Laminoforaminotomy

Cervical disc disease is a collection of medical conditions that impact the spinal cord and roots, frequently seen in individuals during their third and fourth decades of life.

Although non-surgical methods are preferred, surgical intervention is only utilized in specific instances. The type of surgical procedure chosen depends on the individual patient’s cervical anatomy, the location of the herniated disc, and whether osteophyte formation is present. ‘

At present, there are two primary methods available: anterior and posterior. The posterior approach for cervical disc herniation has become comparatively less utilized since the implementation of the anterior approach.

Despite the fact that each approach has its own set of pros and cons, both can yield positive outcomes when utilized appropriately. For the management of cervical foraminal stenosis and soft disc herniation situated in lateral positions, posterior cervical laminoforaminotomy is a successful surgical intervention for alleviating radicular pain.

Compared to anterior methods, posterior approaches utilizing keyhole laminoforaminotomy offer superior visibility of the nerve root, disc, and osteophytes. In a majority of patients experiencing pain, foraminotomy delivers good or excellent outcomes. Optimal outcomes are achieved in scenarios where there is a single level disc disease and a soft disc herniation located laterally.

The posterior approach for cervical pathologies utilizing keyhole foraminotomy, or laminoforaminotomy, although it poses less risk during both the intraoperative and postoperative periods for lateral cervical pathologies, is not as frequently employed as the anterior approach.

When it comes to cervical disc herniation and cervical spondylotic myelopathy, anterior surgery and corpectomy come with a number of drawbacks, one of which is the nearly constant need for sturdy bone grafts. Elderly individuals, smokers, and those with diabetes tend to have lower fusion rates, while complications related to grafts and adjacent segment disease are frequently observed.

Therefore, posterior surgery remains a popular option and is applicable in a broad array of surgical cases. A large percentage of cases report favorable clinical outcomes, exceeding 90%, following cervical posterior foraminotomy.

• According to studies in the medical literature, a posterior cervical approach resulted in good to excellent outcomes (85%) among 171 patients who underwent lateral disc surgery and were followed for a period ranging from 5 to 33 years.
• In another published study, pain relief of 96% and recovery of motor deficits of 98% were reported across 736 cases, with no discernible difference between cases of disc herniation and foraminal stenosis.
• An additional study found in the literature involved 89 cases where cervical posterior foraminotomy was performed, and the patients were subsequently monitored for a duration of 8.6 months. According to Odom’s criteria, the results were deemed good or excellent in 95% of cases.
• Literature has reported 162 cases, in which a 95% recovery rate of preoperative symptoms, with postoperative follow-up conducted over a period of 77 months. The study also highlighted that foraminotomy did not heighten the likelihood of kyphosis.

The keyhole foraminotomy and laminoforaminotomy are posterior cervical surgical approaches employed to remove lateral and cervical foraminal disc hernias and spurs.

Surgical procedures such as the unilateral single-level or multi-level approach and the bilateral single or multi-level (fenestration approach) can be carried out. This procedure can be accompanied by laminectomy or laminoplasty. If a patient has unilateral laminoforaminotomy at one or multiple levels, laminectomy is typically performed, but not laminoplasty.

There is still debate on whether to use the anterior or posterior approach for the treatment of cervical disc herniation that is located laterally or in the cervical foramen. A less risky alternative to the anterior approach is provided by keyhole foraminotomy and laminoforaminotomy, as they enable dorsal resection without the instability associated with the former, resulting in lower mortality rates.

The dorsal approach offers the advantage of being able to follow the ascending nerve root appropriately based on the level of resection, while larger facetectomy may lead to instability and necessitate fusion.

A laminoforaminotomy procedure causes less destabilization of the cervical spine compared to anterior discectomy procedures with or without fusion. In certain cases, drilling of the medial aspect of the pedicle can be performed to reduce the amount of retraction needed for the dural sac and root. Prior to surgery and after surgery, patients can undergo cervical spine imaging, which can reveal that kyphosis is not more likely to occur with laminoforaminotomy.

It has been observed that laminoforaminotomy can lead to postoperative lordosis, even in patients with flattened cervical lordosis. Rarely, kyphosis may develop during the 2nd year of postoperative follow-up, and in such cases, the patient may need to undergo subsequent surgery using the anterior approach.

There is a growing trend of using posterior cervical microendoscopic foraminotomy for managing cervical radiculopathy. The endoscopic technique for posterior cervical microendoscopic foraminotomy is gaining popularity for treating cervical radiculopathy, and it offers several advantages over the traditional keyhole approach. These include:

• A smaller incision
• Reduced muscle injury and blood loss
• Decreased postoperative pain
• A shorter hospital stay

Despite the theoretical advantages of the endoscopic technique, there is still no agreement on the optimal approach.

Complications

Literature reports an intraoperative complication rate of 2.2% or higher in patients who have undergone laminoforaminotomy. More frequent muscle dissection and bone removal can be observed in posterior cervical surgery compared to anterior surgery.

Therefore, one may consider posterior surgery to have a disadvantage in the form of axial neck pain. Excessive intraoperative bleeding may occur in obese patients undergoing surgery in the prone position.

Cord and brain ischemia due to hypotension may be observed in patients who undergo surgery in a sitting position. Other potential complications of this surgery include cerebrospinal fluid leakage, epidural bleeding, pneumocephalus, injury to the vertebral artery, as well as cord and root injuries.

Currently, the anterior approach is the favored method for cervical disc herniation surgery. The posterior laminoforaminotomy is a safe and effective surgical technique with low complication rates for spinal and root decompression caused by cervical disc herniation, despite the current preference for the anterior cervical approach.

A particularly suitable application for posterior laminoforaminotomy is for treating foraminal disc herniation and stenosis. This procedure has several benefits, such as

• Excellent visualization of the nerve root
• Minimal removal of the lamina
• Maintaining spinal stability
• Not requiring fusion

The success rate can be improved by selecting appropriate patients, determining the correct levels, making informed decisions for surgery, and using appropriate techniques.