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Cervical Radiculopathy Treated Surgically on an Outpatient Basis

	Warren D. Parker, M.D., F.A.C.S. Neurosurgeon Neurosurgical Group of Texas Houston, TX, USA
	Susan Spinasanta Medical Editor SpineUniverse Desert Hot Springs, CA, USA

Since the original article¹ was published, outpatient treatment for cervical disc disease has become our routine. I would estimate that as high as 95% of our cervical radiculopathies can be treated as an outpatient. We have yet to have a serious complication.

We believe that treatment of cervical radiculopathy by the posterior approach is much superior to the anterior discectomy and fusion technique in most cases. Reasons for this include the fact that a laminectomy does not create temporary instability and therefore a cervical collar or brace is not necessary. In other words, a patient can drive a car a few days postoperative. A scar in front of the throat is avoided. We have found that a fusion results in extra wear and tear on the joints above and below the fusion resulting in the need for additional surgery years later. Also, the cost of a cervical fusion is usually double that of a laminectomy. In cases of the rarely indicated multiple level procedure utilizing screws and plates, the cost can be as much as four times that of a single-level microlaminectomy. We have found that with the exception of cases involving fractures, tumors or spinal cord compressions, just about all of the cases treated with the fusion technique can be treated with a microlaminectomy technique. Endoscopic techniques for treating cervical disc disease posteriorly are being developed but the incisions employed are not much smaller than our incisions and the fact that all of our patients are dismissed home within six hours postoperative, attests to the lack of significant postoperative discomfort. The endoscopic technique markedly increases the cost of treatment.

Warren D. Parker, M.D., F.A.C.S.

You are fortunate to be living in a period of time when the concepts of traditional spine surgery are dramatically changing. Improvements in anesthesia and technological advancements in surgical techniques and equipment continue to reveal efficient new ways to perform spine surgery safely.

Minimally invasive spine procedures (e.g. microdiscectomy) are making it possible for patients to go home the day of or the day after surgery. These specialized procedures use tiny surgical instruments and small incisions, which affords patients speedier recoveries, fewer complications and less scarring.

The purpose of this article is to introduce you to the study results from an outpatient surgical procedure used to treat Cervical Radiculopathy. However, before proceeding, you need to know what cervical radiculopathy means.

What is Cervical Radiculopathy?

Cervical radiculopathy means a spinal nerve root in the neck is irritated and/or compressed. The spinal nerve roots are located in the spinal canal and the neuroforamen. The neuroforamen are small holes through which the spinal nerves exit the spinal column. Outside the spine these nerves branch off into other parts of the body forming the peripheral (outer) nervous system.

vertebral body, labeled structures, color drawing

Nerve irritation may result from disc herniation, spinal stenosis, osteophyte formation or other degenerative disorders. Nerve irritation may cause sensory and/or motor abnormalities called neurologic deficit. Pain, tingling and numbness are examples of a sensory abnormality. Weakness and reflex loss are examples of a motor abnormality. Cervical radiculopathy may cause symptoms to appear in the neck, shoulders, arms, hands and fingers.

Cervical Nerves (Yellow)

Diagnosis and Non-Surgical Treatment

An MRI or myelography and CT Scan may follow a physical examination and neurological evaluation. These tests help the spine specialist determine where the radiculopathy is located and if the patient’s symptoms correlate to the image studies.

Depending on the cause of the cervical radiculopathy, the spine specialist may first recommend non-surgical treatment. This treatment may include medication and physical therapy. Of course, not all patients are alike and some patients may require surgery.

Outpatient Surgery Study

The study involved 502 patients with cervical radiculopathy. Two hundred of these patients opted for outpatient spine surgery. The ‘outpatient’ operations were performed using general anesthesia, a posterior approach, limited tissue dissection and laminoforaminotomy at each affected level of the spine. A laminoforaminotomy is a procedure where the lamina (bony area covering posterior access to the neuroforamen) is removed, which gives the surgeon access to the affected nerve roots. During this procedure, the nerve roots are decompressed (freed from impingement).

Following surgery, each patient was observed for several hours and discharged when able to meet physical criteria such as walking without assistance. No patient required hospital admission in the post-operative period. Out of the 200 patients, 183 patients followed-up for an average of 19 months.

Evaluation Criteria

The outcome of each patient was determined by reviewing complications, functional outcome, recurrence of radiculopathy (symptoms) and time between surgery and return to work.

The functional outcome of each patient in this study was evaluated using the following criteria¹:

Outcome	Criteria
Excellent	Normal working capability in previous or comparable activity; no, or only occasional, mild residual pain
Good	Normal (full) working capability in previous or comparable activity; mild residual pain
Satisfactory	Reduced working capability; but ability to work in less heavy activity; radicular pain improved
Moderate	Incapable of work; radicular pain improved
Poor	Incapable of work; pain unchanged or worse

Outcome Results

The following patient outcome results include Worker’s Compensation (WC) claims involved and those not involved.

Outcome	% Of Patients	WC Case Claims
Excellent/Good	92.8%	WC not involved
Excellent/Good	77.8%	W/C involved
Poor	3.8%	N/A

Comparing the outcome between outpatient surgical treatment of cervical radiculopathy and inpatient surgical care (hospitalization), the outcomes are similar. The study shows outpatient surgical treatment is safe in selected patients. In fact, there were no infections or significant complications after outpatient surgery.

Conclusion

Although all patients with cervical radiculopathy are not candidates for outpatient surgery, the study results are very encouraging. The absence of post-operative infection and complications combined with successful long-term outcomes shed a bright light on the future of these procedures.

Reference:

1. Tomaras CR, Blacklock JB, Parker WD, Harper RL: Outpatient surgical treatment of cervical radiculopathy. J Neurosurgery 87:41-43, 1997

Reversal of Anterior Cervical Fusion by Placement of an Artificial Disc Prosthesis
Spinal Stenosis: Neck and Back Nerve Compression
Cervical Spine Surgical Outcomes: Analysis of Return-to-Work Data
Spinal Traction
Anterior Cervical Discectomy
Facet Neurotomy

Article written 10/04/2001
Published online 10/04/2001
Last updated 08/06/2007

Dr. Parker should be congratulated on his demonstration of the excellent results that can be achieved utilizing a laminoforaminotomy to treat cervical radiculopathy. Caution and balance is necessary when speaking about this type of treatment. In our experience this procedure is superb for radiculopathy due to soft disc herniations causing arm pain with little neck pain complaints (pure radiculopathy). In patients with spondylotic (compression caused by spurs due to degeneration) an anterior cervical discectomy and fusion is a superior operation (>90% good/excellent results). The anterior procedure can be performed with a plate, thus obviating the need for a hard cervical collar. The functional outcome at one, three and six weeks is the same as those with a posterior procedure. In fact, the neck is much less painful than after a muscle splitting posterior procedure. With regard to wear and tear on adjacent segments, the true rate of junctional degeneration after one or two level anterior cervical discectomy and fusion is similar to that seen after the posterior laminoforaminotomy procedure and likely represents natural degeneration that would have occurred with or without a procedure on the spine. Patients and physicians must be careful not to become so wedded to one procedure that they become unable to match the correct procedure to the patient’s pathology. For soft disc herniations and pure radiculopathy, posterior laminoforaminotomy is a superior operation in the absence of any underlying instability. Again, I congratulate Dr. Parker and his colleague on their results.

Todd Albert, MD

Dr. Parker has written a thoughtful and coherent article advocating the posterior approach to cervical radiculopathy. There are many factors that influence a surgeon's decision to choose an anterior or posterior approach to cervical radiculopathy secondary to degenerative disc disease. These include an individual's training, familiarity with each technique, previous favorable or unfavorable experiences with a particular operation, a concept of pathological mechanisms, and knowledge of the existing literature. Posterior cervical laminoforaminotomy for radiculopathy has been well proven to produce similarly good outcomes as compared to anterior cervical discectomy with or without fusion. At C2-C3 and at C7-T1 it may be the procedure of choice. Laminoforaminotomy also eliminates plate and graft complications because a fusion is not performed, as Dr. Parker points out. This procedure has been championed by Fager et. al. Some surgeons, including myself, have several concerns about the posterior approach for treating all patients with cervical radiculopathy. We suspect that there is a higher incidence of nerve root trauma secondary to manipulation of the nerve while removing the fragment. This is more common at the C4-C5 level, as the C5 nerve root seems to be most sensitive to even minor manipulations. Second, depending on the eccentricity of the disc fragment or osteophyte the posterior procedure may not directly address the area of pathology with only indirect decompression of the nerve. Third, there is a well-published, known higher incidence of recurrence of radiculopathy with the posterior approach compared anterior. Lastly, there is more postoperative pain with the posterior technique compared with anterior discectomy and fusion. Perhaps, newer muscle splitting techniques with microscopic equipment such as the METRx™ system (Medtronic Sofamor Danek, Memphis, TN) will likely diminish or eliminate the post-operative pain issue. I favor anterior cervical discectomy and fusion over posterior laminoforaminotomy in most cases for the above reasons. In certain select patients with lateral soft disc herniations the posterior technique is certainly a viable option.

Mark R. McLaughlin, MD

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