Left C5-C6 Foraminal Disc Herniation
This surgeon is a consultant of Medtronic, but received no compensation for this case discussion.
The patient is a male over 60 years of age, who reports that he had an episode of extremely severe right arm and hand pain beginning approximately 3 months ago. That pain was initially treated with a collar and pain medication but, with no relief.
Epidural injections were then attempted and did provide temporary pain relief. The pain was located in the right side of his neck and radiated into his right shoulder. It was associated with numbness and weakness in his right hand. At this time, his pain has gotten somewhat better however, the numbness and the weakness have remained. He also reports decreased dexterity in his right hand and fingers.
- Right finger extension and finger abduction is 4/5
- There is decreased sensation to pin prick in the right small finger
- Reflexes are normal
- Gait is normal
- Babinski and Hoffman's tests were negative
- Pain medication
- Cervical collar
- Cervical epidural injection
Figure 1A. Anterior posterior x-ray
Figure 1B. Lateral x-ray
Figure 2A. Right para-sagittal T2-weighted magnetic resonance image (MRI)
Figure 2B. C7-T1 axial T2-weighted MRI
Right C7-T1 acute disc herniation versus large osteophyte
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Although this patient's x-rays and sagittal MRI suggest multi-level degenerative disc disease, with slight straightening of the cervical lordosis, he has a very well-defined C8 radiculopathy, and suffered no neck pain or radiculopathy prior to this episode.
If one were to begin treating the "MRI" of this patient, it would be hard to know where to stop and a large operation, with or without fusion, is probably not justified. Therefore, it was decided to do the least operation possible to treat the pathology. Thus, an endoscopic foraminotomy/discectomy was selected.
Intra-operative images (Figs. 3A, 3B)
Figure 3A. METRx™ tube docked in position for cervical microendoscopic foraminotomy. The patient is in a sitting position.
Figure 3B. Intra-operative view of decompressed dura and exiting nerve root.
Six months post-operatively the patient's pain was totally resolved. His strength was 5/5 and his reported dexterity was continuing to improve. He continued to have some numbness in the lateral aspect of his right small finger. The patient did not undergo repeat MRI or x-rays.
Note to patients
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Medtronic Technology Featured
Doctor Fessler describes an elegant method of treating unilateral cervical radiculopathy. In surgical decision-making, there is the trepidation of doing too much or too little. The optimum treatment depends on the balance between the potential benefits of a treatment versus its inherent risks.
Fusion surgery tends to be more durable, but compared to decompression alone, it represents a significant increase in surgical morbidity. Thus, surgeons typically ask themselves if treatment can be successful without a fusion. Avoiding a fusion allows healing to expeditiously occur, without the need for a significant biologic event such as bony union.
Fusion is indicated when there is deformity, threat of progressive deformity, and/or instability. Instability can have iatrogenic causes. In this case, the patient has a focal kyphosis at the involved level, which is adjacent to a spontaneously fused segment. A traditional open midline posterior exposure disrupts the integrity of the posterior paraspinal muscle-tendon complex, which is believed to confer dynamic stability to the spine. Disruption of the posterior dynamic stabilizer of the spine may risk further progression of focal kyphosis. Hence, many surgeons would opt to treat this patient by way of an anterior cervical discectomy and fusion (ACDF).
However, the use of minimally invasive spine (MIS) techniques that limit bony resection and avoids undue muscle-tendon complex disruption may offset the drawbacks of such a posterior approach. Given the added technical difficulty of an anterior approach at the C7-T1 level, particularly in patients with large shoulders, a minimally invasive posterior approach, such as that described by Dr. Fessler, is an appealing treatment option.
While the MIS learning curve remains significant, this strategy is steadily gaining popularity among experienced MIS surgeons who also use a MIS strategy to treat concomitant central canal stenosis through unilateral posterior approaches. Long-term follow-up of these patients through a multi-center prospective registry will be important to define the clinical outcomes of these procedures.