Application of "Zoning Method" foraminotomy in posterior cervical endoscopic surgery / 中国骨伤

OBJECTIVE@#To explore the safety, effectiveness and consistency of "Zoning Method" foraminotomy in posterior cervical endoscopic surgery.@*METHODS@#From March 2016 to October 2018, 21 patients with cervical spondylotic radiculopathy were enrolled. Endoscopic foraminotomy and nucleus pulposus enucleation were performed in the patients. There were 13 males and 8 females, aged from 35 to 56 years old with an average of (47.3±5.1) years. The surgical segment of 6 cases were C, 10 cases were C and 5 cases were C. The "Zoning Method" was proposed and used to complete the foraminotomy under endoscope, and then to perform nucleus pulposus removal and nerve root decompression. The operation length, intraoperative bleeding volume and complications were recorded, and NDI, VAS were evaluated before operation, 1 day after the operation and 1 week after the operation.@*RESULTS@#All the operations were successful. The operation length was(46.10±26.39) min, intraoperative bleeding volume was (50.10±18.25) ml, and there were no complications such as nerve injury, dural tear or vertebral artery injury. All 21 patients were followed up for 3 to 9 months, with a median of 6 months. Postoperative VAS and NDI were obvious improved (0.05).@*CONCLUSION@#Endoscopic foraminotomy with "Zoning Method" is safe clinically significant, and consistent.

Foraminotomía optica para el clipado de aneurisma carótido-oftálmico superior / Optical foraminotomy for clipping of superior carotid-ophthalmic aneurysm

Introducción: Los aneurismas carótido-oftálmicos generalmente causan problemas visuales, y su tratamiento quirúrgico sigue siendo un reto debido al objetivo de preservar y/o mejorar la función visual. Descripción del caso: Presentamos caso de intervención quirúrgica de aneurisma carotídeo-oftálmico superior. Masculino de 64 años de edad con déficit de campo visual inferior izquierdo y cefalea. La reconstrucción angio-TC mostró un aneurisma carotídeo-oftálmico superior izquierdo no roto (4x5 mm). Paciente colocado en posición supina, con la cabeza fija en cabezal Sugita de 4 puntos, con una rotación de 15° hacia el lado contralateral. Una craneotomía pterional clásica con fresado del ala esfenoidal, con apertura de la fisura silviana y carotidea se realizaron bajo el microscopio. Se realiza una incisión dural circunferencial sobre el canal óptico. El techo óseo del canal óptico, así como sus paredes medial y lateral, se eliminan cuidadosamente con una fresa diamantada de 3mm con drill de alta velocidad con irrigación constante para evitar daños térmicos sobre el nervio óptico. El nervio óptico con un disector de Penfield N° 7 se eleva suavemente, lejos de la arteria carótida, para facilitar la exposición del cuello aneurismático para el clipado. Resultados: La apertura extensa del canal óptico y la vaina del nervio óptico se logró con éxito en el paciente, lo que permitió un ángulo de trabajo con la arteria carótida para la correcta visualización del aneurisma. Se logró el correcto clipado en el control de AngioCT postoperatoria. Conclusión: La foraminotomía óptica es una técnica fácil y recomendada para exponer y tratar aneurismas carotídeos-oftálmicos superiores y, además, permitir la descompresión del nervio óptico.

Introduction: Carotid-ophthalmic aneurysms usually cause visual problems, and its surgical treatment remains challenging due to the goal of preserving and/or improving the visual outcome. Case description: We present a surgical intervention of superior carotid-ophtalmic aneurysm. A 64-year-old man with a left inferior visual field deficit and headache. The angio CT reconstruction showed a left incidental superior carotid-ophthalmic aneurysm (4x5mm). Patient positioned in supine, with the head fixed in a 4 pin Sugita headholder with a 15° rotation to the contralateral side. A pterional craniotomy and flattening of sphenoid ridge with the usual drilling procedure with the opening of the Sylvian fissure to the carotid cistern were done under the microscope. A circumferential dural incision is made above the optic canal. The bony roof of the optic canal as well as its medial and lateral walls are carefully removed with a 3mm diamond high speed drill under constant irrigation to avoid thermal damage to the optic nerve. The optic nerve becomes gently retractable with a N° 7 Penfield dissector to some extent away from the carotid artery, to facilitate the aneurysmal neck exposure for clipping. Results: Extensive opening of the optic canal and optic nerve sheath was successfully achieved in the patient allowing a working angle with the carotid artery for correct visualization of the aneurysm. The correct clipping was observed in the postoperative AngioCT control. Conclusion: Optic foraminotomy is an easy and recommended technique for exposing and treating superior carotid-ophthalmic aneurysms and moreover allowing optic nerve decompression.

Meningioma del Tubérculo Selar: Foraminotomía Óptica Precoz Por Vía Pterional Transsilviana / Sellar Tubercle Meningioma: Early Optic Foraminotomy By Transsylvian Pterional Route

Introducción: Los meningiomas constituyen aproximadamente el 10-15%1 de las neoplasias cerebrales, y el 7% de ellos presentan una inserción supraselar. Los meningiomas del tubérculo selar presentan adherencia en este, en el surco quiasmático o en el limbo esfenoidal2,3. Descripción del caso: Mujer de 45 años que consulta por cefalea y déficit severo de la visión del ojo izquierdo, constatado por campimetría visual. En RM se observa imagen extraaxial, en relación al tubérculo selar, con lateralización hacia la izquierda, ingresando al conducto óptico de ese lado. Se realizó abordaje pterional izquierdo, con acceso transsilviano a las cisternas óptica y carotídea izquierdas. Se individualiza la lesión color parduzca en el espacio interóptico, que desplaza hacia lateral y superior el nervio óptico izquierdo. Se retira duramadre que cubre el techo del conducto óptico y luego con fresa diamantada se descomprime4 el mismo de modo precoz, antes de la disección microquirúrgica del meningioma. Con aspirador ultrasónico se lleva a cabo el vaciamiento intratumoral, y luego separamos la capsula tumoral de la aracnoides y las estructuras neurales y vasculares. Luego de la exéresis completa de la lesión, se retira duramadre del tubérculo selar y se realiza fresado del mismo para evitar recurrencias en el sitio de implantación. Resultados: En RM postoperatoria se observa resección completa de la lesión; además la paciente refiere mejoría notoria de su visión que se constata en examen físico. Se confirma dicha mejoría en campimetría visual a los 3 meses postoperatorios. Conclusión: La descompresión precoz del conducto óptico en los meningiomas del tubérculo selar es una maniobra quirúrgica útil para prevenir una mayor lesión del nervio durante la extirpación del tumor; además permite resecar fragmentos intracanaliculares.

Introduction: Meningiomas constitute approximately 10-15%1 of the brain neoplasms and 7% of them present a suprasellar insertion. The meningiomas of the sellar tubercle present adherence in its, in the chiasmatic sulcus or sphenoid limbus2,3. Case description: A 45-year-old woman consulted for headache and severe vision deficit of the left eye, confirmed by visual field campimetry. In MRI an extraaxial image is observed, in relation to the sellar tubercle with lateralization to the left, entering the optic canal. A left pterional approach was performed, with transsylvian access to the left optic and carotid cisterns. The brownish lesion is individualized in the interoptic space, which displaces laterally and superiorly the optic nerve. The dura mater that covers the roof of the optic canal is removed at the beginning of the surgery, and then, with a diamond bur, the optic canal is decompressed4, before the microsurgical dissection of the meningioma. With an ultrasonic aspirator, the tumor debulking is carried out, and then the tumor capsule was separated from the arachnoid and the neural and vascular structures. Finally, the duramater of the tuberculum sellae was removed and the tubercle was drilled to avoid recurrences at the implantation site. Results: In a postoperative MRI, complete resection of the lesion was observed. The patient reported a noticeable improvement in her vision that was confirmed by a physical examination. Confirming this improvement in visual field campimetry was done 3 months postoperatively. Conclusion: Early decompression of the optic canal is essential to avoid further injury during tumor removal of a tuberculum sellae meningioma, as well as allowing the resection of intracanalicular fragments.

Lumbar foraminal neuropathy: an update on non-surgical management / 대한통증학회지

Lumbar foraminal pathology causing entrapment of neurovascular contents and radicular symptoms are commonly associated with foraminal stenosis. Foraminal neuropathy can also be derived from inflammation of the neighboring lateral recess or extraforaminal spaces. Conservative and interventional therapies have been used for the treatment of foraminal inflammation, fibrotic adhesion, and pain. This update reviews the anatomy, pathophysiology, clinical presentation, diagnosis, and current treatment options of foraminal neuropathy.

Diagnosis of C2 Spondylotic Radiculopathy by Physical Examination and Imaging Studies and Treatment by Microscopic Posterior Foraminotomy: A Case Report / 대한척추외과학회지

STUDY DESIGN: Case report. OBJECTIVES: We report the case of a patient with C2 spondylotic radiculopathy who was treated by microscopic posterior foraminotomy. SUMMARY OF LITERATURE REVIEW: C2 spondylotic radiculopathy is rare, but it can occur due to spondylosis, compression by a venous plexus or vertebral artery, or hypertrophy of the atlantoepistrophic ligament. MATERIALS AND METHODS: A 64-year-old woman was hospitalized with severe occipital pain radiating toward the left cervical area and posterior to the left ear. It started 3 years previously, and became aggravated 3 months previously. Foraminal stenosis of C1-2 was observed on magnetic resonance imaging (MRI) and degenerative changes of the facet joint of C1-2 and osteophytes originating from the left atlantoaxial joint were shown on computed tomography (CT). Dynamic rotational CT showed narrowing of the left C1-2 neural foramen when it was rotated to the left. Selective C2 root block was done, but the pain was aggravated. Thus, we decompressed the C2 nerve root by microscopic posterior laminotomy of the C1 vertebra. After surgery, the patient's occipitocervical pain mostly resolved. By the 6-month follow up, pain had not recurred, and instability was not observed on plain radiographs. RESULTS: C2 Spondylotic radiculopathy was diagnosed by physical examination and imaging studies and it was treated by a surgical approach. CONCLUSIONS: C2 spondylotic radiculopathy should be considered when a patient complains of occipitocervical pain triggered by cervical rotation and C1-2 foraminal stenosis is observed on MRI and CT.

Clinical and Radiological Outcomes of Foraminal Decompression Using Unilateral Biportal Endoscopic Spine Surgery for Lumbar Foraminal Stenosis

BACKGROUND: Since open Wiltse approach allows limited visualization for foraminal stenosis leading to an incomplete decompression, we report the short-term clinical and radiological results of unilateral biportal endoscopic foraminal decompression using 0° or 30° endoscopy with better visualization. METHODS: We examined 31 patients that underwent surgery for neurological symptoms due to lumbar foraminal stenosis which was refractory to 6 weeks of conservative treatment. All 31 patients underwent unilateral biportal endoscopic far-lateral decompression (UBEFLD). One portal was used for viewing purpose, and the other was for surgical instruments. Unilateral foraminotomy was performed under guidance of 0° or 30° endoscopy. Clinical outcomes were analyzed using the modified Macnab criteria, Oswestry disability index, and visual analogue scale. Plain radiographs obtained preoperatively and 1 year postoperatively were compared to analyze the intervertebral angle (IVA), dynamic IVA, percentage of slip, dynamic percentage of slip (gap between the percentage of slip on flexion and extension views), slip angle, disc height index (DHI), and foraminal height index (FHI). RESULTS: The IVA significantly increased from 6.24°± 4.27° to 6.96°± 3.58° at 1 year postoperatively (p = 0.306). The dynamic IVA slightly decreased from 6.27°± 3.12° to 6.04°± 2.41°, but the difference was not statistically significant (p = 0.375). The percentage of slip was 3.41% ± 5.24% preoperatively and 6.01% ± 1.43% at 1-year follow-up (p = 0.227), showing no significant difference. The preoperative dynamic percentage of slip was 2.90% ± 3.37%; at 1 year postoperatively, it was 3.13% ± 4.11% (p = 0.720), showing no significant difference. The DHI changed from 34.78% ± 9.54% preoperatively to 35.05% ± 8.83% postoperatively, which was not statistically significant (p = 0.837). In addition, the FHI slightly decreased from 55.15% ± 9.45% preoperatively to 54.56% ± 9.86% postoperatively, but the results were not statistically significant (p = 0.705). CONCLUSIONS: UBEFLD using endoscopy showed a satisfactory clinical outcome after 1-year follow-up and did not induce postoperative segmental spinal instability. It could be a feasible alternative to conventional open decompression or fusion surgery for lumbar foraminal stenosis.

Application of percutaneous foraminotomy with a specially designed drill tip for foraminal stenosis patient: A case report

This case report describes a new method of pain management intervention: percutaneous foraminotomy using the Claudicare system (Seawon Meditech, Korea). In this case, a 77-year-old Asian man visited the hospital with motor weakness in his left foot. He was diagnosed with L4–5 grade three foraminal stenosis using Magnetic Resonance Imaging on both sides. A left L4–5 foraminal decompression was performed using percutaneous foraminotomy. The patient revisited the hospital after 17 months because the same symptoms recurred in his right foot. We observed that the symptoms on the left foot had disappeared completely. We confirmed the lesion on the right side and the postoperative change on the left side on the magnetic resonance imaging (MRI) image. Both the pre- and postoperative MRI images were compared by measuring the dimensions of the foraminal area (28.12 mm² vs. 38.58 mm², repectively). T1W images showed signs of increased epidural soft tissue after percutaneous foraminotomy.

Analysis of clinical efficacy of unilateral open-door cervical laminoplasty combined with foraminotomy for cervical ossification of posterior longitudinal ligament / 中国骨伤

<p><b>OBJECTIVE</b>To explore the clinical efficacy of unilateral open-door laminoplasty combined with foraminotomy for cervical ossification of posterior longitudinal ligament(OPLL).</p><p><b>METHODS</b>The clinical data of 45 patients with OPLL underwent surgical treatment between September 2011 and September 2015 were retrospectively analyzed. There were 26 males and 19 females with a mean age of 53.6 years old(ranged from 28 to 71 years). Among them, 24 cases received the surgery of unilateral open-door cervical laminoplasty combined with foraminotomy(combined group), and 21 cases received a single unilateral open-door cervical laminoplasty(single group). Operation time, intraoperative blood loss, complications including C₅ nerve root palsy and axial symptoms were compared between two groups. Pre-and post-operative Japanese Orthopedic Association(JOA) score, improvement rate of neurological function, Neck Disability Index(NDI) score, and cervical Cobb angle were recorded and analyzed between the two groups.</p><p><b>RESULTS</b>All the patients were followed up for 12-24 months, with an average of (14.3±2.8) months for combined groups and (13.7±3.1) months for single group, and no significant difference was found between the two groups(>0.05). There was no significant difference in operation time and intraoperative blood loss between two groups(>0.05). Postoperative JOA scores obtained obvious improvement in all patients(<0.05). However, there was no significant difference between two groups for the improvement rate of neurological function(>0.05). At final follow-up, NDI scores of combined group and single group were 13.6±1.8 and 16.1±2.4 respectively, there was significant difference between two groups(<0.05). The incidence of C₅ nerve root palsy was lower in combined group(4.2%) than that of single group (28.6%). There was no significant difference in incidence rate of axial symptoms between two groups(>0.05). There was no significant difference in cervical Cobb angle between pre-and post-operative conditions, or between two groups(>0.05).</p><p><b>CONCLUSIONS</b>Unilateral open-door cervical laminoplasty combined with foraminotomy is an effective method to treat cervical OPLL, which could provide sufficient decompression of spinal cord and nerve root, prevent the C₅ nerve root palsy.</p>

Malignant Metastasis Misdiagnosed as Osteoporotic Compression Fracture: A Case Report / 대한신경손상학회지

In cases of vertebral collapse after a trivial injury in elderly patients with severe osteoporosis, it can be a diagnostic challenge to determine whether the cause is a benign compression fracture or malignant metastasis. A 78-year-old male patient was referred to the emergency department for the evaluation of weakness of the left lower limb. He had undergone percutaneous vertebroplasty four months earlier after being diagnosed with L3 osteoporotic compression fracture. He was treated with foraminotomy at the L3–4 level after being diagnosed with foraminal stenosis two months earlier at a spine clinic. Magnetic resonance (MR) images showed significant signal change from the vertebral body to the posterior element, and widely spreading extraspinal extension of soft tissue at L3. Computed tomography scan revealed osteolytic changes in regions including the ventral body and pedicle. Emergent decompressive laminectomy and bone biopsy were performed, and the histologic evaluation showed metastatic squamous cell carcinoma. A retrospective review of previous MR images showed obvious pedicle and facet involvement, and paraspinal extension of soft tissue, which are highly suggestive of malignant metastasis.

Decompressive Sacral Foraminotomy for Nerve Root Injury during Conservative Treatment of Sacral Fracture: A Case Report

A 35-year-old woman visited the emergency department for a pedestrian traffic accident. Severe tenderness was noted at the posterior sacrum area, without open wound or initial neurologic deficit. Fracture of the left sacral ala extended to the S1 foramen, anterior acetabulum, and pubic ramus. Two weeks after the injury, she presented aggravating radiculopathy with the weakness of the left great toe plantar flexion. The S1 nerve root was compressed by the fracture fragments in the left S1 foramen. Decompressive S1 foraminotomy was performed. The postoperative follow-up computed tomography scan showed successful decompression of the encroachment, and the patient recovered well from the radiculopathy with motor weakness. She was able to resume her daily routine activity. We suggest that early decompressive sacral foraminotomy could be a useful additional procedure in selective sacral zone II fractures that are accompanied by radiculopathy with a motor deficit.

Decompressive Sacral Foraminotomy for Nerve Root Injury during Conservative Treatment of Sacral Fracture: A Case Report

A 35-year-old woman visited the emergency department for a pedestrian traffic accident. Severe tenderness was noted at the posterior sacrum area, without open wound or initial neurologic deficit. Fracture of the left sacral ala extended to the S1 foramen, anterior acetabulum, and pubic ramus. Two weeks after the injury, she presented aggravating radiculopathy with the weakness of the left great toe plantar flexion. The S1 nerve root was compressed by the fracture fragments in the left S1 foramen. Decompressive S1 foraminotomy was performed. The postoperative follow-up computed tomography scan showed successful decompression of the encroachment, and the patient recovered well from the radiculopathy with motor weakness. She was able to resume her daily routine activity. We suggest that early decompressive sacral foraminotomy could be a useful additional procedure in selective sacral zone II fractures that are accompanied by radiculopathy with a motor deficit.

Comparison of Surgical Results between Soft Ruptured Disc and Foraminal Stenosis Patients in Posterior Cervical Laminoforaminotomy / 대한신경손상학회지

OBJECTIVE: Posterior cervical laminoforaminotomy is used to relieve cervical nerve root compression caused by a laterally herniated soft cervical disc or spondylotic spur and its several advantages and disadvantages compared with anterior cervical discectomy were reported. We compared surgical results between soft ruptured disc and foraminal stenosis in posterior cervical laminoforaminotomy. METHODS: We performed a retrospective review of 47 patients performed single level posterior cervical laminoforaminotomy for cervical radiculopathy between 2004 and 2012. We divided these patients into two groups, Group A: 27 patients for ruptured disc and Group B: 20 patients for foraminal stenosis and analyzed the demographic factors, amount of medial facetectomy, postoperative instability with neck pain and clinical outcomes. RESULTS: According to the modified Odom's criteria, laminoforaminotomy for the ruptured disc showed 92.6% excellent results and 7.4% good results. For the foraminal stenosis, it was 55.0% excellent and 25.0% good results, which was statistically significant. However when both groups were included, overall success rate showed 91.5%. The extent of medial facetectomy for ruptured disc (31.2%) was smaller than for stenosis (48.8%) and it was statistically significant. Thirteen patients complained of postoperative neck pain for 2 months. There was no instability on dynamic X-ray until the last follow up period and we had two cases complications (4.3%). CONCLUSION: Although the extent of facetectomy for ruptured disc was smaller than it for stenosis, posterior laminoforaminotomy for the ruptured disc showed the better outcomes than foraminal stenosis.

Endoscopic Spine Surgery

Surgical treatment of the degenerative disc disease has evolved from traditional open spine surgery to minimally invasive spine surgery including endoscopic spine surgery. Constant improvement in the imaging modality especially with introduction of the magnetic resonance imaging, it is possible to identify culprit degenerated disc segment and again with the discography it is possible to diagnose the pain generator and pathological degenerated disc very precisely and its treatment with minimally invasive approach. With improvements in the optics, high resolution camera, light source, high speed burr, irrigation pump etc, minimally invasive spine surgeries can be performed with various endoscopic techniques for lumbar, cervical and thoracic regions. Advantages of endoscopic spine surgeries are less tissue dissection and muscle trauma, reduced blood loss, less damage to the epidural blood supply and consequent epidural fibrosis and scarring, reduced hospital stay, early functional recovery and improvement in the quality of life & better cosmesis. With precise indication, proper diagnosis and good training, the endoscopic spine surgery can give equally good result as open spine surgery. Initially, endoscopic technique was restricted to the lumbar region but now it also can be used for cervical and thoracic disc herniations. Previously endoscopy was used for disc herniations which were contained without migration but now days it is used for highly up and down migrated disc herniations as well. Use of endoscopic technique in lumbar region was restricted to disc herniations but gradually it is also used for spinal canal stenosis and endoscopic assisted fusion surgeries. Endoscopic spine surgery can play important role in the treatment of adolescent disc herniations especially for the persons who engage in the competitive sports and the athletes where less tissue trauma, cosmesis and early functional recovery is desirable. From simple chemonucleolysis to current day endoscopic procedures the history of minimally invasive spine surgery is interesting. Appropriate indications, clear imaging prior to surgery and preplanning are keys to successful outcome. In this article basic procedures of percutaneous endoscopic lumbar discectomy through transforaminal and interlaminar routes, percutaneous endoscopic cervical discectomy, percutaneous endoscopic posterior cervical foraminotomy and percutaneous endoscopic thoracic discectomy are discussed.

Area of Ostectomy in Posterior Percutaneous Endoscopic Cervical Foraminotomy: Images and Mid-term Outcomes

STUDY DESIGN: Retrospective. PURPOSE: To analyze whether the cross-sectional area of the intervertebral foramen at the outermost edge of the resection site is associated with postoperative outcomes and whether our fluoroscopic method for determining the resection area is appropriate. OVERVIEW OF LITERATURE: There is no consensus on the criteria for determining an optimal resection area to obtain sufficient decompression while maintaining intervertebral stability in posterior percutaneous endoscopic cervical foraminotomy. Previous reports have recommended a facet resection rate (FRR) of ≤50%. Intervertebral foramen stenosis often extends to the exit zone. The cross-sectional area of the intervertebral foramen is occasionally small at the outermost edge of the resection site. No report has analyzed whether these aspects are associated with postoperative outcomes. METHODS: Lateral margins of the resection area were set at lateral borders of the vertebral body on frontal fluoroscopic view. Because the percutaneous endoscope has a small diameter, surrounding structures can easily be identified using frontal view fluoroscopy to determine the resection area. FRRs were calculated from postoperative computed tomography images. The smallest cross-sectional area of the intervertebral foramen around the lateral edge of the resection area (SALE) was measured and compared wit clinical outcomes. RESULTS: The mean FRR was 41.7% at C5–C6 and 48.9% at C6–C7. SALE was not correlated with clinical outcomes. CONCLUSIONS: Residual stenosis in the lateral portion of the intervertebral foramen is weakly associated with postoperative outcomes. Our process achieved adequate FRRs and favorable postoperative outcomes, suggesting that our criteria for determining the resection area are appropriate.

Preservation of Motion at the Surgical Level after Minimally Invasive Posterior Cervical Foraminotomy

OBJECTIVE: Although minimally invasive posterior cervical foraminotomy (MI-PCF) is an established approach for motion preservation, the outcomes are variable among patients. The objective of this study was to identify significant factors that influence motion preservation after MI-PCF. METHODS: Forty-eight patients who had undergone MI-PCF between 2004 and 2012 on a total of 70 levels were studied. Cervical parameters measured using plain radiography included C2–7 plumb line, C2–7 Cobb angle, T1 slope, thoracic outlet angle, neck tilt, and disc height before and 24 months after surgery. The ratios of the remaining facet joints after MI-PCF were calculated postoperatively using computed tomography. Changes in the distance between interspinous processes (DISP) and the segmental angle (SA) before and after surgery were also measured. We determined successful motion preservation with changes in DISP of ≤3 mm and in SA of ≤2°. RESULTS: The differences in preoperative and postoperative DISP and SA after MI-PCF were 0.03±3.95 mm and 0.34±4.46°, respectively, fulfilling the criteria for successful motion preservation. However, the appropriate level of motion preservation is achieved in cases in which changes in preoperative and postoperative DISP and SA motions are 55.7 and 57.1%, respectively. Based on preoperative and postoperative DISP, patients were divided into three groups, and the characteristics of each group were compared. Among these, the only statistically significant factor in motion preservation was preoperative disc height (Pearson’s correlation coefficient=0.658, p<0.001). The optimal disc height for motion preservation in regard to DISP ranges from 4.18 to 7.08 mm. CONCLUSION: MI-PCF is a widely accepted approach for motion preservation, although desirable radiographic outcomes were only achieved in approximately half of the patients who had undergone the procedure. Since disc height appears to be a significant factor in motion preservation, surgeons should consider disc height before performing MI-PCF.

Correlation between MRI Grading System and Surgical Findings for Lumbar Foraminal Stenosis

OBJECTIVE: Magnetic resonance imaging (MRI) grading systems using sagittal images are useful for evaluation of lumbar foraminal stenosis. We evaluated whether such a grading system is useful as a diagnostic tool for surgery. METHODS: Between July 2014 and June 2015, 99 consecutive patients underwent unilateral lumbar foraminotomy for lumbar foraminal stenosis. Surgically confirmed foraminal stenosis and the contralateral, asymptomatic neuroforamen were assessed based on a 4-point MRI grading system. Two experienced researchers independently evaluated the MR sagittal images. Interobserver agreement and intraobserver agreement were analyzed using κ statistics. RESULTS: The mean age of patients (54 women, 45 men) was 62.5 years. A total of 101 levels (202 neuroforamens) were evaluated. MRI grades for operated neuroforamens were as follows: Grade 0 in 0.99%, Grade 1 in 5.28%, Grade 2 in 14.85%, and Grade 3 in 78.88%. Interobserver agreement was moderate for operated neuroforamens (κ=0.511) and good for asymptomatic neuroforamens (κ=0.696). Intraobserver agreement by reader 1 for operated neuroforamens was good (κ=0.776) and that for asymptomatic neuroforamens was very good (κ=0.831). In terms of lumbar level, interobserver agreement for L5–S1 (κ=0.313, fair) was relatively lower than the other level (κ=0.804, very good). CONCLUSION: MRI grading system for lumbar foraminal stenosis is thought to be useful as a diagnostic tool for surgery in the lumbar spine; however, it is less reliable for symptomatic L5–S1 foraminal stenosis than for other levels. Thus, various clinical factors as well as the MRI grading system are required for surgical decision-making.

Comparative Analysis between Total Disc Replacement and Posterior Foraminotomy for Posterolateral Soft Disc Herniation with Unilateral Radiculopathy : Clinical and Biomechanical Results of a Minimum 5 Years Follow-up

OBJECTIVE: To compare the clinical outcomes and biomechanical effects of total disc replacement (TDR) and posterior cervical foraminotomy (PCF) and to propose relative inclusion criteria. METHODS: Thirty-five patients who underwent surgery between 2006 and 2008 were included. All patients had single-level disease and only radiculopathy. The overall sagittal balance and angle and height of a functional segmental unit (FSU; upper and lower vertebral body of the operative lesion) were assessed by preoperative and follow-up radiographs. C2–7 range of motion (ROM), FSU, and the adjacent segment were also checked. RESULTS: The clinical outcome of TDR (group A) was tended to be superior to that of PCF (group B) without statistical significance. In the group A, preoperative and postoperative upper adjacent segment level motion values were 8.6±2.3 and 8.4±2.0, and lower level motion values were 8.4±2.2 and 8.3±1.9. Preoperative and postoperative FSU heights were 37.0±2.1 and 37.1±1.8. In the group B, upper level adjacent segment motion values were 8.1±2.6 and 8.2±2.8, and lower level motion values were 6.5±3.3 and 6.3±3.1. FSU heights were 37.1±2.0 and 36.2±1.8. The postoperative FSU motion and height changes were significant (p<0.05). The patient’s satisfaction rates for surgery were 88.2% in group A and 88.8% in group B. CONCLUSION: TDR and PCF have favorable outcomes in patients with unilateral soft disc herniation. However, patients have different biomechanical backgrounds, so the patient’s biomechanical characteristics and economic status should be understood and treated using the optimal procedure.

Novel Foraminal Expansion Technique

The technique we describe was developed for cervical foraminal stenosis for cases in which a keyhole foraminotomy would not be effective. Many cervical stenosis cases are so severe that keyhole foraminotomy is not successful. However, the technique outlined in this study provides adequate enlargement of an entire cervical foraminal diameter. This study reports on a novel foraminal expansion technique. Linear drilling was performed in the middle of the facet joint. A small bone graft was placed between the divided lateral masses after distraction. A lateral mass stabilization was performed with screws and rods following the expansion procedure. A cervical foramen was linearly drilled medially to laterally, then expanded with small bone grafts, and a lateral mass instrumentation was added with surgery. The patient was well after the surgery. The novel foraminal expansion is an effective surgical method for severe foraminal stenosis.

Indirect Repair with Surgicel® and Fibrin Glue for Postoperative Cerebrospinal Fluid Leakage after Cervical Anterior Foraminotomy: A Case Report

STUDY DESIGN: A case report. OBJECTIVES: To report a case of indirect repair of cerebrospinal fluid (CSF) leakage after cervical anterior foraminotomy using Surgicel® and fibrin glue. SUMMARY OF LITERATURE REVIEW: There is no single modality that is best practice for this type of case because it is difficult to apply primary repair for a case of CSF leakage after cervical anterior decompression. MATERIALS AND METHODS: A 49-year-old female patient was diagnosed with CSF leakage on the second day after cervical anterior foraminotomy. We performed coverage with Surgicel® and fibrin glue at the CSF leak site. RESULTS: The patient was treated with indirect repair of CSF leakage without any complications. The clinical and radiological outcomes were excellent upon follow-up 1 year postoperatively. CONCLUSIONS: Indirect repair using Surgicel® and fibrin glue is an effective treatment for postoperative CSF leakage after cervical anterior foraminotomy.

Long-Term Outcome of Posterior Cervical Inclinatory Foraminotomy

OBJECTIVE: A modified surgical technique of posterior cervical foramintomy called posterior cervical inclinatory foraminotomy (PCIF) was introduced in previous preliminary article. PCIF allows better preservation of facet joint and capsule than conventional techniques. The authors conducted a study to investigate long-term outcomes of PCIF. METHODS: We retrospectively reviewed demographic, radiologic, and clinical data from the patients who underwent PCIFs at our institution. Criteria included a minimum of 48 month follow-up and PCIFs for patients with radiculopathy from foraminal stenosis (C2-T1; single or multilevel) with persistent or recurrent root symptoms despite conservative treatment for more than 3 months. Patients who had undergone previous cervical operation were excluded. The visual analogue scale (VAS) score was used for clinical follow-up, and radiologic follow-up was performed to compare the changes of cervical sagittal alignment, focal angle and disc-space height of treated segment. RESULTS: The PCIFs were performed between April 2007 and March 2011 on 46 patients (32 males and 14 females) with a total of 73 levels affected. The average duration of follow-up was 74.4 months. Improvements in radiculopathic pain were seen in 39 patients (84.7%), and VAS score decreased from 6.82±1.9 to 2.19±1.9. Posterior neck pain also improved in 25 patients (71.4%) among 35 patients, and VAS score decreased from 4.97±2.0 to 2.71±1.9. The mean disc-space heights of treated segment were 5.41±1.03 mm preoperatively and decreased to 5.17±1.12 mm postoperatively. No statistically significant changes in cervical sagittal alignment, focal angle were seen during the follow-up period (Cox proportional hazards analysis and Student t-test, p>0.05). CONCLUSION: The PCIF is highly effective in treating patients with cervical spondylotic radiculopathy, leading to long-lasting relief in pain. Long-term radiologic follow-up showed no significant spinal angular imbalance.