Journal of Neurosurgery: Spine
Jay Jagannathan, Jonathan H. Sherman, Tom Szabo, Christopher I. Shaffrey and John A. Jane Sr.
This study details long-term clinical and radiographic outcomes following single-level posterior cervical foraminotomy for degenerative disc or osteophyte disease.
The authors conducted a retrospective review of 162 cases involving patients treated by a single surgeon using a posterior cervical foraminotomy. Inclusion criteria were a minimum of 5 years' clinical and radiographic follow-up and unilateral single-level posterior cervical foraminotomy for degenerative disease between C-3 and C-7. Patients who had undergone previous operations, those who underwent bilateral procedures, and those who underwent foraminotomy as part of a larger laminectomy were excluded. The Neck Disability Index (NDI) was used for clinical follow-up, and radiographic follow-up was performed using static and dynamic lateral radiographs to compare focal and segmental alignment and changes in disc-space height.
The mean presenting NDI score was 18 (range 2–39). The most common presenting symptoms were radiculopathy (110 patients [68%]), neck pain (85 patients [52%]), and subjective weakness (91 patients [56%]). The mean preoperative focal angulation at the surgically treated level was 4.2° (median 4.1°, range 7.3–15.3°), and the mean preoperative segmental curvature between C-2 and C-7 was 18.0° (median 19.3°, range −22.1 to 39.3°). The mean postoperative NDI score was 8 (range 0–39). Improvement in NDI scores was seen in 150 patients (93%). Resolution of radiculopathy was experienced by 104 patients (95% of patients with radiculopathy). The mean radiographic follow-up was 77.3 months (range 60–177 months). No statistically significant changes in focal or segmental kyphosis or disc-space height were seen among the overall cohort with time (Cox proportional hazards analysis and Student t-test, p > 0.05). The mean postoperative focal angulation was 4.1° (median 3.9°, range −9.9° to 15.1°) and mean postoperative segmental angulation was 17.6° (median 15.4°, range −40.2 to 35.3°). Postoperative instability on dynamic imaging was present in 8 patients (4.9%); 7 of these patients were clinically asymptomatic and were treated conservatively, and 1 required cervical fusion. Postoperative loss of lordosis (defined as segmental Cobb angle < 10°) was seen in 30 patients (20%), 9 of whom had clinical symptoms and 4 of whom required further surgical correction. Factors associated with worsening sagittal alignment (Cox proportional hazards analysis, p < 0.05) included age > 60 at initial surgery, the presence of preoperative cervical lordosis of < 10°, and the need for posterior surgery after the initial foraminotomy
The posterior cervical foraminotomy is highly effective in treating patients with cervical radiculopathy and results in long-lasting pain relief and improved quality-of-life outcomes in most patients. Long-term radiographic follow-up shows no significant trend toward kyphosis, although select patient subsets (patients older than 60 years, patients who had previous posterior surgery, and patients with < 10° of lordosis preoperatively) appear to be at higher risk and require closer follow-up.
Jay Jagannathan, Christopher I. Shaffrey, Rod J. Oskouian, Aaron S. Dumont, Christian Herrold, Charles A. Sansur and John A. Jane Sr.
Although the clinical outcomes following anterior cervical discectomy and fusion (ACDF) surgery are generally good, 2 major complications are graft migration and nonunion. These complications have led some to advocate rigid internal fixation and/or cervical immobilization postoperatively. This paper examines a single-surgeon experience with single-level ACDF without use of plates or hard collars in patients with degenerative spondylosis in whom allograft was used as the fusion material.
The authors conducted a retrospective review of a prospective database of (Cloward-type) ACDF operations performed by the senior author (J.A.J.) between July 1996 and June 2005. Radiographic follow-up included static and flexion/extension radiographs obtained to assess fusion, focal and segmental kyphosis, and change in disc space height. At most recent follow-up, the patients' condition was evaluated by an independent physician examiner. The Odom criteria and Neck Disability Index (NDI) were used to assess outcome.
One hundred seventy patients underwent single-level ACDF for degenerative pathology during the study period. Their most common presenting symptoms were pain, weakness, and radiculopathy; 88% of patients noted ≥ 2 neurological complaints. The mean hospital stay was 1.76 days (range 0–36 days), and 3 patients (2%) had major immediate postoperative complications requiring reoperation. The mean duration of follow-up was 22 months (range 12–124 months). Radiographic evidence of fusion was present in 160 patients (94%). Seven patients (4%) showed radiographic evidence of pseudarthrosis, and graft migration was seen in 3 patients (2%). All patients had increases in focal kyphosis at the operated level on postoperative radiographs (mean −7.4°), although segmental alignment was preserved in 133 patients (78%). Mean change in disc space height was 36.5% (range 28–53%). At most recent clinical follow-up, 122 patients (72%) had no complaints referable to cervical disease and were able to carry out their activities of daily living without impairment. The mean postoperative NDI score was 3.2 (median 3, range 0–31).
Single-level ACDF without intraoperative plate placement or the use of a postoperative collar is an effective treatment for cervical spondylosis. Although there is evidence of focal kyphosis and loss of disc space height, radiographic evidence of fusion is comparable to that attained with plate fixation, and the rate of clinical improvement is high.
Michael G. Fehlings and Randolph J. Gray
Jay Jagannathan, Ekawut Chankaew, Peter Urban, Aaron S. Dumont, Charles A. Sansur, John Kern, Benjamin Peeler, W. Jeffrey Elias, Francis Shen, Mark E. Shaffrey, Richard Whitehill, Vincent Arlet and Christopher I. Shaffrey
In this paper, the authors review the functional and cosmetic outcomes and complications in 300 patients who underwent treatment for lumbar spine disease via either an anterior paramedian or conventional anterolateral retroperitoneal approach.
Seven surgeons performed anterior lumbar surgeries in 300 patients between August 2004 and December 2006. One hundred and eighty patients were treated with an anterior paramedian approach, and 120 patients with an anterolateral retroperitoneal approach. An access surgeon was used in 220 cases (74%). Postoperative evaluation in all patients consisted of clinic visits, assessment with the modified Scoliosis Research Society–30 instrument, as well as a specific questionnaire relating to wound appearance and patient satisfaction with the wound.
At a mean follow-up of 31 months (range 12–47 months), the mean Scoliosis Research Society–30 score (out of 25) was 21.2 in the patients who had undergone the anterior paramedian approach and 19.4 in those who had undergone the anterolateral retroperitoneal approach (p = 0.005). The largest differences in quality of life measures were observed in the areas of pain control (p = 0.001), self-image (p = 0.004), and functional activity (p = 0.003), with the anterior paramedian group having higher scores in all 3 categories. Abdominal bulging in the vicinity of the surgical site was the most common wound complication observed and was reported by 22 patients in the anterolateral retroperitoneal group (18%), and 2 patients (1.1%) in the anterior paramedian group. Exposures of ≥ 3 levels with the anterolateral approach were associated with abdominal bulging (p = 0.04), while 1- or 2-level exposures were not (p > 0.05). Overall satisfaction with incisional appearance was higher in patients with an anterior paramedian incision (p = 0.001) and with approaches performed by an access surgeon (p = 0.004).
Patients who undergo an anterior paramedian approach to the lumbar spine have a higher quality of life and better cosmetic outcomes than patients undergoing an anterolateral retroperitoneal approach.