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Standalone Anterior Cervical Discectomy and Fusion Versus Combination with Foraminotomy for the Treatment of Cervical Spondylotic Radiculopathy Secondary to Bony Foraminal Stenosis
Accepted Manuscript Standalone anterior cervical discectomy and fusion vs. combination with foraminotomy for the treatment of cervical spondylotic radiculopathy secondary to bony foraminal stenosis Qunfeng Guo, MD, Liang Wang, MD, Bangke Zhang, MD, Jiayao Jiang, MD, Xiang Guo, MD, Xuhua Lu, MD, Bin Ni, MD PII:
S1878-8750(16)30645-3
DOI:
10.1016/j.wneu.2016.07.099
Reference:
WNEU 4392
To appear in:
World Neurosurgery
Received Date: 18 April 2016 Revised Date:
25 July 2016
Accepted Date: 27 July 2016
Please cite this article as: Guo Q, Wang L, Zhang B, Jiang J, Guo X, Lu X, Ni B, Standalone anterior cervical discectomy and fusion vs. combination with foraminotomy for the treatment of cervical spondylotic radiculopathy secondary to bony foraminal stenosis, World Neurosurgery (2016), doi: 10.1016/j.wneu.2016.07.099. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Standalone anterior cervical discectomy and fusion vs. combination with foraminotomy for the
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treatment of cervical spondylotic radiculopathy secondary to bony foraminal stenosis
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Qunfeng Guo, MD,1 Liang Wang, MD,1 Bangke Zhang, MD,1 Jiayao Jiang, MD,1 Xiang Guo, MD,1
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Xuhua Lu, MD, 1 Bin Ni, MD1 ＊
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Shanghai, People’s Republic of China
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From the Department of Orthopedics, Changzheng Hospital, The Second Military Medical University,
Corresponding author: Xuhua Lu and Bin Ni, Department of Orthopedics, Changzheng Hospital, The
Second Military Medical University, 415 Fengyang Road, Huangpu District, Shanghai 200003,
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People’s Republic of China; Email: [email protected] (Xuhua Lu) and [email protected] (Bin
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Ni); Telephone: 0086-21-81886805.
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Qunfeng Guo and Liang Wang contributed equally to this work.
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Key words: discectomy; foraminotomy; foraminal stenosis; radiculopathy; cervical spine
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Introduction
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Cervical spondylotic radiculopathy (CSR) is a common pathology leading to arm pain. Posterior or
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anterior cervical foraminotomy (PCF or ACF) and anterior cervical discectomy and fusion (ACDF) are
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indicated for CSR that were refractory to nonsurgical management. PCF and ACF are suitable for CSR
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secondary to foraminal stenosis or a laterally located, herniated disc. They can preserve the motion of
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the index level, but they has several disadvantages, including postoperative neck pain, the progression
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of kyphosis, and the potential development of a motor palsy. [1, 2]ACDF remains the gold standard for
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treating cervical spondylotic myelopathy (CSM) and CSR due to central, paramedian and even lateral
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discs and spurs at one or two levels.[3] However, it’s difficult to remove the most lateral portion of
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large osteophytes, with some risks of nerve root damage and of vertebral artery (VA) injury.[4, 5] In
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addition, unilateral predominant wide decompression was associated with C5 palsy induced by
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extremely wide and asymmetric dural expansion after ACDF in cases with pre-existing C4/5 foraminal
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stenosis.[6]ACDF combined with ACF, a hybrid technique, can decompress not only the entrance zone
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(medial) of the intervertebral foramen, but also the exit zone (lateral). It can achieve wide
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decompression and theoretically avoid C5 palsy related to extremely wide and asymmetric
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decompression with ACDF. [6] Therefore, it may be an optional treatment for significant bony
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foraminal stenosis caused by most lateral osteophytes. However, there were few reports about this
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hybrid technique.
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In this study, the results of ACDF combined with ACF for the treatment of CSR caused by
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significant bony foraminal stenosis would be analyzed. The outcomes were compared to that of
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standalone ACDF for CSR due to lateral spurs. It aimed to substantiate the efficacy and safety of 2
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ACDF combined with ACF .
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Materials and Methods
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General information of the patients
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The records of 24 consecutive patients who underwent ACDF combined with ACF at our hospital
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between January 2003 and December 2013 were reviewed. The inclusion criteria were CSR with
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significant bony foraminal stenosis or that mixed with CSM at one level. All the patients were
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presented with radiating arm pain which was refractory to at least 6 weeks of conservative management.
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The exclusion criteria were
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than 1/2 length or width of the intervertebral foramen,
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osteophytes occupying no more
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CSR caused by soft disc fragment,
foraminal stenosis caused by hypertrophy of
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the posterior facet joint, ⑷ossification of posterior longitudinal ligament (OPLL), and
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non-degenerative cervical spine disease. In addition, a control group with 24 cases who underwent
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standalone ACDF because of CSR secondary to posterolateral spurs were randomly enrolled. The
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outcomes of two groups were compared to testify the efficacy and safety of ACDF combined with ACF.
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The study had been approved by the ethical committees of our hospital. The patients took an informed
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consent.
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Clinical outcomes
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Details of the operation were collected, including operation levels, foraminotomy side, operation time,
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blood loss, hospital stay and complications. Neck pain, arm pain (scored with the visual analog scale
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[VAS])[7] and neck disability index (NDI)[8] were recorded by questionnaires. Revision surgery rate at
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the adjacent segments and the index level was also recorded.
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Radiological outcomes
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cases with
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All the patients underwent lateral, flexion–extension and oblique radiographs, computed tomography
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(CT) scan and magnetic resonance imaging (MRI) of the cervical spine preoperatively (Fig 1a-d).
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Radiographs and CT scan after operation and at follow-up intervals were assessed (Fig 2 a-c). Bone
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fusion was judged on flexion–extension lateral radiographs. In the suspicious cases, the fusion status
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was confirmed by CT scan. The surgical segmental angle and C2-7 angle were measured on lateral
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radiographs in neutral position.[9]
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Statistical analysis
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The values were presented as the mean and standard deviation. T test, analysis of variance and
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chi-square test were used for statistical analysis. Probability values less than 0.05 were considered
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statistically significant. Analyses were performed using SPSS (SPSS Inc., Chicago, IL) 17.0.
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Surgical procedure
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After endotracheal anesthesia was applied, the patient was placed in the supine position. A right-sided
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transverse incision was made at the level of the interspace that was to be treated. Firstly, anterior
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discectomy was done as described by Smith and Robinson[10] and Cloward[11]. And then, anterior
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cervical foraminotomy in the ACDF combined with ACF group was conducted as follows.
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The medial portion of the longus colli muscle was excised and mobilized laterally to expose the
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transverse processes above and below the affected disc space. Dissection between the vertebral artery
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(VA) and the wall of foramen transversarium was firstly done with a small nerve stripper. Then,
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resection of anterior wall of the foramen transversarium was performed using a rongeur. As a result, the
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VA could be adequately exposed and laterally retracted. (Fig 3 a,b) With well protection of the VA, the
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anterior-lateral part of the uncinate process was removed using an osteotome (2-4mm in width) in the 4
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direction of about 45° angled with the coronal and sagittal planes. And then, the posterior part of the
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uncinate process and the bony pathology were removed with the osteotome along the direction of nerve
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root. At last, the remnant thin cortical bone overlying the dural sac and nerve root was removed with
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curettes and rongeurs. (Fig 3 c-e) In recent years, a high speed bur was often employed for bone
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resection instead of the small osteotome. It could generate high temperature during decompression.
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Therefore, ice brine was dripped to avoid thermal damage to the nerve root. In addition, epidural
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bleeding from the venous plexus was often encountered during removing the osteophytes at the
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intervertebral foramen. Gelatine sponge was usually employed to achieve hemostasis.
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After an adequate decompression, a cage was inserted into the disc space and an anterior cervical titanium plate was placed and secured with four screws.
Postoperatively, every patients wore a Philadelphia collar for 8 weeks.
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Results
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The general information of the patients were presented in Table 1. There was no significant difference
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between two groups in the general information except for operation time and blood loss. The operation
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time was longer and the blood loss was more in the ACDF combined with ACF group than in the
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ACDF group (all P＜0.05).
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At the final follow up, all the patients obtained bone fusion and returned to normal work. The
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fusion rate was 100% in each group. In both groups, the neck VAS, arm VAS and NDI were
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significantly reduced postoperatively (all P＜0.05). And the segmental curve and C2-C7 lordosis were
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significantly improved after operation (all P＜0.05) (Table 2). However, there was no significant 5
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difference between two groups in clinical and radiological outcomes(P＞0.05). Arm pain were
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accelerated in 3 patients in the ACDF combined with ACF group and in one patient in the ACDF group
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after operation but were cured with the help of nonsteroidal anti-inflammatory drugs (NSAIDS) within
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7 days.
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5 Discussion
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The location of the pathology causing cervical radiculopathy was classified as foraminal, referring to
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the pedicle zone mostly above the superior facet[12, 13], or posterolateral, referring to the area between
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the central canal and the entrance to the foramen. ACDF was considered to be the gold standard for
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treating cervical radiculopathy due to posterolateral discs and spurs.[3] But for significant bony
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foraminal stenosis, an affiliated foraminotomy might be required to achieve adequate decompression.
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In this study, anterior cervical discectomy and fusion (ACDF) combined with anterior cervical
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foraminotomy (ACF) was performed in cases with cervical radiculopathy due to significant bony
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foraminal stenosis. Good clinical and radiographic results manifested by neck and arm VAS, NDI,
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segment height and curve as well as C2-C7 angle were obtained, being compatible to that with ACDF.
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Foraminotomy could directly remove the compression pathology and maintain the motion of the
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index level. It was effective in the treatment of spondylosis or soft, lateral herniated discs causing
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foraminal stenosis and radiculopathy, in the absence of significant deformity or instability.[14]
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However, either ACF or posterior cervical foraminotomy (PCF) had drawbacks. PCF could lead to
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postoperative cervical kyphosis or instability secondary to resection of the facet joint[15], postoperative
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neck pain secondary to muscle stripping during the open procedure, and motor palsy[1]. Motor palsy 6
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was not an uncommon complication resulted from PCF. The reported rate could be up to 10%.
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Excessive retraction during removing the anterior compression pathology was regarded as a possible
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cause of the palsy[16]. In order to achieve adequate decompression and minimize the risk of nerve root
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injury, Jagannathan et al.[17]conducted more radical facetectomy and pediculectomy. However,
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postoperative instability and loss of lordosis developed in 4.9% and 20% patients, respectively.
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Therefore, anterior decompression might be preferable if there were significant bony compression
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pathology causing foraminal stenosis.[1] In our study, the bony pathologies were directly removed by
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anterior approach. Arm pain was greatly released. Neither motor palsy nor postoperative instability
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developed.
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Since its introduction, ACF has attracted much attention and reached acceptable results. It was
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aimed to preserve the functional motion of the operated level and avoid adjacent segment disease, but
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accelerated degeneration of the index level and adjacent segment degeneration also developed after
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ACF. Park et al.[18] conducted a study to evaluate the long term results of ACF in the treatment of
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cervical radiculopathy. They found intervertebral height loss in all operated levels, together with
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restriction of the range of motion by about 40 %, and spontaneous fusion in 10 %. Furthermore,
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significant worsening of neck VAS and delayed shoulder problems was observed[18]. They concluded
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that removal of osteophytes and the uncinate process to perform bony decompression inevitably
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violates the posterolateral corner of the disc space, resulting in spillage of disc materials, narrowing of
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the disc space, and induction of degenerative processes[18]. And the ongoing degeneration was
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assumed to be related to long-term deterioration of the clinical outcome[19]. Therefore, intervertebral
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fusion might be required, especially in cases with preoperative instability. It was revealed that ACDF
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did not increase the rate of adjacent segment failure necessitating secondary surgical intervention
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compared to foraminotomy.[20] Therefore, we conduct ACDF combined ACF for significant bony
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foraminal stenosis in our study. As a result, no patients experienced adjacent segment disease. Segment
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curve and C2-C7 angle were well reconstructed. This might be the reason for the maintenance of good
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clinical results presenting as reduced neck VAS, arm VAS and NDI.
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Although good outcomes were obtained in both groups, ACDF combined with ACF was more
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technically demanding than ACDF. Firstly, the foraminal stenosis in the ACDF combined with ACF
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group was caused by significant bony pathology. It was difficult to remove most lateral bony pathology.
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As a result, the operation time is often more than that with standalone ACDF, and the rate of nerve root
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injury might be increased. In our study, therefore, we firstly conducted anterior discectomy before
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foraminotomy to broaden the manipulation room and obtain more bony landmarks. Then a high-speed
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bur or a small osteotome could be safely used to remove the bony pathology under good view. Finally,
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the remnant thin cortical bone overlying the dural sac and nerve root was removed with curettes and
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rongeurs, reducing stimulation to the nerve root. In addition, if high speed bur was employed, ice brine
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should be used to avoid thermal damage to the nerve root. In our study, arm pain were accelerated in 3
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patients in the ACDF combined with ACF group after operation. Luckily, they were cured with the help
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of NSAIDS within 7 days. Thermal damage or stimulation to the nerve root might be responsible for
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the temporally accelerated arm pain. Secondly, vertebral artery injury was a severe complication
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associated with ACF. Park et al.[18] preserved a thin layer of the cortical bone of the lateral wall of the
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uncinate process to protect the VA. So did in the study by Saringer et al.[21]. However, in their studies,
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posterolateral sponylotic spurs or disc fragments were the main causative agents. [18, 21] In our cases
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of the ACDF combined with ACF group, the bony pathologies occupied the foramen, more lateral and
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anterior than theirs. It was more difficult to remove the lateral bony pathology than posterolateral
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sponylotic spurs or disc fragments. The uncinate process must be resected. Therefore, the anterior wall
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of the foramen transversarium was opened and the VA was adequately exposed. As a result, the
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vertebral artery could be seen directly and well protected during decompression, reducing the risk of
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VA injury. In addition, before resection of the anterior wall of the foramen transversarium, dissection
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inside the foramen transversarium might be required to avoid injury to VA or vertebral vein. Thirdly,
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epidural bleeding from the venous plexus was often encountered. In our study, the blood loss was more
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in the ACDF combined with ACF group than in the ACDF group. In our experience, hemostasis could
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be achieved using gelatine sponge. And ice-brine was also helpful for hemostasis. Although ideal clinical results were obtained, there were limitations in our study. Firstly, there
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was bias in case selection. CSR in the ACDF group was caused by posterolateral osteophytes. However,
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the osteophytes in the ACDF combined with ACF group was more lateral than that in the ACDF group.
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Secondly, this was a retrospective study and the results might be limited by the small samples. Thirdly,
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other surgical methods such as PCF, PCF combined with ACDF and PCF with posterior fixation were
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not available in this study. In our experiences, standard ACDF is still the treatment of choice for most
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CSR due to posterolateral or lateral discs and spurs.[3]However, it is technically difficult to remove
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most lateral osteophytes which originate from the overtebral joint and occupy the pedicle zone and near
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the vertebral artery (Fig 4). For such cases, we performed ACDF combined with ACF to remove the
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pathology with well protection of the vertebral artery under good view(Fig 3). If CSR was caused by
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posterolateral herniated disc at the low level of the cervical spine, especially at C7/T1, ACDF is often
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intraindicated by limited surgical fields, especially for patients with short neck. However, PCF can well
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remove the posterolateral herniated disc especially with the help of microsurgical tools. If foraminal
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stenosis was caused by hypertrophy of the facet joint, we often performed posterior fixation after PCF
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to avoid secondary cervical instability or kyphosis.(Fig 5) Although ACDF can also be performed after
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PCF to maintain stability of the cervical spine, unfortunately, we have few experience. Therefore, in
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order to make a algorithm, a prospective randomized controlled study with various surgical options
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would be needed.
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For CSR with foraminal stenosis secondary to significant bony pathology that can not be managed by
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standalone ACDF, ACDF combined with ACF was an effective and safe treatment of strategy.
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Figure legends
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Fig. 1 Preoperative radiographs, CT scan and MRI a. lateral radiograph in neutral position b,c. oblique
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radiograph and CT scan showing bony pathology causing foraminal stenosis (black arrows) d. MRI
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showing foraminal stenosis (black arrow)
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Fig. 2 Postoperative radiographs and CT scan a. lateral radiograph in neutral position b,c. oblique
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radiograph and CT scan showing adequate decompression with bony pathology being removed (black
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arrows)
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Fig. 3 Anterior cervical foraminotomy a. resection of anterior wall of the foramen transversarium
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(black arrow) and VA exposure b,c. resection of the anerior-lateral part of the uncinate process with VA
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being laterally retracted d. resection of the posterior part of the uncinate process e. decompression was
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completed
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Fig. 4 Cervical spondylotic radiculopathy (CSR) due to bony foraminal stenosis managed with ACDF a.
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preoperative lateral radiograph in neutral position b,c. oblique radiograph and CT scan showing bony
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pathology causing foraminal stenosis at C5/6 (white arrows) d. MRI showing foraminal stenosis (white
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arrow) e. lateral radiograph in neutral position after ACDF f, g. oblique radiograph and CT scan
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showing inadequate decompression with partial bony pathology left at the pedicle zone (white arrows)
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Fig.5 Cervical spondylotic myelopathy combined with foraminal stenosis managed with posterior
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cervical foraminotomy(PCF) a. preoperative CT scan showing foraminal stenosis caused by
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hypertrophy of the facet joint(white arrow) on the left side b. posterior laminectomy and foraminotomy
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(white arrow) with lateral mass screw fixation being performed.
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Table 1 General information of the patients ACDF+ACF group
ACDF group
No. of patients
24
24
Sex (male/female)
13/11
14/10
Age (years)
47.3±9.9
51.2±8.3
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Operation levels
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Information
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C5/6
13
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Foraminotomy side (left/right)
10/14
12/12
Operation time (minutes)
88.8±22.4 *
67.5±15.8
Blood loss (ml)
185.8±118.0 *
63.3±65.2
Fusion time(months)
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Hospital stay (days)
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C4/5
6.3±0.7
6.0±0.8
3.9±1.1
3.7±0.9
56.5±14.0
58.5±13.3
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Table 2 Clinical and radiological parameters before and after operation Information
ACDF+ACF group
ACDF group
Preoperative
4.8±1.6
4.6±1.8
Postoperative
0.4±0.7*
0.4±0.6*
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VAS score for neck pain
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VAS score for arm pain 8.4±0.9
Postoperative
0*
Preoperative
35.9±5.5
35.2±5.4
Postoperative
1.8±2.5*
1.6±2.4*
Segmental angle Preoperative
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NDI
8.3±0.9
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0*
1.7±3.5
2.0±3.3
6.3±3.1*
6.6±2.8*
Preoperative
12.1±8.5
13.6±7.9
Postoperative
17.1±8.7*
18.6±7.9*
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C2-C7 angle
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Data expressed as mean ± standard deviation. ACDF, anterior cervical discectomy and fusion; ACF, anterior cervical foraminotomy; VAS, visual analog scale; NDI, neck disability index * P＜0.05 , compared with the preoperative data using paired t test.
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ACCEPTED MANUSCRIPT Highlights Anterior cervical discectomy and fusion (ACDF) can not remove most lateral osteophytes.
Outcome of ACDF with anterior cervical foraminotomy (ACF) was compatible to ACDF.
ACDF with ACF was suitable for treating most lateral bony foraminal stenosis.
Although with high risk, ACDF with ACF was effective for bony foraminal stenosis.
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ACCEPTED MANUSCRIPT Abbreviation list ACDF, anterior cervical discectomy and fusion; ACF, anterior cervical foraminotomy;
CT, computed tomography; OPLL, ossification of posterior longitudinal ligament;
MRI, magnetic resonance imaging; NDI, neck disability index;
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PCF, posterior cervical foraminotomy;
NSAIDS, nonsteroidal anti-inflammatory drugs;
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VA, vertebral artery;
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VAS, visual analog scale
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CSR, cervical spondylotic radiculopathy;
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CSM, cervical spondylotic myelopathy;
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Conflicts of Interest: None.
S1878-8750(16)30645-3
DOI:
10.1016/j.wneu.2016.07.099
Reference:
WNEU 4392
To appear in:
World Neurosurgery
Received Date: 18 April 2016 Revised Date:
25 July 2016
Accepted Date: 27 July 2016
Please cite this article as: Guo Q, Wang L, Zhang B, Jiang J, Guo X, Lu X, Ni B, Standalone anterior cervical discectomy and fusion vs. combination with foraminotomy for the treatment of cervical spondylotic radiculopathy secondary to bony foraminal stenosis, World Neurosurgery (2016), doi: 10.1016/j.wneu.2016.07.099. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Standalone anterior cervical discectomy and fusion vs. combination with foraminotomy for the
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treatment of cervical spondylotic radiculopathy secondary to bony foraminal stenosis
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Qunfeng Guo, MD,1 Liang Wang, MD,1 Bangke Zhang, MD,1 Jiayao Jiang, MD,1 Xiang Guo, MD,1
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Xuhua Lu, MD, 1 Bin Ni, MD1 ＊
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Shanghai, People’s Republic of China
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From the Department of Orthopedics, Changzheng Hospital, The Second Military Medical University,
Corresponding author: Xuhua Lu and Bin Ni, Department of Orthopedics, Changzheng Hospital, The
Second Military Medical University, 415 Fengyang Road, Huangpu District, Shanghai 200003,
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People’s Republic of China; Email: [email protected] (Xuhua Lu) and [email protected] (Bin
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Ni); Telephone: 0086-21-81886805.
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Qunfeng Guo and Liang Wang contributed equally to this work.
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Key words: discectomy; foraminotomy; foraminal stenosis; radiculopathy; cervical spine
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Introduction
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Cervical spondylotic radiculopathy (CSR) is a common pathology leading to arm pain. Posterior or
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anterior cervical foraminotomy (PCF or ACF) and anterior cervical discectomy and fusion (ACDF) are
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indicated for CSR that were refractory to nonsurgical management. PCF and ACF are suitable for CSR
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secondary to foraminal stenosis or a laterally located, herniated disc. They can preserve the motion of
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the index level, but they has several disadvantages, including postoperative neck pain, the progression
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of kyphosis, and the potential development of a motor palsy. [1, 2]ACDF remains the gold standard for
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treating cervical spondylotic myelopathy (CSM) and CSR due to central, paramedian and even lateral
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discs and spurs at one or two levels.[3] However, it’s difficult to remove the most lateral portion of
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large osteophytes, with some risks of nerve root damage and of vertebral artery (VA) injury.[4, 5] In
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addition, unilateral predominant wide decompression was associated with C5 palsy induced by
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extremely wide and asymmetric dural expansion after ACDF in cases with pre-existing C4/5 foraminal
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stenosis.[6]ACDF combined with ACF, a hybrid technique, can decompress not only the entrance zone
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(medial) of the intervertebral foramen, but also the exit zone (lateral). It can achieve wide
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decompression and theoretically avoid C5 palsy related to extremely wide and asymmetric
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decompression with ACDF. [6] Therefore, it may be an optional treatment for significant bony
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foraminal stenosis caused by most lateral osteophytes. However, there were few reports about this
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hybrid technique.
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In this study, the results of ACDF combined with ACF for the treatment of CSR caused by
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significant bony foraminal stenosis would be analyzed. The outcomes were compared to that of
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standalone ACDF for CSR due to lateral spurs. It aimed to substantiate the efficacy and safety of 2
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ACDF combined with ACF .
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Materials and Methods
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General information of the patients
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The records of 24 consecutive patients who underwent ACDF combined with ACF at our hospital
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between January 2003 and December 2013 were reviewed. The inclusion criteria were CSR with
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significant bony foraminal stenosis or that mixed with CSM at one level. All the patients were
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presented with radiating arm pain which was refractory to at least 6 weeks of conservative management.
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The exclusion criteria were
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than 1/2 length or width of the intervertebral foramen,
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osteophytes occupying no more
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CSR caused by soft disc fragment,
foraminal stenosis caused by hypertrophy of
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the posterior facet joint, ⑷ossification of posterior longitudinal ligament (OPLL), and
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non-degenerative cervical spine disease. In addition, a control group with 24 cases who underwent
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standalone ACDF because of CSR secondary to posterolateral spurs were randomly enrolled. The
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outcomes of two groups were compared to testify the efficacy and safety of ACDF combined with ACF.
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The study had been approved by the ethical committees of our hospital. The patients took an informed
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consent.
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Clinical outcomes
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Details of the operation were collected, including operation levels, foraminotomy side, operation time,
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blood loss, hospital stay and complications. Neck pain, arm pain (scored with the visual analog scale
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[VAS])[7] and neck disability index (NDI)[8] were recorded by questionnaires. Revision surgery rate at
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the adjacent segments and the index level was also recorded.
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Radiological outcomes
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All the patients underwent lateral, flexion–extension and oblique radiographs, computed tomography
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(CT) scan and magnetic resonance imaging (MRI) of the cervical spine preoperatively (Fig 1a-d).
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Radiographs and CT scan after operation and at follow-up intervals were assessed (Fig 2 a-c). Bone
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fusion was judged on flexion–extension lateral radiographs. In the suspicious cases, the fusion status
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was confirmed by CT scan. The surgical segmental angle and C2-7 angle were measured on lateral
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radiographs in neutral position.[9]
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Statistical analysis
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The values were presented as the mean and standard deviation. T test, analysis of variance and
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chi-square test were used for statistical analysis. Probability values less than 0.05 were considered
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statistically significant. Analyses were performed using SPSS (SPSS Inc., Chicago, IL) 17.0.
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Surgical procedure
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After endotracheal anesthesia was applied, the patient was placed in the supine position. A right-sided
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transverse incision was made at the level of the interspace that was to be treated. Firstly, anterior
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discectomy was done as described by Smith and Robinson[10] and Cloward[11]. And then, anterior
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cervical foraminotomy in the ACDF combined with ACF group was conducted as follows.
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The medial portion of the longus colli muscle was excised and mobilized laterally to expose the
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transverse processes above and below the affected disc space. Dissection between the vertebral artery
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(VA) and the wall of foramen transversarium was firstly done with a small nerve stripper. Then,
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resection of anterior wall of the foramen transversarium was performed using a rongeur. As a result, the
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VA could be adequately exposed and laterally retracted. (Fig 3 a,b) With well protection of the VA, the
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anterior-lateral part of the uncinate process was removed using an osteotome (2-4mm in width) in the 4
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direction of about 45° angled with the coronal and sagittal planes. And then, the posterior part of the
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uncinate process and the bony pathology were removed with the osteotome along the direction of nerve
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root. At last, the remnant thin cortical bone overlying the dural sac and nerve root was removed with
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curettes and rongeurs. (Fig 3 c-e) In recent years, a high speed bur was often employed for bone
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resection instead of the small osteotome. It could generate high temperature during decompression.
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Therefore, ice brine was dripped to avoid thermal damage to the nerve root. In addition, epidural
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bleeding from the venous plexus was often encountered during removing the osteophytes at the
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intervertebral foramen. Gelatine sponge was usually employed to achieve hemostasis.
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After an adequate decompression, a cage was inserted into the disc space and an anterior cervical titanium plate was placed and secured with four screws.
Postoperatively, every patients wore a Philadelphia collar for 8 weeks.
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Results
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The general information of the patients were presented in Table 1. There was no significant difference
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between two groups in the general information except for operation time and blood loss. The operation
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time was longer and the blood loss was more in the ACDF combined with ACF group than in the
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ACDF group (all P＜0.05).
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At the final follow up, all the patients obtained bone fusion and returned to normal work. The
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fusion rate was 100% in each group. In both groups, the neck VAS, arm VAS and NDI were
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significantly reduced postoperatively (all P＜0.05). And the segmental curve and C2-C7 lordosis were
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significantly improved after operation (all P＜0.05) (Table 2). However, there was no significant 5
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difference between two groups in clinical and radiological outcomes(P＞0.05). Arm pain were
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accelerated in 3 patients in the ACDF combined with ACF group and in one patient in the ACDF group
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after operation but were cured with the help of nonsteroidal anti-inflammatory drugs (NSAIDS) within
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7 days.
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5 Discussion
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The location of the pathology causing cervical radiculopathy was classified as foraminal, referring to
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the pedicle zone mostly above the superior facet[12, 13], or posterolateral, referring to the area between
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the central canal and the entrance to the foramen. ACDF was considered to be the gold standard for
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treating cervical radiculopathy due to posterolateral discs and spurs.[3] But for significant bony
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foraminal stenosis, an affiliated foraminotomy might be required to achieve adequate decompression.
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In this study, anterior cervical discectomy and fusion (ACDF) combined with anterior cervical
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foraminotomy (ACF) was performed in cases with cervical radiculopathy due to significant bony
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foraminal stenosis. Good clinical and radiographic results manifested by neck and arm VAS, NDI,
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segment height and curve as well as C2-C7 angle were obtained, being compatible to that with ACDF.
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Foraminotomy could directly remove the compression pathology and maintain the motion of the
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index level. It was effective in the treatment of spondylosis or soft, lateral herniated discs causing
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foraminal stenosis and radiculopathy, in the absence of significant deformity or instability.[14]
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However, either ACF or posterior cervical foraminotomy (PCF) had drawbacks. PCF could lead to
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postoperative cervical kyphosis or instability secondary to resection of the facet joint[15], postoperative
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neck pain secondary to muscle stripping during the open procedure, and motor palsy[1]. Motor palsy 6
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was not an uncommon complication resulted from PCF. The reported rate could be up to 10%.
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Excessive retraction during removing the anterior compression pathology was regarded as a possible
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cause of the palsy[16]. In order to achieve adequate decompression and minimize the risk of nerve root
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injury, Jagannathan et al.[17]conducted more radical facetectomy and pediculectomy. However,
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postoperative instability and loss of lordosis developed in 4.9% and 20% patients, respectively.
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Therefore, anterior decompression might be preferable if there were significant bony compression
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pathology causing foraminal stenosis.[1] In our study, the bony pathologies were directly removed by
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anterior approach. Arm pain was greatly released. Neither motor palsy nor postoperative instability
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developed.
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Since its introduction, ACF has attracted much attention and reached acceptable results. It was
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aimed to preserve the functional motion of the operated level and avoid adjacent segment disease, but
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accelerated degeneration of the index level and adjacent segment degeneration also developed after
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ACF. Park et al.[18] conducted a study to evaluate the long term results of ACF in the treatment of
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cervical radiculopathy. They found intervertebral height loss in all operated levels, together with
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restriction of the range of motion by about 40 %, and spontaneous fusion in 10 %. Furthermore,
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significant worsening of neck VAS and delayed shoulder problems was observed[18]. They concluded
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that removal of osteophytes and the uncinate process to perform bony decompression inevitably
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violates the posterolateral corner of the disc space, resulting in spillage of disc materials, narrowing of
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the disc space, and induction of degenerative processes[18]. And the ongoing degeneration was
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assumed to be related to long-term deterioration of the clinical outcome[19]. Therefore, intervertebral
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fusion might be required, especially in cases with preoperative instability. It was revealed that ACDF
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did not increase the rate of adjacent segment failure necessitating secondary surgical intervention
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compared to foraminotomy.[20] Therefore, we conduct ACDF combined ACF for significant bony
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foraminal stenosis in our study. As a result, no patients experienced adjacent segment disease. Segment
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curve and C2-C7 angle were well reconstructed. This might be the reason for the maintenance of good
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clinical results presenting as reduced neck VAS, arm VAS and NDI.
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Although good outcomes were obtained in both groups, ACDF combined with ACF was more
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technically demanding than ACDF. Firstly, the foraminal stenosis in the ACDF combined with ACF
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group was caused by significant bony pathology. It was difficult to remove most lateral bony pathology.
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As a result, the operation time is often more than that with standalone ACDF, and the rate of nerve root
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injury might be increased. In our study, therefore, we firstly conducted anterior discectomy before
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foraminotomy to broaden the manipulation room and obtain more bony landmarks. Then a high-speed
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bur or a small osteotome could be safely used to remove the bony pathology under good view. Finally,
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the remnant thin cortical bone overlying the dural sac and nerve root was removed with curettes and
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rongeurs, reducing stimulation to the nerve root. In addition, if high speed bur was employed, ice brine
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should be used to avoid thermal damage to the nerve root. In our study, arm pain were accelerated in 3
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patients in the ACDF combined with ACF group after operation. Luckily, they were cured with the help
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of NSAIDS within 7 days. Thermal damage or stimulation to the nerve root might be responsible for
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the temporally accelerated arm pain. Secondly, vertebral artery injury was a severe complication
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associated with ACF. Park et al.[18] preserved a thin layer of the cortical bone of the lateral wall of the
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uncinate process to protect the VA. So did in the study by Saringer et al.[21]. However, in their studies,
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posterolateral sponylotic spurs or disc fragments were the main causative agents. [18, 21] In our cases
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of the ACDF combined with ACF group, the bony pathologies occupied the foramen, more lateral and
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anterior than theirs. It was more difficult to remove the lateral bony pathology than posterolateral
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sponylotic spurs or disc fragments. The uncinate process must be resected. Therefore, the anterior wall
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of the foramen transversarium was opened and the VA was adequately exposed. As a result, the
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vertebral artery could be seen directly and well protected during decompression, reducing the risk of
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VA injury. In addition, before resection of the anterior wall of the foramen transversarium, dissection
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inside the foramen transversarium might be required to avoid injury to VA or vertebral vein. Thirdly,
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epidural bleeding from the venous plexus was often encountered. In our study, the blood loss was more
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in the ACDF combined with ACF group than in the ACDF group. In our experience, hemostasis could
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be achieved using gelatine sponge. And ice-brine was also helpful for hemostasis. Although ideal clinical results were obtained, there were limitations in our study. Firstly, there
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was bias in case selection. CSR in the ACDF group was caused by posterolateral osteophytes. However,
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the osteophytes in the ACDF combined with ACF group was more lateral than that in the ACDF group.
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Secondly, this was a retrospective study and the results might be limited by the small samples. Thirdly,
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other surgical methods such as PCF, PCF combined with ACDF and PCF with posterior fixation were
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not available in this study. In our experiences, standard ACDF is still the treatment of choice for most
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CSR due to posterolateral or lateral discs and spurs.[3]However, it is technically difficult to remove
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most lateral osteophytes which originate from the overtebral joint and occupy the pedicle zone and near
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the vertebral artery (Fig 4). For such cases, we performed ACDF combined with ACF to remove the
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pathology with well protection of the vertebral artery under good view(Fig 3). If CSR was caused by
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posterolateral herniated disc at the low level of the cervical spine, especially at C7/T1, ACDF is often
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intraindicated by limited surgical fields, especially for patients with short neck. However, PCF can well
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remove the posterolateral herniated disc especially with the help of microsurgical tools. If foraminal
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stenosis was caused by hypertrophy of the facet joint, we often performed posterior fixation after PCF
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to avoid secondary cervical instability or kyphosis.(Fig 5) Although ACDF can also be performed after
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PCF to maintain stability of the cervical spine, unfortunately, we have few experience. Therefore, in
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order to make a algorithm, a prospective randomized controlled study with various surgical options
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For CSR with foraminal stenosis secondary to significant bony pathology that can not be managed by
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standalone ACDF, ACDF combined with ACF was an effective and safe treatment of strategy.
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Figure legends
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Fig. 1 Preoperative radiographs, CT scan and MRI a. lateral radiograph in neutral position b,c. oblique
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radiograph and CT scan showing bony pathology causing foraminal stenosis (black arrows) d. MRI
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showing foraminal stenosis (black arrow)
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Fig. 2 Postoperative radiographs and CT scan a. lateral radiograph in neutral position b,c. oblique
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radiograph and CT scan showing adequate decompression with bony pathology being removed (black
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arrows)
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Fig. 3 Anterior cervical foraminotomy a. resection of anterior wall of the foramen transversarium
9
(black arrow) and VA exposure b,c. resection of the anerior-lateral part of the uncinate process with VA
10
being laterally retracted d. resection of the posterior part of the uncinate process e. decompression was
11
completed
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Fig. 4 Cervical spondylotic radiculopathy (CSR) due to bony foraminal stenosis managed with ACDF a.
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preoperative lateral radiograph in neutral position b,c. oblique radiograph and CT scan showing bony
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pathology causing foraminal stenosis at C5/6 (white arrows) d. MRI showing foraminal stenosis (white
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arrow) e. lateral radiograph in neutral position after ACDF f, g. oblique radiograph and CT scan
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showing inadequate decompression with partial bony pathology left at the pedicle zone (white arrows)
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Fig.5 Cervical spondylotic myelopathy combined with foraminal stenosis managed with posterior
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cervical foraminotomy(PCF) a. preoperative CT scan showing foraminal stenosis caused by
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hypertrophy of the facet joint(white arrow) on the left side b. posterior laminectomy and foraminotomy
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(white arrow) with lateral mass screw fixation being performed.
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Table 1 General information of the patients ACDF+ACF group
ACDF group
No. of patients
24
24
Sex (male/female)
13/11
14/10
Age (years)
47.3±9.9
51.2±8.3
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Operation levels
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Information
11
C5/6
13
14
Foraminotomy side (left/right)
10/14
12/12
Operation time (minutes)
88.8±22.4 *
67.5±15.8
Blood loss (ml)
185.8±118.0 *
63.3±65.2
Fusion time(months)
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Hospital stay (days)
10
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C4/5
6.3±0.7
6.0±0.8
3.9±1.1
3.7±0.9
56.5±14.0
58.5±13.3
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Data expressed as mean ± standard deviation unless otherwise indicated. ACDF, anterior cervical discectomy and fusion; ACF, anterior cervical foraminotomy * P＜0.05 , compared with the ACDF group using t test.
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Table 2 Clinical and radiological parameters before and after operation Information
ACDF+ACF group
ACDF group
Preoperative
4.8±1.6
4.6±1.8
Postoperative
0.4±0.7*
0.4±0.6*
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VAS score for neck pain
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VAS score for arm pain 8.4±0.9
Postoperative
0*
Preoperative
35.9±5.5
35.2±5.4
Postoperative
1.8±2.5*
1.6±2.4*
Segmental angle Preoperative
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NDI
8.3±0.9
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Preoperative
0*
1.7±3.5
2.0±3.3
6.3±3.1*
6.6±2.8*
Preoperative
12.1±8.5
13.6±7.9
Postoperative
17.1±8.7*
18.6±7.9*
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C2-C7 angle
EP
Postoperative
Data expressed as mean ± standard deviation. ACDF, anterior cervical discectomy and fusion; ACF, anterior cervical foraminotomy; VAS, visual analog scale; NDI, neck disability index * P＜0.05 , compared with the preoperative data using paired t test.
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ACCEPTED MANUSCRIPT Highlights Anterior cervical discectomy and fusion (ACDF) can not remove most lateral osteophytes.
Outcome of ACDF with anterior cervical foraminotomy (ACF) was compatible to ACDF.
ACDF with ACF was suitable for treating most lateral bony foraminal stenosis.
Although with high risk, ACDF with ACF was effective for bony foraminal stenosis.
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ACCEPTED MANUSCRIPT Abbreviation list ACDF, anterior cervical discectomy and fusion; ACF, anterior cervical foraminotomy;
CT, computed tomography; OPLL, ossification of posterior longitudinal ligament;
MRI, magnetic resonance imaging; NDI, neck disability index;
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PCF, posterior cervical foraminotomy;
NSAIDS, nonsteroidal anti-inflammatory drugs;
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VA, vertebral artery;
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VAS, visual analog scale
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CSR, cervical spondylotic radiculopathy;
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CSM, cervical spondylotic myelopathy;
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Conflicts of Interest: None.