J Korean Neurosurg Soc.  2023 Jul;66(4):426-437. 10.3340/jkns.2022.0233.

Ultrasonic Osteotome Assisted Posterior Endoscopic Cervical Foraminotomy in the Treatment of Cervical Spondylotic Radiculopathy Due to Osseous Foraminal Stenosis

• Jiang Y
• Li C
• Yuan L
• Luo C
• Mao Y
• Yu Y

• KMID: 2543534
• DOI: http://doi.org/10.3340/jkns.2022.0233

Abstract

Objective
: To investigate the efficacy and safety of the posterior endoscopic cervical foraminotomy (PECF) using ultrasonic osteotome for the treatment of cervical osseous foraminal stenosis，focusing on introduction of the advantages of ultrasonic osteotome in partial pediculectomy and ventral osteophyte resection in PECF.
Methods
: Nineteen patients with cervical osseous foraminal stenosis who underwent PECF using ultrasonic osteotome in our institution between April 2018 and April 2021 were enrolled in this study. All the patients were followed up more than 12 months. The patients’ medical data, as well as pre- and postoperative radiologic findings were thoroughly investigated. The visual analogue score (VAS), Japanese Orthopaedic Association (JOA) score, cervical dysfunction index (Neck disability index, NDI), and modified MacNab criteria were used to assess the surgical efficacy.
Results
: All the patients were successfully treated with PECF using ultrasonic osteotome. The pre- and postoperative VAS, NDI, and JOA scores were significantly improved (p<0.05). According to the modified MacNab criteria, 17 patients were assessed as “excellent”, two patients were assessed as “good” at the last follow-up. There was no dura tear, nerve root damage, incision infection, neck deformity, or other complications.
Conclusion
: Adequate nerve root decompression can be accomplished successfully with the help of ultrasonic osteotome in PECF, which has the advantage of reducing the probability of damage to the nerve root and dura mater, in addition to the original merits of endoscopic surgery.

Keyword

Ultrasonic osteotome; Cervical osseous foraminal stenosis; Percutaneous; Posterior endoscopic cervical foraminotomy; Minimally invasive surgery

Figure

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  Fig. 1. Illustration showing the causes of cervical spondylotic radiculopathy. A : Indicating disc collapse, disc herniation and osteophyte hyperplasia with osseous foraminal stenosis respectively. B : Cervical disc herniation extruding the nerve root. C : Cervical nerve root compressed by osseous foraminal stenosis.

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  Fig. 2. A : Illustration showing the operating room layout. The host machine of the ultrasonic osteotome is next to endoscopic workstation. The operator is using endoscopic ultrasonic osteotome compatible with endoscopic working channel in PECF. B : Illustration showing ultrasonic osteotome (XD860A SMTP Technology, Beijing, China) profile, including diameter, length, and shape.

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  Fig. 3. A : Schematic diagram showing the position of the patient under movable C-arm fluoroscope. B : The patient was placed in the prone position with head fixed in the Mayfield clamp under general anesthesia.

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  Fig. 4. A : Lateral fluoroscopy showing the spinal needle was introduced to touch the bone, which is C5-6 facet joint. B : Anteroposterior fluoroscopy showing the tip of needle was located in projection of pedicle. C and D : The position of the working cannula was controlled radiologically in anteroposterior and lateral position; (C) lateral view and (D) anteroposterior view.

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  Fig. 5. Intraoperative endoscopic view of representative case 1. A : The “V-point” structure was identified. B : The C7 pedicle was identified which located inferior of the left C7 nerve root. The pedicle was close and at same level to root and dura. Using high-speed drill here was dangerous. C : Endoscopic ultrasound osteotome was used to perform partial pediculectomy. D : The ventral osteophyte was exposed after partial pediculectomy (white arrow represented hyperplasia of Luschka joint, black arrow represented the space which the original position of the pedicle located and now be removed). E : The ventral osteophyte was handled by ultrasonic osteotome without significant neural retraction. F : The C7 nerve root was fully decompressed and freed.

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  Fig. 6. Illustrations showing the application of endoscopic ultrasonic osteotome in posterior endoscopic cervical foraminotomy. A : Showing the application of endoscopic ultrasonic osteotome compatible with endoscopic working channel and the “key hole”. B-D : Illustrations showing the top view of application of ultrasonic osteotome. B : Endoscopic ultrasound osteotome was used to perform partial pediculectomy to enlarge the operation space. C : The ventral osteophyte could be handled by ultrasonic osteotome. D : The affected nerve root was 360° decompressed safely. E and F : Illustrations showing the side view of application of ultrasonic osteotome. E : After resection of medial half of the facet joint, endoscopic ultrasound osteotome was used to perform partial pediculectomy to enlarge the operation space. F : The ventral osteophyte could be handled by ultrasonic osteotome.

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  Fig. 7. Intraoperative endoscopic view of representative case 2. A : Left C4 nerve root was exposed which located within narrowed C3-C4 intervertebral foramen. The distance between the upper and lower pedicle was significantly reduced. B : Endoscopic ultrasound osteotome was used to perform partial C3 pediculectomy (at the same level with C4 nerve root). C : Endoscopic ultrasound osteotome was used to perform partial C4 pediculectomy and partial vertebral body resection (this location is below the level of the nerve root). D : The left C4 nerve root was fully decompressed and freed.

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  Fig. 8. During the follow-up time, the neck and arm VAS scores, JOA scores and the NDI improved significantly. VAS : visual analogue score, preop : preoperative, F/U : follow-up, JOA : Japanese Orthopaedic Association, NDI : Neck disability index.

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  Fig. 9. Clinical results according to the modifield MacNab criteria.

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  Fig. 10. The preoperative and postoperative imaging data of representative case 1. A, C, and G : Preoperative magnetic resonance imaging (MRI) and computed tomography (CT) studies showed osseous foraminal stenosis at the left side of the C6/7 level. B, D, and H : Postoperative MRI and CT image showed removal of the ventral osseous and decompression of the nerve root (arrow in D and H represented the intervertebral foramen has been enlarged). E : Preoperative CT reconstruction scan showed severe hyperplasia of Luschka joint with narrowing of the left C6-C7 foramen. F : Postoperative sagittal CT reconstruction showed the enlargement of C6-C7 intervertebral foramen (arrow) with partial pediculectomy and ventral osseous removal. I : The 3D reconstruction showed the keyhole (arrow) decompression range, which preserved the facet joint more than 50%.

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  Fig. 11. The preoperative and postoperative imaging data of representative case 2. A, C and G : Preoperative magnetic resonance imaging (MRI) and computed tomography (CT) reconstruction images showing osseous foraminal stenosis at the left side of the C3/4 level due to cage subside and insufficient decompression. B, D, and H : Postoperative MRI and CT image showed removal of the osseous and decompression of the nerve root (arrow in D and H represented the intervertebral foramen has been enlarged). E : Preoperative sagittal CT reconstruction scan showing intervertebral height was lost and the distance between the upper and lower pedicle was significantly reduced with narrowing of the left C3-C4 foramen. F : Postoperative sagittal CT reconstruction shows the left C3-C4 intervertebral foramen (arrow) was enlarged with partial pediculectomy and ventral osteophyte removal. I : The position of the working cannula was controlled radiologically in the lateral position. J : The 3D reconstruction showed the keyhole (arrow) decompression range, which preserved the facet joint more than 50%.

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  Fig. 12. Illustration showing the pedicle and the nerve root are in the same level. It is dangerous when the high-speed rotating bit bounce or slip, resulting involvement of nerve elements. A : So, the nerve root and dural sac should be pushed away. Even so, the risk remains. Moreover, excessive pushing will also cause damage to the nerves. B : On the contrary, endoscopic ultrasound osteotome has advantages in this respect. It can help us securely resect part of the pedicle without worrying about to involve nerve elements (C).

Reference

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