Posterior Percutaneous Endoscopic Cervical Foraminotomy and Diskectomy: Case Presentation and Surgical Technique

48 Posterior Percutaneous Endoscopic Cervical Foraminotomy and Diskectomy: Case Presentation and Surgical Technique

Chi Heon Kim and Chun Kee Chung

48.1 Case Presentation

The patient, a 41-year-old female, presented with the chief complaints of right arm pain and triceps weakness (onset was 6 months earlier). Several epidural injections had been performed, but her pain was not relieved. The intensity of pain was 10/10 on neck/arm, and the neck disability index was 35/50.

Neurological examination revealed right triceps weakness (manual motor test IV/V) and Spurling’s test was positive. The MRI showed disk protrusion and slight superior migration at the C6–C7 right neural foramen (Fig. 48.1).

Plain-film standing lateral cervical radiographs showed kyphosis at neutral and limited extension (Fig. 48.2).

48.2 Literature Review

• Anterior cervical diskectomy and fusion (ACDF) is currently the standard treatment for cervical disk disease.^1,2 However, there are problems associated with fusion, such as limitation of motion and possible adjacent-segment pathology.^1,2

• Artificial disk replacement was introduced to address issues of ACDF. However, various problems associated with artificial cervical disks, such as heterotopic ossification, mechanical failure, and spontaneous fusion, have been reported.^3,4,5,6

• Motion preservation surgeries may be an alternative depending on patient age and activity level. Traditional posterior foraminotomy and diskectomy could be performed with full endoscopic techniques.^{7,8,9,10,11,12,13}

• If cervical kyphosis is caused by pain, the curvature may be improved with alleviation of neck/arm pain.⁷ Therefore, in this case, posterior percutaneous endoscopic cervical foraminotomy and diskectomy (P-PECD) may be considered.

48.3 Surgical Technique^7,8,9 (Video 48.1)

48.3.1 Position and Anesthesia

• P-PECD is performed under general anesthesia in a prone position with three-point pin fixation devices and a table-mounted holder (Mayfield system, Integra, Plainsboro, NJ) or craniocervical traction with a Gardner-Wells tongs skeletal fixation system (Fig. 48.3).⁷

Fig. 48.1 Preoperative MRI. Left, foraminal view; right, axial view.

Fig. 48.2 Preoperative plain radiographs. Left to right: flexion, neutral, and extension positioning.

Fig. 48.3 Skeletal traction. Skeletal traction is performed to enlarge the interlaminar space.

48.3.2 Skin Incision and Introduction of Endoscope

• The V point is bounded by the inferior margin of the cephalic lamina, the medial junction of the facet joints, and the superior margin of the caudal lamina (Fig. 48.4).^7,8

• After identification of the V point with the fluoroscope, the skin incision is made with a scalpel, and then the obturator, working channel, and endoscope are introduced sequentially (Fig. 48.5).

• The endoscope and working channel are held in one hand, and endoscopic instruments are deployed with the other hand (Fig. 48.6).

Fig. 48.4 (a) The V point in a 3D reconstructed CT scan. (b) Operative view.

48.3.3 Preparation of V Point

• Muscles attached around the V point are cleared out with the forceps and coagulator. The ligamentum flavum (LF), inferior margin of the cranial lamina, superior margin of the caudal lamina, and starting point of the facet joint are visualized (Fig. 48.4b).

48.3.4 Drilling of Lamina and Facet Joint

• The entire operation is performed under visual control and continuous irrigation with normal saline.^7,8,10,11 The opened bevel of the working channel is directed toward the medial side to avoid accidentally compressing the spinal cord.^7,8

• Bone drilling is started from the V point with the endoscopic drill. A side-cutting drill (shaver) covered by a protector can be utilized.

• The extent of bone drilling is dependent on the size and location of the herniated disk material, and it is usually within a 3- to 4-mm radius around the V point.^7,8 The size of bone removal can be assessed with the diameter of the endoscopic instrument.^7,8

• The sequence of drilling is cranial lamina, caudal lamina, and facet joint.

• Thinned inner cortex of lamina is removed with a Kerrison punch.

• Usually, the removal of facet joint is less than 10% of the entire joint for diskectomy (Fig. 48.7).

Fig. 48.5 Introduction of endoscopy. Left to right: skin incision with scalpel, insertion of obturator, and insertion of endoscope after insertion of working channel.

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