Akihito Minamide, MD, PhD Department of Orthopaedic Surgery Wakayama Medical University, Wakayama, JAPAN

Transcription

1 SURGICAL TECHNIQUES/DECISION -MAKING IN CERVICAL SPINE SURGERY: Cervico-Thoracic Junction Pathology Radiculopathy Akihito Minamide, MD, PhD Department of Orthopaedic Surgery Wakayama Medical University, Wakayama, JAPAN CSRS 20th Instructional Course, December 2, Manchester Grand Hyatt Hotel, San Diego, CA, USA

2 Factors Affecting the Nerve Roots Anterior: - protruded discs - osteophytes of the uncovertebral region Posterior: - superior articular process - degeneratiive or hyperthrophied ligamentum flavum - periradicular fibrous tissues

3 Anatomic relation between the nerve roots and the discs in the intervertebral foramina Tanaka N, et al. Spine 2000;25(3): A: Shoulder B: Anterior C: Axillary D: No Contact

4 Table 2. The Anatomic Relation Between the Nerve Roots and the Discs in the Intervertebral Foramina Locations of Discs Relative to NR NR Shoulder Anterior Axillary No Contact C5 (n-36) 12 (33%) 24 (67%) - - C6 (n-36) 4 (11%) 6 (17%) 26 (72%) - C7 (n-36) - 4 (11%) 32 (89%) - C8 (n-36) NR = nerve root (22%) 28 (78%)

5 Frequency of cervical radiculopathy High Frequency: C5/6 and C6/7 An epidemiological study of acute prolapsed cervical intervertebral disc: The frequency occurred in 75% in C5/6 and C6/7 levels. Kelsey JL, et al. J Bone Joint Surg [Am] 1984;66: Frequency of the cervical radiculopathy: C6: 26% C7: 61% C8: 8% Murphey F, et al. Clin Neurosurg 1973;20:9 17. At the C7 T1 disc level, the C8 nerve roots did not have contact with the disc at the entrance zone of the intervertebral foramina. The low frequency of C8 radiculopathy may be caused more by the transverse course of the nerve root in the intervertebral foramina and less by overlap with the C7 T1 disc in the intervertebral foramina.

6 Origin of Pain in the Neck or Scapular Regions Pain Preceding Arm or Finger Symptoms Tanaka Y, et al. Spine 2006;31(17):E The neck and scapular regions were divided into 5 subregions: Nape (NA) Superior angle of scapula (SA) Suprascapular (SS) Interscapular (IS) Scapular (SC) regions The pain usually precedes other radicular symptoms such as pain, numbness, and motor weakness in the arm and/or fingers. The initial symptom was neck or scapular pain alone and subsequent symptoms appeared the next day or thereafter.

7 Diagnostic Indices for the Determination of Involved Nerve Root Level Paraesthesia/Sensory Change in Fingers Muscle Weakness Diminished Tendon Reflex C5 None Deltoid Biceps C6 Thumb Biceps Biceps C7 Index/middle Triceps Triceps C8 Little Hand Intrinsic muscles Triceps

8 C8 radiculopathy Drop Finger: intrinsic muscles weakness -The drop finger is caused by C7 or C8 radiculopathy. Hoppenfield S. Prentice Hall, Upper Saddle River, 1976, pp Murphey F, eta al. J Neurosurg 1973;38: Drop Hand Drop Finger Differential Diagnosis Posterior interosseus nerve palsy Cubital tunnel syndrome

9 Case 1 65 y/o Male drop finger on the right side for 6 months Past History: - 55 y/o: ACDF at C5/6-62 y/o: Cervical laminoplasty (C3-7) for myelopathy following to ACDF C7/T1 C7/T1 C8 radiculopathy due to disc herniation at C7/Th1

10 What kind of surgery do you plan? 1. Anterior approach or 2. Posterior approach? Anterior 1. Anterior cervical discectomy and fusion (ACDF) 2. Anterior cervical foraminotomy 3. Cervical artificial disc replacement Posterior 1. Posterior cervical foraminotoy (open, microscope-assisted, endoscope-assisted) 2. Cervical lamino-foraminotoy and posterior fusion

11 Cervical Anterior Fusion There were Advantages: - direct decompression - local stabilization Disadvantages: - Airway obstruction due to swelling or hematoma - Dysphagia, esophageal injury - Hoarseness - Dislocation of implanted bone, Pseudarthrosis - Adjacent intervertebral disorders

12 Minimally Invasive Posterior Cervical Foraminotomy Reports Microscope-assisted 92.8% of patients reported an excellent or good outcome returned to work or comparable duties at a mean of 2.9weeks Parker WD,et al. Neurosunf Endoscope-assisted Excellent or Good results in 97 out of 100 patients Mean return to full activity ; 1.9 weeks Adamson TE, J Neurosurg Fessler RG, et al. Neurosurgery Ruetten S, et al. Minim Invasive Neurosurg 2007.

13 Minimally Invasive Posterior Cervical Foraminotomy There are Advantage Small incision Less soft tissue damages - axial neck pain Preserve neck motion Avoid - to the adjacent disorders according to spinal fusion Disadvantage Learning curve - disorientation Complications - bleeding - nerve root irritation

14 has developed with Microendoscopic Spinal Surgery 1996 MED Foley KT Smith MM 1999 METRx-MED System development 3CCD camera 2005 Optical tools Hi-Vision camera Special Instruments Kerrison's rongeurs Drill SONOPET Curved Kerrison's rongeurs Midas Legend system Curved high-speed drill Ultrasonic Knife SNOPET

15 Progress of Video Image Contribution to the development of microendoscopic spinal surgery disposable endoscope 1CCD camera 3mm endoscope 3CCD camera 4mm endoscope Hi-vision camera

16 Surgical viewpoint and Working area Microscopeassisted Endoscope-assisted

17 Cervical MicroEndoscopic Foraminotomy (CMEF) The patient is turned to the prone position, and is fixed in a Mayfield headholder. The neck position is a neutral or slightly flexion. The tubular retractor is put on the lamina and facet joint. Inter-lamina V

18 Image of decompression area inferior facet superior facet Ultrasonic Knife SONOPET The decompression area of the top and bottom is from pedicle to pedicle. The outside is beyond the Luschka joint.

19 Intervertebral Disc Herniation Take out the disc herniarion while being careful to varix and bleeding.

20 Conclusion The frequency of C8 radiculopathy was low. At the C7 T1 disc level, the C8 nerve roots did not have contact with the disc at the entrance zone of the intervertebral foramina. The neck or scapular pain usually precedes other radicular symptoms such as pain, numbness, and motor weakness in the arm and/or fingers. The drop finger is caused by C7 or C8 radiculopathy. The CMEF is an effective surgery to improve clinical symptoms of cervical radiculopathy. The CMEF would be helpful in choosing a surgical method for patients with cervical radiculopathy.