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The Biportal Endoscopic Posterior Cervical Inclinatory Foraminotomy Neurospine 2020;17(Suppl 1):S145-153. Neurospine https://doi.org/10.14245/ns.2040228.114 pISSN 2586-6583 eISSN 2586-6591 Case Report: The Biportal Endoscopic Posterior Technical Note Cervical Inclinatory Foraminotomy Corresponding Author for Cervical Radiculopathy: Technical Chul-Woo Lee https://orcid.org/0000-0002-6562-977X Report and Preliminary Results Department of Neurosurgery, St. Peter’s 1 2 Hospital, 2633 Nambusunhwan-ro, Kwan-Su Song , Chul-Woo Lee Gangnam-gu, Seoul 06268, Korea 1Department of Neurosurgery, Him-Plus Neurosurgery Clinic, Sooncheon, Korea E-mail: [email protected] 2Department of Neurosurgery, St Peter’s Hospital, Seoul, Korea Received: April 28, 2020 Revised: May 6, 2020 The purpose of the current study was to introduce a surgical technique for posterior cervical Accepted: May 11, 2020 inclinatory foraminotomy (PCIF) using a percutaneous biportal endoscopic (BE) approach. Consecutive 7 patients underwent BE-PCIF for their cervical radiculopathy. Postoperative radiologic images (x-rays, computed tomography [CT], and magnetic resonance imaging [MRI]) were evaluated postoperatively for optimal neural decompression status and stabili- ty. A visual analogue scale (VAS) for the arm pain and the Neck Disability Index were used to evaluate clinical results in the preoperative and postoperative periods. Mean follow-up periods were 6.42 ± 2.99 months. The mean operative time was 101.42 ± 49.30 minutes. Postoperative MRI and CT revealed complete removal of herniated discs and ideal neural decompression of the treated segments in all patients. Disc height and stability were pre- This is an Open Access article distributed under served on postoperative x-rays. Preoperative VAS and Oswestry Disability Index scores im- the terms of the Creative Commons Attribution proved significantly after the surgery. BE-PCIF may be an effective surgical treatment of the Non-Commercial License (https://creativecom- mons.org/licenses/by-nc/4.0/) which permits cervical radiculopathic lesions, which provides successful surgical decompression as far as unrestricted non-commercial use, distribution, distal part of foramen with better operative view and more easy surgical manipulation. This and reproduction in any medium, provided the approach may also minimize iatrogenic damages of the posterior cervical musculo-liga- original work is properly cited. mentous structures and help to maximize the preservation of the facet joint. Copyright © 2020 by the Korean Spinal Neurosurgery Society Keywords: Radiculopathy, Foraminotomy, Endoscopy, Cervical vertebrae, Inclinatory INTRODUCTION pain caused by muscle stripping and injury of the ligamentous structures with the open procedure.7-9 There are various surgical options to treat the pathologies Several minimally invasive PCF techniques using a tubular that cause cervical radiculopathy. posterior cervical foraminot- system and endoscope were developed to decrease the postop- omy (PCF) has evolved continuously and its favorable clinical erative neck pain due to iatrogenic muscle injury.6,10-12 Recently, results were proved by many studies since Spurling and Sco- biportal endoscopic (BE) spine surgery was introduced and its ville1 reported the methods of posterolateral approach for cer- clinical efficacy was also reported by several authors.13 vical radiculopathy. PCF has several advantages compared to Chang et al.14 introduced posterior cervical inclinatory fo- anterior approach, such as the ability to avoid damage of the raminotomy (PCIF), which suggested a method to minimize anterior vital structures and graft problem without the loss of the facet resection an prevent postoperative instability. motion segment.1-6 We attempted inclinatory cervical foraminotomy by applying However, some concerns with PCF also exist, such as degen- BE spine surgery technique to treat cervical radiculopathic pa- eration with kyphosis at the operated-level secondary to partial thologies. resection of the facet joint and persistent neck and shoulder The purpose of the present study was to introduce the surgi- www.e-neurospine.org S145 Song KS and Lee CW The Biportal Endoscopic Posterior Cervical Inclinatory Foraminotomy cal technique of BE-PCIF and present preliminary clinical and joint hypertrophy, tropism, size, and shape of bony spur and in- radiologic results. As far as we know, this is the first report to clination angle of the spinous process. This allowed the surgeon describe the endoscopic PCIF technique. to determine the amount of the facet joint resection and ap- proach angle for ideal decompression with the preservation of MATERIALS AND METHODS segmental stability. The new procedure was explained to the patients in detail, 4. Surgical Technique and all patients provided informed consent. 1) Equipments used in BE-PCIF During the operation, we used a 4-mm solid egg diamond 1. Patients burr (CNS Medical Co., Inc., Pocheon, Korea), 5-mm shaver Seven patients underwent BE-PCIF with/without discectomy (Striker Corp., Kalamazoo, MI, USA), 3.5-mm bendable dia- for their cervical radiculopathy between June 2019 and Febru- mond burr (All care, Seoul, Korea) and 0° 4.0-mm-diameter ary 2020. Pre- and postoperative radiologic images (x-ray, com- arthroscope (Striker, Corp.). Ninety degrees 3.75-mm radiofre- puted tomography [CT], and magnetic resonance imaging quency ablator (VAPR, DePuy Mitec, Warsaw, IN, USA) and [MRI]) were taken and compared. Postoperative MRI and CT 30° 1.4-mm microablator radiofrequency probe (DePuy, Rayn- were evaluated on the second day after operation for the confir- ham, MA, USA) were used to control intraoperative bleeding. mation of adequate neural decompression. X-rays were also ex- We also used standard foraminotomy instruments such as seri- amined at last follow-up to investigate the change of disc height, al dilator, Kerrison punches (1, 2 mm), 1.5-mm pituitary for- cervical sagittal alignment and the dynamic angle at operated ceps (standard and up-bite), and variable small angled chisels level.15 Demographic characteristics, classification of patholo- and curettes (Fig. 1). gies, distribution of operation level, operative time, and surgical complications were reviewed. Clinical results were evaluated 2) Surgical procedure and compared preoperatively and postoperatively using a visual The operation was performed in a prone position under gen- analogue scale (VAS) for arm pain and the Neck Disability In- eral anesthesia. The abdomen was relaxed using an H-shape dex (NDI).16 Statistical calculations, including means and stan- pillow to avoid increased abdominal pressure. A gel-type facial dard deviations, were obtained using SPSS ver. 17.0 (SPSS Inc., pad was used to protect the face and eyeballs from direct high Chicago, IL, USA). Paired t-tests were used to compare the dif- contact pressure. The neck was flexed and upper back was ferences in each parameter of the perioperative outcome. Statis- slanted down to reduce the chance of intraoperative bleeding tical significance was established at a p-value of less. by good venous return. A cervical traction device was not used. The patient’s head was fixed and both shoulders were pulled by 2. Indication, Inclusion, and Exclusion Criteria plasters (Fig. 2). BE-PCIF was indicated in the patients with cervical radicu- The entire posterior neck is prepared with an antiseptic solu- lopathy due to foraminal stenosis with or without paracentral tion and draped. The surgeon stands on the opposite side of the or foraminal disc protrusion. The exclusion criteria were the lesion. For making 2 portals, under the guidance of C-arm fluo- presence of segmental instability, severe kyphosis, central ste- roscopy, 2 skin incisions of 0.5 cm long were made vertically along nosis, ossification posterior longitudinal ligament, myelopathy, lateral margin of the spinous process. The first skin incision for a and patients with associated infection, tumor, and fracture in cranial portal was made at the level of the upper cervical spinous the region of the spinal segment. process related to the target while the other skin incision for a cau- dal portal was made at the level of lower cervical spinous process. 3. Preoperative Evaluation The distance between these 2 portals was about 2 cm (Fig. 3). Patients were routinely evaluated with anteroposterior, later- Serial dilators were used to dissect the neck muscle and ac- al, oblique, and dynamic x-rays to assess spine alignment, disc quire operative space. A 0° endoscope (Striker) was inserted space height, foraminal bony encroachment, and instability. through the cranial portal after inserting the cannula. A saline Additional radiographic evaluations such as MRI and CT were irrigation system was applied with a natural drainage system (2 taken to evaluate the degree of foraminal stenosis and acquire m high from operation room floor). Surgical instruments were detailed information about the facet joint such as degree of inserted through the caudal working portal. After triangulation S146 www.e-neurospine.org Neurospine 2020;17(Suppl 1):S145-153. Song KS and Lee CW The Biportal Endoscopic Posterior Cervical Inclinatory Foraminotomy A B C D E F G H I Fig. 2. Patient’s operative position. Neck and bilateral shoul- Fig. 1. The equipments were used in biportal endoscopic pos- ders were fixed with plaster without headrest. The upper back terior cervical inclinatory foraminotomy. 0° 4-mm diameter was slanted down. arthroscope (A), 4-mm diameter solid egg diamond burr (B), 5-mm diameter shaver (C), 3.5-mm diameter bendable
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