Elsevier

World Neurosurgery

Volume 112, April 2018, Pages e23-e30
World Neurosurgery

Original Article
Percutaneous Full-Endoscopic Anterior Transcorporeal Procedure for Cervical Disc Herniation: A Novel Procedure and Early Follow-Up Study

https://doi.org/10.1016/j.wneu.2017.12.001Get rights and content

Objective

To describe the surgical technique of percutaneous full-endoscopic anterior transcorporeal cervical discectomy (PEATCD) in detail and report the clinical outcomes and radiologic changes in patients with cervical intervertebral disc herniation (CIVDH).

Methods

A novel procedure, PEATCD, was performed on 36 patients with CIVDH between June 2015 and June 2016. A retrospective study of these patients was carried out over a follow-up period of 12–24 months. The visual analog scale scores, Japanese Orthopedic Association (JOA) scores, and improvement rates (IRs) of the JOA scores were used to evaluate neurologic symptoms. Radiologic follow-up included magnetic resonance imaging, computed tomography scan, and standard radiographs.

Results

All patients reported immediate postoperative relief of neck and arm pain compared with the recorded preoperative levels of discomfort, and the JOA scores improved gradually during the follow-up period. The IRs of the neurologic evaluations ranged from 60% to 100%, the average being 85.47% ± 9.32%. The decrease in the intervertebral disc height was statistically significant (P < 0.0001), and there were no adverse clinically related symptoms. No collapse of the drilled vertebrae was recorded, and the bone defects showed significant decreases within 3 months after the operation. There were no surgery-related complications.

Conclusions

PEATCD combines the benefits of an anterior transcorporeal approach with endoscopy, preserves the cervical motion segment and causes less damage to the disc, and significantly decreases surgical trauma. Therefore, PEATCD is a safe, effective, minimally invasive, alternative procedure for patients with CIVDH.

Introduction

Anterior cervical discectomy and fusion (ACDF) was first reported in the 1950s and is still the standard surgical procedure for the treatment of cervical intervertebral disc herniation (CIVDH) because of its excellent clinical outcomes and good fusion rates.1, 2, 3, 4, 5, 6 Nonetheless, with the increased number of procedures, there has been an increase in reports of complications stemming from this procedure, such as loss of intervertebral disc height (IDH), pseudarthrosis, and access complications, especially the degeneration of adjacent segments.7, 8, 9, 10, 11, 12 A study by Hilibrand et al.7 reported a clinical assessment of 374 patients 10 years after receiving ACDF. In this cohort, there was a 2.9% annual incidence of symptomatic adjacent segment disease. To reduce these and other complications, different modifications and techniques have been prescribed.13, 14, 15, 16, 17, 18, 19, 20, 21, 22

The transcorporeal method to dispose of cervical spondylosis was first reported in 1993 by George et al.23 These investigators modified Verbiest's original oblique transcorporeal technique for anteriorly located lesions in the cervical spinal canal and achieved a good surgical field as the result. However, one drawback involved excessive exposure of the vertebral artery; the intraoperative bone resection was an unavoidable consequence that increased the risk of injury to the vertebral artery and collapse of the drilled vertebrae.23 Since then, this technique has been developed into transuncal anterior foraminotomy and transvertebral discectomy, the former being applied to cervical radiculopathy and the latter mainly used for central CIVDH.22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33 Nakai et al.30 and Sakai et al.24 improved this technique by creating a relatively small channel by means of an operating microscope when performing cervical discectomy, as opposed to a large bone resection on the vertebral body; exposure of the vertebral artery was unnecessary.23 The transcorporeal method can completely preserve the front part of the disc and the cervical motion segment, and longitudinal follow-up studies have revealed no reports of drilled vertebrae collapse.24, 32, 34 However, from a surgical point of view, it is exceedingly difficult to operate through a narrow channel even with an operating microscope, especially if blood obscures the view.

Full-endoscopic operations are performed with continuous saline irrigation, which can stanch the bleeding by hydraulic pressure and discharge any residual blood within the surgical site to present a clear field. Full-endoscopic operations also provide bright light and amplified images, which greatly aid the procedures. Percutaneous full-endoscopic anterior transcorporeal cervical discectomy (PEATCD) combines the benefits of endoscopy with anterior transcorporeal herniotomy (ATH), a technique first described by Deng et al.35 However, an irregular and relatively small channel was displayed on their radiologic images, which might result in unsatisfactory decompression and deficiency for seeking the disc fragment. To our knowledge, our report is the first to present preliminary follow-up results from a cohort study using PEATCD, in which we performed an alternative method to establish the bony channel.

Section snippets

Patient Cohort

Thirty-six patients underwent the PEATCD procedure, which was performed by the same surgeon between June 2015 and June 2016. Patient data pertaining to sex, age, duration of symptoms, and indications for surgery are shown in Table 1.

Patient Selection

The inclusion criteria were as follows: 1) single-level central or mediolateral soft herniation, 2) failed conservative therapy for at least 4 weeks or symptomatic deterioration, 3) neurologic symptoms that were consistent with the results of preoperative radiologic

Clinical Outcomes

A total of 36 PEATCD procedures were successfully performed in this study, without any complications during the surgery. The average operating time was 74.69 ± 12.41 minutes (range, 51–100 minutes), and the length of hospital stay after the operation was 1.61 ± 0.84 days (range, 1–4 days). After surgery, the patients were required to wear a cervical collar for at least 3 weeks, and the clinical outcome for each patient was evaluated over a 12-month follow-up period. By the final follow-up time,

Discussion

Full-endoscopic surgery has made great advancements in recent years. For example, the use of water-mediated endoscopic surgery rather than air-mediated endoscopic surgery has decreased the risk of infection by preventing exposure of tissues to air. In conventional ATH, intraoperative manipulation is exceedingly difficult because of the narrow channel, especially when active bleeding in the channel needs to be staunched. In some cases, ACDF or corpectomy can be applied as alternative procedures;

Conclusions

PEATCD combines the benefits of an anterior transcorporeal approach with endoscopy, preserves the cervical motion segment and causes less damage to the disc, and significantly decreases surgical trauma. Therefore, PEATCD is a safe, effective, minimally invasive, alternative procedure for patients with CIVDH.

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    Conflict of interest statement: This work was financially supported by the Doctoral Science Research Startup Funding of the Affiliated Hospital of Zunyi Medical University (2017-01) and the National Natural Science Foundation of China (31760266).

    Qian Du and Xin Wang are co–first authors.

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