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SYMPOSIUM - MINIMALLY INVASIVE SPINE SURGERY
Year : 2020  |  Volume : 3  |  Issue : 1  |  Page : 41-53

Current status of full-endoscopic spine surgery in cervical spine: Anterior and posterior approach


Department of Neurosurgery, Spine Center, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea

Date of Submission05-Feb-2020
Date of Decision05-Feb-2020
Date of Acceptance05-Feb-2020
Date of Web Publication05-Feb-2020

Correspondence Address:
Prof. Jin-Sung Luke Kim
Prof. Jin-Sung Luke Kim, Department of Neurosurgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo Daero, Seocho-gu, 137-701 Seoul.
South Korea
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/isj.isj_23_19

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  Abstract 

The techniques for the treatment of cervical disc herniation and cervical myelopathy have evolved over the last two decades. Anterior cervical decompression and fusion has been considered to be the gold standard technique to date. Recently, it has been shown that full-endoscopic spine surgery with upgraded technology and instrumentation has the capability to decompress the exiting nerve root and thecal sac effectively in the cervical spine. Good clinical outcomes have been reported in the literature with endoscopic procedures. The full-endoscopic spine technique can be an alternative to avoid interbody fusion surgeries. Successful decompression under constant visualization with a small incision and minimal surgical trauma can be achieved. There are two percutaneous endoscopic cervical spine approaches: anterior and posterior. Decision-making depends on anatomical and pathological considerations. Attaining full-endoscopic cervical spine technique requires a steep learning curve, practical training under the experts, and proper selection of patients. The recent developments related to endoscopic equipment with the availability of better optics, three-dimensional monitors, lighting systems, and newer generation endoscopes have made these techniques applicable in complex surgeries as well. The objective of this review was to provide a technical description of full-endoscopic anterior and posterior cervical spine surgeries and their current status in management of various cervical spine pathologies.

Keywords: Anterior, cervical disc herniation, ervical foraminotomy, full-endoscopic technique, minimally invasive spine surgery, PECD, percutaneous endoscopy, posterior


How to cite this article:
Sharma SB, Luke Kim JS, Siddappa ND, Jabri HE. Current status of full-endoscopic spine surgery in cervical spine: Anterior and posterior approach. Indian Spine J 2020;3:41-53

How to cite this URL:
Sharma SB, Luke Kim JS, Siddappa ND, Jabri HE. Current status of full-endoscopic spine surgery in cervical spine: Anterior and posterior approach. Indian Spine J [serial online] 2020 [cited 2020 Jul 6];3:41-53. Available from: http://www.isjonline.com/text.asp?2020/3/1/41/277802




  Introduction Top


The posterior laminoforaminotomy was first reported by Barr[1] in 1934 to treat cervical intervertebral disc herniation (CIVDH) surgically. Till now anterior cervical discectomy and fusion (ACDF), first described by Smith and Robinson[2] and by Cloward[3] in the 1950s, has been the most common surgical procedure proving successful in the treatment of symptoms caused by cervical disc degenerative disease including disc herniations and other compressive pathologies. Since then, further explorations of anterior and posterior surgical approaches led to the evolution of anterior cervical decompression alone or with fusion, anterior foraminotomy using various techniques, posterior microscope-assisted or endoscope-assisted “keyhole foraminotomy,” and cervical disc replacement.[4],[5],[6],[7],[8],[9],[10],[11],[12],[13] Although these techniques generally provide acceptable results, ACDF has remained the gold standard surgical treatment of CIVDH and has generally been described as a safe and effective procedure with good fusion rates.[14],[15],[16],[17],[18],[19] However, it is also associated with complications such as postoperative hematoma, unilateral recurrent laryngeal nerve palsy, cerebrospinal fluid (CSF) leakage, worsening of preexisting symptoms, Horner’s syndrome, implant failure, superficial surgical wound infection, adjacent segment disease, and pseudoarthrosis.[20] Recent advances in technology along with the development of techniques have led to achieving similar clinical outcomes, but with the added benefit of shorter hospital stay, negligible blood loss, minimal tissue injury, early functional outcome, and so on.[20],[21],[22] The difference between full-endoscopic surgery and endoscopic-assisted surgery is shown in [Table 1]. One of these techniques is the popular percutaneous endoscopic spinal surgery. Initially, the procedure was described by Hijikata[23] and Kambin and Sampson,[24] who introduced the concept of percutaneous lumbar nucleotomy, whereas Tajima et al.[25] first described the anterior percutaneous endoscopic cervical discectomy (PECD) in 1989. Full-endoscopic cervical discectomy (FECD) was developed based on the recent advances in endoscopic technique and their successful usage in different fields. Full-endoscopic operations can be divided into two groups: anterior full-endoscopic cervical discectomy (AFECD) and posterior full-endoscopic cervical discectomy (PFECD).[26],[27] The objective of FECD is the decompression of the spinal cord or exiting nerve root under direct visualization through a percutaneous endoscopic approach.[28],[29] The improvisation of the endoscopic instruments has allowed the FECD to increase its usage. FECD is no longer a technique used only for intradiscal decompression (automated nucleotomy and chemonucleolysis). Currently central, paracentral, or foraminal soft disc herniations can be treated by FECD, and devices such as laser and high-speed endoscopic drill allow the surgeons to perform these procedures.[26],[27],[28],[29],[30] Therefore, FECD could become an alternative option to the ACDF, total disc replacement, and posterior microdiscectomy for the treatment of cervical disc herniations. Compared with the aforementioned procedures, FECD offers similar pain relief and advantages such as a clear vision of the surgical pathology, shorter surgical time, faster recovery, and less damage to tissues.[31] This article reviewed the AFECD and PFECD procedures.
Table 1: AOSpine Consensus on nomenclature for working-channel endoscopic spine procedures. (Courtesy by C. Hofstetter and J.S. Kim)

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  Anterior Full-Endoscopic Cervical Discectomy Top


Indications

The following are the indications for AFECD: (a) soft cervical disc herniation shown on computed tomographic (CT) and magnetic resonance imaging (MRI) scan; (b) neck pain and radicular symptoms consistent with radiological findings; and (c) unsuccessful conservative treatment for 6 weeks, no bony spur larger than 2mm, regardless of the herniation size, disc space preserved at least 4mm, and symptoms of the patient concordant with provocative discography.

Disc herniation in the segments C4–C5, C5–C6, and C6–C7 are accessible. Approaching the segments C3–C4 or C7–T1 by this technique is difficult but possible.[25],[29],[31],[32],[33]

Contraindications

The following are the contraindications reported by several authors: evident segmental instabilities or deformities, anterior disc height of 4mm or less, calcified or hard disc herniation, and sequestered disc fragment; cervical myelopathy with severe spondylosis or severe neurological deficit; high-grade migrated disc herniation; ossification of the posterior longitudinal ligament; history of anterior cervical surgery; and other conditions such as neoplasms, fracture, infection, and epidural fibrosis.[28],[29],[31],[32],[34]

Surgical technique

This procedure is performed using a working-channel endoscope with an inbuilt channel for passage of grasping forceps, dissectors, radio-frequency coagulator, and side-firing laser. Also, 0.9% normal saline is employed for continuous irrigation for clear visualization, hemostasis, and neural protection when radio frequency or laser is used. The surgery is performed on an aware patient, in a supine position on a radiolucent operating table and under superficial local anesthesia. The neck is held in a slightly extended position. The index level and the midline are marked under the C-arm using anteroposterior (AP) and lateral views [Figure 1]. A local anesthetic is infiltrated in the skin at the entry point. For paracentral disc herniation, a contralateral approach is recommended, but in the case of central disc herniation, anterior cervical access from the right side is preferred. The pulse of the carotid artery is felt with the left-hand fingers, and the carotid vessels are retracted laterally with the middle finger, whereas the tracheoesophageal complex is mobilized medially with the index finger. Then the tip of the index finger should feel the surface of the vertebral body. After confirming the correct location of the index level under fluoroscopic guidance, a spinal needle is inserted puncturing the skin and then gently through the anterior wall of the cervical disc and advanced 5mm [Figure 2]. An intraoperative discography is performed with a mixture of 0.5-mL contrast medium and indigo carmine dye to differentiate the herniated nucleus tissue during decompression under endoscopic view. A guidewire is introduced through the cannulated needle. Then, a 3-mm skin incision is made. Afterward, a sequential dilatation with dilators measuring 1- and 2-mm is carried out to create the working cannula. Further, a trephine is inserted through the cannula to cut the annulus. Later, the discectomy can be carried out using micro-forceps or laser under direct endoscopic visualization. The laser commonly used is the holmium:yttrium-aluminum-garnet (Ho:YAG), which ablates and shrinks the herniated disc. The laser also helps in enlarging the annular tear/ablating the posterior end plate to release the trapped nuclear fragments behind the posterior longitudinal ligament for subsequent smooth removal of the herniated mass. Decompression ends when no more disc fragments are visualized directly in the posterior longitudinal ligament through the endoscope or when the dural sac is observed.[25],[26],[27],[28],[32],[35][Figure 3] exemplifies the case of a 57-year-old woman with radicular pain in the left arm and hyperesthesia in the left C8 dermatome. The patient was diagnosed with a C7–T1 soft cervical disc herniation, and she underwent AFECD with favorable postoperative outcomes.
Figure 1: Supine position on a radiolucent table and the neck is slightly extended (Courtesy by Sang-Ho Lee, Wooridul Spine Hospital)

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Figure 2: Intraoperative fluoroscopy on lateral view showing the correct placement of spinal needle on anteroposterior (A) and lateral (B) views. Fluoroscopic lateral view (C) for an anterior full-endoscopic cervical discectomy (FECD) approach with grasping of ruptured fragments.

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Figure 3: Preoperative (A and B) and postoperative (C and D) MRI of the cervical spine. (A) T2-weighted sagittal view showing a C7–T1 soft disc herniation. (B) T2-weighted axial image with central and left paracentral disc herniation. (C and D) T2-weighted sagittal and axial images showing complete decompression at C7–T1. Red lines in (A and C) show the C7–T1 level in axial view (B and D)

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Complications

Complications in patients who underwent AFECD have been reported to be very few. However, these complications sometimes can be severe, and usually are access related such as vascular injury, prevertebral hematoma, swallowing dysfunction, esophageal injury, nerve injuries, wound infection, and cervical spinal cord compression.[36] Lee and Lee[31] reported long-term outcomes of 37 patients who underwent AFECD. They found four patients with recurrence and development of progressive kyphosis that was subsequently treated by ACDF procedure. Proper selection of patients suitable for this procedure is essential to avoid postoperative kyphosis and other procedure-related complications. Preservation of the anterior two-thirds of the cervical disc could prevent sagittal balance disorders. Ruetten et al.,[41] in a prospective, randomized, controlled study of 49 patients treated by ACDF and 54 by AFECD, reported transient difficulty for swallowing in 5 cases of ACDF and 2 cases of AFECD. The revision rate of ACDF cases was 6.1% compared with 7.4% of AFECD cases. Yang et al.[34] reported an incidence of 2.4% revision rate in 42 patients treated by this technique. The authors reported one patient complained of a temporary postoperative headache, which was attributed to the height of the drip stand (80cm) and the prolonged continuous high intraoperative hydrostatic pressure to address the high levels of epidural venous bleeding. Another patient developed a postoperative hematoma, which was most likely due to the penetration of the longus colli muscle when the working sleeve was set up. In this patient, an ACDF revision was performed to remove the large hematoma, which had compressed the spinal cord. Tzaan[37] reported an incidence of 2% complications in 107 patients treated by the technique. The author reported one patient with postoperative headache and one case of iatrogenic damage of the carotid artery. No immediate serious complications were reported by Oh et al.[38] in their published series. However, 12 of their patients needed revision surgeries for various indications, such as worsened cervical stenosis and collapsed disc height, and 4 presented with recurrences during the follow-up. Nassr et al.,[57] in a retrospective radiographic analysis study of 87 patients after one- or two-level ACDF with anterior plate instrumentation, reported the occurrence of disc height loss because of inadvertent needle puncture of normal disc at the time of marking the disc level. They observed that an incorrect level localization/disc puncture by needle increases threefold risk of disc degeneration of a normal disc. As AFECD is performed by introducing a needle and cannula through the disc space and the endoscope is much larger than the needle, so there can be more chances of disc degeneration and subsequent kyphosis.

Technical comments

A precise and direct approach towards the site of pathology, direct visualization of the herniated mass, and the preservation of anatomical planes of the neck are the highlights of AFECD. Experience must be gained beforehand by performing open anterior cervical approaches and spinal endoscopic procedures in lumbar spine. This technique requires a steep learning curve.[29] The authors recommend an entry point as carefully as possible to the midline for preventing the injury of longus colli muscles and cervical sympathetic chain.[35] A safe zone recommended should be the space between the medially located air column of the airway seen in the AP projection (this represents the trachea along with the underlying esophagus) and the carotid pulse on the lateral side.[29] Also, strict intraoperative fluoroscopic control during placement of the guidewire, dilators, and working cannula inside the disc avoid further catastrophic complications (direct damage of spinal cord). Therefore, the working cannula should be located in the midline on AP projection and should not advance beyond the posterior vertebral line on lateral projection.[35] Concerning the success rate, Ahn et al.[32] reported a success rate of 88.3% in 111 subjects, Tzaan[37] reported 91% in 107 patients, and Oh et al.[38] reported 87% in 101 patients. The two significant factors associated with the excellent long-term outcome are unilateral radiculopathy symptoms and lateral disc herniation.[32]


  Posterior Full-Endoscopic Cervical Discectomy Top


Spurling and Scoville[51] showed the effectiveness of a method to treat cervical foraminal stenosis caused by a lateral disc herniation or osteophytes since 1944, which is the basis for PFECD. The approach consisted of an open laminoforaminotomy to decompress the lateral recess and the intervertebral foramen under the direct visualization of the exiting nerve root.[39],[40] In the case of appropriately selected patients, posterior laminoforaminotomy results in a success rate of 93%–97% of patients.[41],[42] Because this technique avoids an undue extensive subperiosteal stripping of the cervical paraspinal muscles, postoperative neck pain might be minimal or nonexistent.[43] Subsequently, cervical microendoscopic foraminotomy was a successful upgrade of the open procedure, indicating lesser damage to cervical muscles and similar or better visualization than the previous technique.[44],[45] Hur et al.[46] showed a novel decompression technique that approaches the cervical spine posteriorly but through minimally invasive methods using tubular retractor avoiding detachment of posterior musculature for cervical spondylotic myelopathy. Later, Ruetten et al.[47] described the full-endoscopic posterior foraminotomy for cervical disc herniation, and Shen[48] presented a case series using full-endoscopic posterior cervical bilateral decompression technique with a unilateral approach to treating central canal stenosis and myelopathy.

Indications

The following are indications for PFECD: foraminal cervical disc herniations with failure in conservative treatment for at least 6 weeks; foraminal stenosis with unilateral symptoms; lateral craniocaudal sequestered discs; and central canal stenosis with myelopathy.[29],[33],[48]

Contraindications

The following contraindications have been described in the literature: segmental instability, cervical deformity, a medial location of the herniated disc, and extradural lesions mimicking a lateral or foraminal disc herniation.[29],[33]

Surgical technique

The surgical instruments used in this technique differ from those used in AFECD. The endoscope and working cannula are larger in caliber because the decompression and discectomy are not intradiscal [Figure 4]. Endoscopic drill and Kerrison punch are used for performing foraminotomy or laminoforaminotomy [Figure 5]. An endoscope of 6.9-mm outer diameter with a 25° angle and a beveled opening working cannula with an outer diameter of 7.9mm are used. Continuous irrigation of normal saline solution and use of radio-frequency probe help in hemostasis. The surgery is performed under general anesthesia, and some authors prefer local anesthesia with intraoperative fluoroscopy. The patient is positioned prone either on a Mayfield or on a standard soft head rest and the head is stabilized with a tape.
Figure 4: A bigger and longer endoscope is used for a posterior full-endoscopic cervical discectomy (FECD) approach[48]

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Figure 5: Different drilling tips: (A) diamond ball-tipped, (B) side-cutting burr, and (C) unprotected-cutting burr with flexible tip[48]

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The surgical table is tilted in a reverse Trendelenburg position [Figure 6]. To identify the entry point, one should mark the lamina–facet junction under fluoroscopy on the AP view at the suggested level. A 15-cm, 18-gauge needle is introduced at the entry point to check the direction in lateral view. A 9-mm skin incision is made and fascia cut under fluoroscopy in lateral view. An obturator is introduced to feel the inferior border of the upper lamina, the superior edge of the inferior lamina, and the medial border of the facet joint complex. These anatomical landmarks look like a “V” letter; their confluence is called the “V” point [Figure 7].
Figure 6: Reverse Trendelenburg position for posterior full-endoscopic cervical discectomy (FECD)[48]

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Figure 7: Posterior view on a 3D CT scan showing the “V” point (red lines). This area should orientate the surgeon for starting the foraminotomy or laminoforaminotomy[48]

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Consequently, the beveled working cannula is inserted and obturator removed [Figure 8]. At this point, the endoscope can be introduced through the working cannula and the continuous irrigation system started. The soft tissue is cleared off the field by coagulation with the radio frequency wand and removed with endoscopic forceps. Once the osseous structures have been exposed, the lower border of the superior laminae is drilled exposing the attachment of the ligamentum flavum cranially, and the drill is directed laterally toward the facet joint and caudally toward the cervical pedicle, subsequently. Finally, the intersection of the ascending facet with the inferior laminae is drilled. Eventually, the ligamentum flavum and foraminal ligament are cut to expose the exiting nerve root and underlying disc space using a nerve dissector and Kerrison punches. A nerve hook is used to feel the medial wall of the pedicle to avoid excessive violation of the facet joint complex. After exposure of the exiting nerve root, the intervertebral disc can be explored. A herniated disc can be removed through the axilla or shoulder of the exiting nerve root depending on the site of pathology. It is also possible to observe the lateral margin of the spinal cord for an adequate orientation and decompression of the exiting nerve root. After a successful discectomy, the exiting nerve root should feel free when it is palpated with a nerve hook.[29],[33][Figure 9] shows the case of a 24-year-old man with severe neck and left shoulder pain. The patient was diagnosed with a C3–C4 left foraminal cervical disc herniation. Postoperative good outcomes were noted in the patient. [Figure 10],[Figure 11],[Figure 12],[Figure 13][Figure 14] show the case of a 66-year-old male patient who presented with significant cord impingement at C3–C4 and C5–C6 and was managed by unilateral laminotomy and bilateral decompression with posterior full-endoscopic approach. Postoperative good outcome was noted in the patient. [Figure 15],[Figure 16],[Figure 17][Figure 18] show the case of a 47-year-old male patient with high risk with the history of C4–C5 tubular-guided laminoforaminotomy. Later, the patient presented with radiating pain in C6 dermatome managed by full-endoscopic posterior C5–C6 laminoforaminotomy. Good functional outcome was noted in the patient.
Figure 8: Intraoperative fluoroscopic images during posterior full-endoscopic cervical discectomy (FECD). (A) The lamina–facet junction is localized on anteroposterior (AP) view. (B) Skin and fascia incision are made at the index level. (C) Obturator is placed in the “V” point. (D) Sequential dilation through the obturator. (E) The working cannula is located over the “V” point. (F) The working cannula is shown in a correct position on AP view[48]

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Figure 9: Posterior PECD in a 24-year-old man. (A and B) Preoperative MRI of the cervical spine; red arrows show a left-side C3–C4 foraminal disc herniation. (C) Fluoroscopic lateral projection showing an endoscopic nerve hook exploring intervertebral space. Postoperative MRI: (D) T2-weighted sagittal view shows an almost imperceptible postoperative bone defect at C3–C4 (red arrow); (E) the foraminotomy (red arrow) on the left side in the axial view is shown. (F) Postoperative 3D CT scan posterior view showing the bone hole (red arrow) on the left side of C3–C4

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Figure 10: Intraoperative fluoroscopy images showing the cannula placement for C3–C4 level decompression[48]

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Figure 11: Intraoperative fluoroscopy and endoscopic images showing contralateral decompression[48]

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Figure 12: Intraoperative endoscopic images showing contralateral and ipsilateral thecal sac after decompression[48]

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Figure 13: Preoperative MRI of a 66-year-old man showing significant cord impingement at C3–C4 and C5–C6 on both sagittal and axial views[48]

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Figure 14: MRI of the same patient: 24 months postoperative C3–C4 and C5–C6[48]

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Figure 15: Preoperative CT images showing 47-year-old high-risk patient with complaints of radiating pain in C6 dermatome, aggravated since 6 months

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Figure 16: Preoperative and postoperative MRI of 47-year-old male patient showing C5–C6 foraminal stenosis managed by full-endoscopic laminoforaminotomy C5–C6

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Figure 17: Postoperative CT images of the same patient followed by full-endoscopic laminoforaminotomy C5–C6

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Figure 18: Dynamic images of the same patient followed by full-endoscopic laminoforaminotomy C5–C6

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Complications

Complications such as neck pain, injury or irritation of spinal nerves and spinal cord, intraoperative bleeding or postoperative epidural bleeding, dural injury, headache, seizures or postoperative neurological deficit caused by the increased pressure of continuous irrigation system, infections, impaired wound healing, surgical-induced instability, and persistent symptoms could happen.[33],[34],[49]



Wu and Yan[50] reported two cases of approach-related intraoperative total spinal anesthesia during PFECD. Perforation at C6 lamina with the spinal needle during the approach led to leakage of anesthetic drugs through the iatrogenic hole to the subarachnoid space. Ruetten et al.[27] reported an incidence of 3% of complications and a recurrence rate of 3.4% in 89 patients who underwent PFECD. Wan et al.[51] reported 96% good outcome (24 patients), including 22 excellent outcomes and 2 good outcomes according to the Macnab criteria. The only patient with a fair outcome underwent an ACDF at 5 weeks postoperatively. During the follow-up, at three months postoperative, one of their patients experienced increased arm pain after a pain-free period. Cervical MRI and CT examinations showed no recurrent disc herniation. The patient’s symptoms were relieved after he underwent ultrasound-guided selective nerve root block and trigger-point dry needling. No patients needed reoperation because of recurrent disc herniation or symptom deterioration.[51] Yang et al., in a retrospective and comparative study of AFECD and PFECD (42 patients in every group), reported a complication rate of 4.8% (2/42) in patients who underwent PFECD. The authors observed a temporary pain in the contralateral side in one patient by excessive manipulation of the myelin during the procedure and another case for surgical revision after PFECD.[34] In a comparative study of 28 patients observed for lumbar endoscopic discectomy, Joh et al.[52] found eight patients with complaints of neck pain. The authors established that highly increased cervical epidural pressure by continuous saline irrigation was the leading cause of neck pain.[52] Shen[48] reported no intraoperative or postoperative complications in an 18-patient case series.

Technical comments

The disadvantage of full-endoscopic laminectomy/laminotomy techniques described here includes longer operative time because it is a “one-instrument-at-a-time” technique — only one instrument used inside the working channel. So proper patient selection and the understanding of limitations with a steep learning curve are advisable.[33],[48] A concern regarding PFECD is the exploration of the epidural space can cause significant bleeding and difficulty in the visibility through the endoscope. Hence, control of the bleeding from cervical venous plexus should be given priority in this technique. The use of a radio-frequency probe and hemostatic agents can be useful at this step. The beveled working cannula can be used as a protector of the exiting nerve root during the exploration of disc space or the discectomy.[26] Facet joint along with capsule removal should be less than 50% to avoid procedure-induced segmental instability,[14] and radiographic follow-up done in patients with less than 10° cervical lordosis because of the higher risk of progressive segmental kyphosis.[53] The clinical outcomes reported in a study of 32 patients with foraminal disc herniation and unilateral radiculopathy treated by PFECD were excellent (91%) at the final follow-up (mean of 30 ± 7 months). Radiological outcomes showed that cervical curve, segmental angle, and posterior and anterior length were not changed significantly in patients with more or less than 10° of cervical lordosis, concluding that cervical curvature does not worsen after PFECD.[54] Ruetten et al.[55] studied 100 patients and reported that medication for access-related pain was not required in any patient after discharge. After 2 years, 76 patients presented complete relief of their pain, 8 showed occasional pain or clearly reduced pain, and 3 showed no improvement. In another randomized control trial of full-endoscopic posterior PECD versus standard ACDF for soft cervical disc herniations by Ruetten et al.,[27] a total of 175 patients were followed up for 2 years. The authors reported 87.4% of good outcomes, concluding that PFECD is a safe and effective option to conventional surgery in properly selected patients. Concluding the advantages of the PFECD approach, no risks of injury to the anterior structures of the neck, trachea, esophagus, carotid artery, thyroid, recurrent laryngeal nerve, and jugular vein were noted. Because of the minimal retraction of the cervical muscles, the technique is highly precise for this kind of pathology.

Moreover, endoscopic visualization with a light source and a continuous irrigation system is beneficial. However, this procedure has a steep learning curve; orientation through the endoscope, especially for beginner surgeons, could be difficult. The full-endoscopic techniques differ from the microscopic or microendoscopic technique in the way of working with the surgeon’s hands. The endoscopic surgeon works with one hand and guides the endoscope with the other hand. In the other techniques, both hands can be used for surgical instruments (suction and working tools).[33],[55],[56],[57]


  Conclusion Top


Full-endoscopic techniques for cervical discectomy (anterior and posterior) have shown good clinical outcomes with a low rate of complications. These techniques have a steep learning curve and proper training under expert hands is needed. These procedures performed by experienced endoscopic surgeons in appropriately selected patients are feasible and practical. Each approach (anterior and posterior) has to be considered based on the location of the pathology and other indications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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