Abstract

Background: The literature documents that laminoforaminotomy (CLF), whether performed open, minimally invasively, or microendoscopically, is safer than anterior cervical diskectomy/fusion (ACDF) for lateral cervical disease.

Methods: ACDF for lateral cervical disc disease and/or spondylosis exposes patients to multiple major surgical risk factors not encountered with CLF. These include; carotid artery or jugular vein injuries, esophageal tears, dysphagia, recurrent laryngeal nerve injuries, tracheal injuries, and dysphagia. CLF also exposes patients to lower rates of vertebral artery injury, dural tears (DT)/cerebrospinal fluid fistulas, instability warranting fusion, adjacent segment disease (ASD), plus cord and/or nerve root injuries.

Results: Further, CLF vs. ACDF for lateral cervical pathology offer reduced tissue damage, operative time, estimated blood loss (EBL), length of stay (LOS), and cost.

Conclusion: CLFs’, whether performed open, minimally invasively, or microendoscopically, offer greater safety, major pros with few cons, and decreased costs vs. ACDF for lateral cervical disease.

Keywords: Cervical Laminoforaminotomy (CLF), Safety, Reduced Cost, Disc Disease, Spondylosis, Lateral Recess Stenosis, Reduced Morbidity, Preservation Stability, Lack of Fusion, Anterior Cervical Diskectomy/Fusion (ACDF)

INTRODUCTION

Cervical laminoforaminotomy (CLF), whether performed open, minimally invasively (MI), or microendoscopically (ME) for lateral/foraminal cervical disc disease, are safer than anterior cervical diskectomy/fusion (ACDF) [ Table 1 ].[ 1 - 17 ] Notably, ACDF risks uniquely include, carotid artery or jugular vein injuries, esophageal tears, dysphagia, tracheal injuries, and recurrent laryngeal nerve injuries not posed by CLF. Further, CLF vs. ACDF offer marked reductions in the frequency of vertebral artery injuries, cord/nerve root deficits, spinal instability, dural tears (DT), tissue damage, operative time, estimated blood loss (EBL), adjacent segment disease, length of stay, and cost.

Table 1:

Minimally Invasive, Microendoscopic, or Open Cervical Laminoforaminotomy with/without Microdiskectomy vs. Anterior Cervical Diskectomy/Fusion (ACDF) for Lateral Disease.

Pros with Few Cons for Open Cervical Lamoinoforaminotomy (CLF) vs. ACDF for Lateral Cervical Disc/Spondylosis

Several studies emphasized the multiple pros without significant cons for performing open CLF vs. predominantly ACDF for addressing lateral cervical disc disease/spondylosis [ Table 1 ].[ 3 - 5 ] In 2002, Epstein cited the various benefits of open CLF over ACDF for addressing lateral/foraminal cervical disc disease or spondylosis [ Table 1 ].[ 4 ] Church et al. (2014) subsequently confirmed the safety/efficacy of 338 open CLF for lateral cervical disease; results showed an overall 3.3% incidence of perioperative adverse events (AE) and 6.2% frequency of the need for repeated surgery to address recurrent radiculopathy [ Table 1 ].[ 3 ] Again, in 2015, Epstein further confirmed the pros and limited cons of performing open CLF vs. ACDF for lateral cervical pathology; open CLF avoided carotid artery and jugular vein injuries, dysphagia esophageal, tracheal, and recurrent laryngeal nerve (RLN) injuries [ Table 1 ].[ 5 ] Further, they contributed to lower frequencies of vertebral artery injuries, intraoperative dural tears (DT)/cerebrospinal fluid (CSF) leaks, infections, instability requiring fusion (i.e., the AE attributed to instrumentation/failure), and cord/root injuries.

Good/Excellent Postoperative Outcomes with Limited Adverse Events for Open CLF

Three studies documented good/excellent postoperative outcomes with limited reports of adverse events following open CLF [ Table 1 ].[ 13 - 15 ] Yilmaz (2016) et al. found that performing 83 open CLF to address posterolateral soft discs or foraminal stenosis resulted in 66 excellent and 13 good outcomes (Odom’s Criteria); additionally, 79 (95%) showed improvement in postoperative radicular complaints, with just two adverse events (i.e., AE: 1 dural tear, and one wrong level surgery) [ Table 1 ].[ 13 ] Further pros for CLF included; better operative exposure to limit perioperative neural injuries, a shortened LOS, and greater preservation of stability (i.e., avoidance of fusion). Performing 35 open keyhole (KH) CLF to address 21 lateral/foraminal soft discs and 14 with foraminal osteophytes, Yolas et al. (2016) documented an 88.5% incidence of good/excellent outcomes with no instances of postoperative instability [ Table 1 ].[ 14 ] When Yoo et al. (2017) evaluated the overall outcomes for 27 patients undergoing open CLF for soft disc herniations vs. 20 for lateral/foraminal stenosis, they found both groups exhibited 92.6% excellent and 7.4% good outcomes (Odom’s Criteria), with better results recorded for those with soft discs [ Table 1 ].[ 15 ]

Microscopic Tubular Assisted Posterior Cervical Laminoforaminotomy (MTPF) vs. Open CLF

Winder et al. (2011) compared the results for MTPF (42 patients) vs. open CLF (65 patients) for patients with lateral cervical disease; although both groups sustained comparable perioperative AE, and operating room times, MTPF reduced tissue damage, intraoperative blood loss, postoperative pain, and LOS [ Table 1 ].[ 11 ]

Results for Minimally Invasive CLF (MICLF) vs. ACDF for Lateral Cervical Discs/Osteophytes

Three studies described better outcome scores and reduced length of stay (LOS) for MICLF over ACDF [ Table 1 ].[ 8 , 10 , 17 ] Sahai et al., (2019) compared outcomes for MICLF vs. ACDF for 1216 patients from 14 studies; although patients from both groups demonstrated comparable perioperative adverse events, reoperation rates, and similar Visual Analog Scores (VAS) - Neck and Neck Disability Scores (NDI), those undergoing MICLF had better VAS-Arm Scores. [ Table 1 ].[ 8 ] Comparing MICLF vs. ACDF vs. cervical disc arthroplasty (CDR), Srikantha et al. (2021) found MICLF proved a more effective operation for carefully selected patients [ Table 1 ].[ 10 ] In Zou et al. (2022) meta-analysis of 1175 patients undergoing MICLF vs. ACDF for lateral cervical disease, MICLF patients demonstrated significant reductions in LOS but comparable frequencies of perioperative adverse events, reoperation rates, and similar outcomes [ Table 1 ].[ 17 ]

Success of Microendoscopic Laminoforaminotomy (MELF) for Lateral Cervical Disease

Two series showed that MELF were safe and effective, with MELF and ACDF yielding comparable results when addresssing lateral cervical disease [ Table 1 ].[ 1 , 16 ] Adamson et al. (2001) evaluated the outcomes of 100 MELF performed for unilateral cervical radiculopathy; 97 were able to return to work, with only 2 experiencing intraoperative durotomies and one wound infection [ Table 1 ].[ 1 ] For unilateral C4 radiculopathy, Zeitouni et al. (2023) found that 21 patients undergoing MELF vs. 21 having ACDF demonstrated comparable outcomes (VAS Scores), length of stay (LOS), duration of surgery, time to return to work, incidence of perioperative AE, reoperation rates, and incidence of adjacent segment disease (ASD) warranting surgery [ Table 1 ].[ 16 ]

Learning Curve for Percutaneous Endoscopic CLF (PPE CLF) Procedures Requires Performing the First 26 of the 64 Cases

Yao et al. (2022) determined that the learning curve for PPE CLF procedures occurred after the first 26 of 64 cases (i.e., before surgeons showed a “trend” for decreased operating room time and greater “proficiency”); this further correlated with an overall 82.8% incidence of good/excellent outcomes for the 65 patients at 12-24 postoperative months [ Table 1 .][ 14 ]

Lower Cost for Open CLF, Posterior Cervical Foraminotomy/Cervical Posterior Microdiskectomy (PCF/CPM) or MICLF vs. ACDF for Unilateral Cervical Radiculopathy

Three studies demonstrated reduced costs for variants of CLF (i.e..., open CLF, PCF/CPM, MICLF) vs. ACDF when addressing lateral cervical pathology [ Table 1 ].[ 2 , 6 , 7 ] For 101 patients, Mansfield et al. (2014) compared the 3-year perioperative costs for 1-level ACDF vs. MICLF; average ACDF (largely implants) cost $8192 vs. $4320 for MICLF, but outcomes were comparable for both groups [ Table 1 ].[ 7 ] Two years following open CLF vs. ACDF, Liu et al. (2016) documented comparable postoperative AE (4% vs. 7%) and reoperation rates (6% vs. 4%), but CLF cost less [ Table 1 ].[ 6 ] In 2018, Ament et al. documented reduced costs for performing PCF/CPM vs. ACDF to treat unilateral radiculopathy; direct costs were markedly greater for ACDF at one year ($131,951 per Quality-Adjusted Life Year) vs. a reduced $79,856 cost for PCF/CPM. [ Table 1 ].[ 2 ] Of note, both groups demonstrated comparable reoperation rates and quality of outcomes.

Rare Postoperative Instability and Adjacent Segment Disease After Minimally Invasive Cervical Laminoforaminotomy (MICLF) With/Without Microdiskectomy

Over an average of 44.4 postoperative months, Skovrlj et al. showed that 5 of 70 total patients undergoing MICLF required additional surgery at eight levels (i.e., five at the index surgical level and 3 for new adjacent level disease); summarized, this meant that only 1.1% of patients undergoing MICLF required fusions per year, with another 0.9% warranting surgery for ASD/year [ Table 1 ].[ 9 ] Additionally, postoperative adverse events were rare, with just 3 (4.3%) occurring out of 70 patients undergoing MICLF (i.e., at 95 levels) over 2.5 postoperative years; AE included one dural tear, one wound hematoma, and one increase in radiculopathy.

CONCLUSION

CLF and its’ minimally invasive, microendoscopic, and microdiskectomy variants offer greater safety, major pros with few cons, and decreased costs vs. ACDF for patients with lateral/foraminal cervical disc disease and/or spondylosis [ Table 1 ].[ 1 - 17 ]

Ethical approval

Institutional Review Board approval is not required.

Declaration of patient consent

Patient’s consent not required as there are no patients in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

Disclaimer

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.

References

1. Adamson TE. Microendoscopic posterior cervical laminoforaminotomy for unilateral radiculopathy: Results of a new technique in 100 cases. J Neurosurg. 2001. 95: 51-7

2. Ament JD, Kaarnati T, Kulabya E, Kim KD, Jackson JP. Treatment of cervical radiculopathy: A review of the evolution and economics. Surg Neurol Int. 2018. 9: 35

3. Church EW, Halpern CH, Faught RW, Balmuri U, Attiah MA, Hayden S. Cervical laminoforaminotomy for radiculopathy: Symptomatic and functional outcomes in a large cohort with long-term follow-up. Surg Neurol Int. 2014. 5: S536-43

4. Epstein NE. A review of laminoforaminotomy for the management of lateral and foraminal cervical disc herniations or spurs. Surg Neurol. 2002. 57: 226-33 discussion 233-4

5. Epstein NE. Open laminoforaminotomy: A lost art?. Surg Neurol Int. 2015. 6: S600-7

6. Liu WJ, Hu L, Chou PH, Wang JW, Kan WS. Comparison of anterior cervical discectomy and fusion versus posterior cervical foraminotomy in the treatment of cervical radiculopathy: A systematic review. Orthop Surg. 2016. 8: 425-31

7. Mansfield HE, Canar WJ, Gerard CS, O’Toole JE. Single-level anterior cervical discectomy and fusion versus minimally invasive posterior cervical foraminotomy for patients with cervical radiculopathy: a cost analysis. Neurosurg Focus. 2014. 37: E9

8. Sahai N, Changoor S, Dunn CJ, Sinha K, Hwang KS, Faloon M. Minimally invasive posterior cervical foraminotomy as an alternative to anterior cervical discectomy and fusion for unilateral cervical radiculopathy: A systematic review and meta-analysis. Spine (Phila Pa 1976). 2019. 44: 1731-9

9. Skovrlj B, Gologorsky Y, Haque R, Fessler RB, Qureshi SA. Complications, outcomes, and need for fusion after minimally invasive posterior cervical foraminotomy and microdiscectomy. Spine J. 2014. 14: 2405-11

10. Srikantha U, Hari A, Lokanath YK. Minimally invasive cervical laminoforaminotomy-Technique and outcomes. J Craniovertebr Junction Spine. 2021. 12: 361-7

11. Winder MJ, Thomas KC. Minimally invasive versus open approach for cervical laminoforaminotomy. Can J Neurol Sci. 2011. 38: 262-7

12. Yao R, Yan M, Liang Q, Wang H, Liu Z, Li F. Clinical efficacy and learning curve of posterior percutaneous endoscopic cervical laminoforaminotomy for patients with cervical spondylotic radiculopathy. Medicine (Baltimore). 2022. 101: e30401

13. Yilmaz H, Erturk AR, Karatus A, Atci IB, Yurt A. Posterior laminoforaminotomy in the treatment of lateral cervical herniated disc and foraminal stenosis. Turk J Med Sci. 2016. 46: 424-9

14. Yolas C, Ozdemir NG, Okay HO, Kanat A, Senol M, Atci IB. Cervical disc hernia operations through posterior laminoforaminotomy. J Craniovertebr Junction Spine. 2016. 7: 91-5

15. Yoo HJ, Park HJ, Seong YH, Roh SW. Comparison of surgical results between soft ruptured disc and foraminal stenosis patients in posterior cervical laminoforaminotomy. Korean J Neurotrauma. 2017. 13: 124-9

16. Zeitouni D, Pfortmiller D, Monk SH, Franklin D, Cowan D, Tenorio I. Microendoscopic posterior cervical laminoforaminotomy for C4 radiculopathy. World Neurosurg. 2023. 180: e729-32

17. Zou T, Wang PC, Chen H, Feng XM, Sun HH. Minimally invasive posterior cervical foraminotomy. Neurosurg Rev. 2022. 45: 3609-18