- Department of NeuroScience, Winthrop Neuroscience, Winthrop University Hospital, Mineola, NY, USA
Correspondence Address:
Nancy E. Epstein
Department of NeuroScience, Winthrop Neuroscience, Winthrop University Hospital, Mineola, NY, USA
DOI:10.4103/2152-7806.170435
Copyright: © 2015 Surgical Neurology International This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.How to cite this article: Epstein NE. Open laminoforaminotomy: A lost art?. Surg Neurol Int 25-Nov-2015;6:
How to cite this URL: Epstein NE. Open laminoforaminotomy: A lost art?. Surg Neurol Int 25-Nov-2015;6:. Available from: http://surgicalneurologyint.com/surgicalint_articles/open-laminoforaminotomy-a-lost-art/
Abstract
Background:Open cervical laminoforaminotomy (CLF) provides safe and effective decompression/excision of lateral/foraminal disc herniations/spurs contributing to nerve root compression. CLF's advantages over anterior cervical discectomy/fusion (ACDF) include the lack of risk to anterior structures (esophagus, trachea, carotid, and recurrent laryngeal nerve) and the avoidance of a fusion. Further, advantages over minimally invasive surgery CLF (MIS CLF) include a lower incidence of dural tears, infections, and neural injury. Furthermore, complications are now more often reported in medicolegal suits rather than the spinal surgical literature.
Methods:Here, in a select review of the spinal literature in which we specifically focused on the benefits, risks, and complication of open CLF versus the various MIS CLS techniques.
Results:Open CLF is a unique posterior cervical surgical technique that is technically demanding. When using an MIS CLF approach that provides limited visualization and maneuverability while incurring greater morbidity (e.g., risks more dural tears, infection, and neural damage).
Conclusions:Why not utilize open CLF, adequately and safely, to decompress lateral/foraminally compromised cervical nerve roots, and avoid the risks of MIS CLF or ACDF? Presently, too many spine surgeons automatically choose MIS CLF or ACDF over open CLF; is this because it is a “lost art”?
Keywords: Limit morbidity, lost art, minimally invasive surgery: Anterior cervical diskectomy/fusion, open laminoforaminotomy
INTRODUCTION
Although it provides safe and effective decompression of lateral/foraminally compromised cervical nerve roots, open cervical laminoforaminotomy (CLF) appears to be a lost art [Figures
Figure 5
This illustration (Joseph A. Epstein/copyright-copyright Nancy E. Epstein) shows a laminectomy performed from C2 to C5. On the left medial facetectomy/foraminotomy is illustrated at C2–C3, C3–C4, C4–C5, and C5–C6 levels, sufficient to expose the foraminally exiting nerve roots. Additionally illustrated on the right is (multiple arrows) is decompression of the dura/thecal sac at multiple levels where there was prior compression, while also demonstrating more extensive partial facetectomies at the C2–C3, C3–C4, C4–C5, and C5–C6 levels
Figure 6
In
TEACHING VERSUS NONTEACHING HOSPITAL SETTINGS IMPACT CERVICAL SURGICAL OUTCOMES
Outcomes of cervical spine surgery depend on hospital setting
The premise of this study was that the extent/severity of cervical spine operations performed in teaching versus nonteaching hospitals likely differ. To better evaluate this, Fineberg et al. in 2013, compared the outcomes of 212,385 cervical spine operations (anterior/posterior fusion, decompressions [LF, laminectomy, laminoplasty]) performed for myelopathy/radiculopathy within both of these settings utilizing a national population-based database (2002–2009).[
Resident training for cervical laminoforaminotomy
Recognizing that most neurosurgical programs do not adequately provide training in open CLF, Ghobrial et al. in 2015 developed a skill simulation course for training residents.[
SAFETY/EFFICACY OF OPEN CERVICAL LAMINOFORAMINOTOMY
In 1993, Zeidman and Ducker emphasized the safety/efficacy of performing CLF in the sitting position for 172 patients with radiculopathy [
In 2003, Harrop et al. evaluated the safety/efficacy of managing 19 patients with cervicothoracic radiculopathy/disc disease utilizing LFs [
In 2009, Heary et al. in conjunction with the Joint Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons and Congress of Neurological Surgeons, performed an evidence-based evaluation of the efficacy of CLF (LF) for managing cervical radiculopathy [
In 2014, Church et al. reported (in 2014) on the safety/efficacy of CLF (foraminotomy [FOR]) for treating 1085 patients with soft disc herniations versus osteophytes [
Also in 2014, Bydon et al. evaluated the frequency/timing of persistent/renewed radiculopathy or reoperations required an average of 4.15 years following 151 “open” unilateral posterior cervical foraminotomy (PCF) [
OUTPATIENT SURGICAL TREATMENT OF CERVICAL RADICULOPATHY WITH OPEN CERVICAL LAMINOFORAMINOTOMY; ITS BETTER TO BE LUCKY THAN GOOD
In 1997, Tomaras et al. performed outpatient open cervical LF utilizing “limited posterior dissections” (not MIS procedures) to complete LF in 200 carefully selected patients (without significant comorbidities and willingness to do this) [
MINIMALLY INVASIVE SURGERY FOR CERVICAL LAMINOFORAMINOTOMY
100 microendoscopic-assisted laminoforaminotomies
In 2001, Adamson reported on the performance of 100 microendoscopic-assisted LFs to treat unilateral cervical radiculopathy attributed to lateral/foraminal disc/spur/stenosis [
Microendoscopic foraminotomy in 25 patients
In 2002, Fessler and Khoo discussed the safety/efficacy of a microendoscopic foraminotomy (MEF) technique successfully utilized in 25 patients with lateral/foraminal disc/spurs [
Minimally invasive modified keyhole laminoforaminotomy
In 2006, Figueiredo et al. performed 39 minimally invasive modified keyhole LF from the C3-C4 through the C7-T1 levels; anatomic landmarks of the posterior cervical vertebral body facilitated an adequate decompression of the intervertebral foramen with minimal bone removal [
Minimally invasive surgery consisting of cervical laminoforaminotomy in 19 studies
In 2011, Clark et al. noted the potential benefits of MIS surgery in general; these included smaller incisions, the potential for reduced pain, less blood loss, and shortened LOS [
MetRx tubular retractor system with the operating microscope utilized in 32 patients undergoing MIS-CLF
Also in 2011, Lidar and Salame retrospectively evaluated 32 patients undergoing MIS-CLF utilizing a MetRx tubular retractor system with the operating microscope over a 4 year period (2004–2008) [
Microscopic tubular assisted posterior cervical laminoforaminotomy (42 patients) versus open laminoforaminotomy (65 patients)
In 2011, Winder and Thomas performed 107 LF: 42 utilized a microscopic tubular assisted posterior CLF (MTPF) approach (1999–2009) versus 65 patients who were treated with open LF [
Posterior endoscopic minimally invasive surgery for decompression of cervical spondylotic myelopathy
In 2014, Yadav et al. evaluated the safety/efficacy of utilizing an MIS LF either unilaterally or bilaterally for the treatment of cervical spondylotic myelopathy (CSM) over single or multiple levels [
COMPLICATIONS OF MINIMALLY INVASIVE SURGERY LAMINOFORAMINOTOMY
Postoperative cervical spinal epidural hematoma after laminoforaminotomy
In 2013, Choi et al. presented the case of a 65-year-old male who had an MIS CLF performed on the right side at the C5–C6 and C6–C7 levels [
Complications of instrumentation with minimally invasive cervical laminoforaminotomy and lateral mass screw placement
In 2012, Mikhael et al. under fluoroscopic guidance utilized an MIS tubular system (paramedian muscle splitting approach) to perform multilevel posterior cervical LF with lateral mass screw placement.[
ONE LEVEL MICROENDOCOPIC LAMINOFORAMINOTOMY VERSUS CERVICAL ARTHROPLASTY FOR CERVICAL SPONDYLOTIC RADICULOPATHY
In 2013, Liu et al. compared the results for treating one-level cervical spondylotic radiculopathy utilizing either a microendoscopic LF (MELF: 52 patients) versus cervical arthroplasty (CA) techniques (45 patients) [
MINIMALLY INVASIVE ENDOSCOPIC CERVICAL LAMINOFORAMINOTOMY VERSUS “OPEN” CERVICAL LAMINOFORAMINOTOMY: DO THE RISKS OUTWEIGH THE BENEFITS?
In 2009, Epstein discussed the learning curve associated with utilizing MIS CLF endoscopic approaches to the cervical spine versus “open” CLF and asked “was it worth it?”.[
A SHORT TUTORIAL ON THE SELECTION AND PERFORMANCE OF OPEN CERVICAL LAMINOFORAMINOTOMY [FIGURES 1-6]
Magnetic resonance, computed tomography, and Myelo-CT findings for patients who are candidates for open cervical laminoforaminotomy
For patients to be candidates for open CLF, the magnetic resonance (MR), computed tomography (CT), and/or Myelo-CT findings should demonstrate a lateral/foraminal soft disc herniation or mild-moderate spur (major spurs should be resected anteriorly). In order to differentiate soft disc from calcified spur, both MR- and CT-based studies should be performed; the MR scans best demonstrate the soft-tissues, while the CT scans readily identify the calcification/ossification (e.g., also determine whether ossification of the posterior longitudinal ligament [OPLL] is present). Note that large spurs or OPLL at single or multiple levels may warrant a ventral approach, or if the lordosis is preserved, a multilevel bilateral decompressive procedure (e.g., laminectomy with/without fusion). If there is focal hypertrophy of multiple facet joints unilaterally, that contribute to significant cord as well as root compression, then a laminectomy rather than multiple keyhole foraminotomies/hemilaminectomies should be performed [Figures
SUMMARY
Spine surgeons, particularly in major teaching hospitals, now often adopt minimally invasive approaches to address complex cervical pathology or choose maximally invasive complex fusions where smaller open procedures may suffice. Specifically, as time goes on, fewer professors themselves know how to perform open CLF to address unilateral radiculopathy attributed to lateral/foraminal disc/spurs. Therefore, they will choose either variants of MIS CLF to address these lesions (e.g., with typically inadequate/limited exposure and greater morbidity), or even more frequently, opt for overly extensive ACDF. With the oversight of such “mentors,” one should carefully look at the learning curves for both professors and spine residents alike. Again, these data will not likely be found in the spine literature, but rather, among medicolegal suits.
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Conflicts of interest
There are no conflicts of interest.
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