as segmental Cobb angle < 10°) was seen in 30 (18.5%) of patients. The overall cohort did not show any statistically significant progression of the focal or segmental kyphosis with time. Age over 60 years at the time of surgery and preoperative lordosis of less than 10° have been identified as risk factors of worsening sagittal alignment. Since the original description in the late 1940s, the surgical approaches to cervical radiculopathy secondary to laterally based discoligamentous and osseous pathology have been a choice between ACDF and posterior foraminal decompression. Many anatomical, pathophysiological, and patient factors influence the choice between these treatment approaches. Multiple studies have shown that in matched cohorts the clinical outcomes of ACDF and posterior foraminotomy are similar. The most important factor that influences the approach to treatment of unilateral single-level radiculopathy is surgeon bias. There has been a resurgence of interest in posterior foraminotomy, especially with recent popularization of minimally invasive surgery (MIS) techniques using tubular access.1,6,7,11 The 2 concerns with posterior foraminotomies are same-level degeneration/kyphosis secondary to partial resection of the facet joint and persistent neck and shoulder pain secondary to muscle stripping with the open procedure. In vitro studies have shown that segmental hypermobility of the cervical spine results if a foraminotomy involves resection of more than 50% of the facet.13 In another cadaveric in vitro study Onan et al.9 demonstrated that isolated cervical facet joints are highly mobile in comparison with facet joints within the constraints of intact motion segments. This has prompted surgeons to be more conservative with the amount of facet joint resected when performing a posterior foraminotomy. The surgical technique reported by John Jane’s team in this issue of Journal of Neurosurgery: Spine, which involves resecting the medial half of the facet joint to enable excellent nerve root decompression, importantly does not seem to have a deleterious effect on segmental stability or sagittal plane alignment. Jane’s team also identified the risk factors for delayed instability based on observations in a small subset of patients with worsening sagittal balance following surgery. These observations made by Jagannathan et al. in the current review, which were lackJ Neurosurg Spine 10:343–346, 2009 See the corresponding article in this issue, pp 347–356.
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Jan 1, 2013
Christopher J Stevens + 5
Open Access