ENDOSCOPIC OVER-THE-TOP POSTERIOR DECOMPRESSION IN CERVICAL MYELOPATHY: CASE REPORTABSTRACT
Cervical endoscopy is one of the most advanced stages in the learning curve for endoscopic techniques in spine surgery, requiring precise control of instruments to avoid severe complications. We report the case of a 53-year-old female patient with bilateral cervicobrachialgia and myelopathy caused by severe central stenosis at C2-C3. After the failure of conservative treatment, an endoscopic posterior over-the-top cervical decompression was performed. The surgery was completed, with significant improvement in pain and neurological function. At six months of follow-up, the patient showed an increase in her mJOA score, indicating improved functionality. This case demonstrates that the endoscopic technique can be effective and safe in treating cervical stenosis with spinal cord compression and myelopathy. However, further studies are needed to confirm its efficacy compared to other surgical approaches. Level of Evidence IV; Case Report.
Keywords:
Endoscopic Surgical Procedure; Spinal Stenosis; Spinal Cord Diseases; Minimally Invasive Surgical Procedures.
RESUMO
A endoscopia cervical é um dos estágios mais avançados da curva de aprendizado em técnicas endoscópicas para cirurgias de coluna, exigindo controle preciso de instrumentos para evitar complicações graves. Relatamos o caso de uma paciente de 53 anos com cervicobraquialgia bilateral e mielopatia causada por estenose central grave em C2-C3. Após falha no tratamento conservador, foi realizada uma descompressão cervical posterior over-the-top endoscópica. A cirurgia foi concluída com sucesso, com melhora significativa da dor e função neurológica. No seguimento de seis meses, a paciente apresentou aumento de sua pontuação na escala mJOA, indicando melhora funcional. Este caso demonstra que a técnica endoscópica pode ser eficaz e segura no tratamento de estenoses cervicais com compressão medular e mielopatia, embora novos estudos sejam necessários para confirmar sua eficácia em comparação com outras abordagens cirúrgicas. Nível de Evidência IV; Relato de Caso.
Descritores:
Procedimentos Cirúrgicos Endoscópicos; Estenose Espinal; Doenças da Medula Espinal; Procedimentos Cirúrgicos Minimamente Invasivos.
RESUMEN
La endoscopia cervical es una de las etapas más avanzadas en la curva de aprendizaje de técnicas endoscópicas para cirugías de columna, que requiere un control preciso de los instrumentos para evitar complicaciones graves. Reportamos el caso de una paciente de 53 años con cervicobraquialgia bilateral y mielopatía causada por una estenosis central grave en C2-C3. Tras el fracaso del tratamiento conservador, se realizó una descompresión cervical posterior endoscópica over-the-top. La cirugía se completó con éxito, con una mejora significativa en el dolor y la función neurológica. A los seis meses de seguimiento, la paciente mostró un aumento en su puntuación mJOA, lo que indica una mejora en la funcionalidad. Este caso demuestra que la técnica endoscópica puede ser eficaz y segura en el tratamiento de la estenosis cervical con compresión medular y mielopatía, aunque se necesitan más estudios para confirmar su eficacia en comparación con otros enfoques quirúrgicos. Nivel de Evidencia IV; Reporte de Caso.
Descriptores:
Procedimientos Quirúrgicos Endoscópicos; Estenosis Espinal; Enfermedades de la Médula Espinal; Procedimientos Quirúrgicos Mínimamente Invasivos.
INTRODUCTION
Cervical endoscopy represents one of the final steps in the learning curve of endoscopic technique in the spinal column. The total and absolute control of the endoscope, working sleeve, instruments, and drill is an indispensable condition for performing the technique safely, avoiding serious neurological and vascular complications1.
The endoscopic technique in the cervical spine can be performed through anterior or posterior access. The previous access allows the treatment of disc hernias in any location, but the perforation of the entire extent of the disc can accelerate the disc degenerative process. The posterior access allows the treatment of lateral disc hernias, with limitations in cases of central hernias2. Yu et al. described a variation of the posterior approach with resection of the supero-medial part of the pedicle to treat central hernias3.
Regarding stenoses, mainly due to the posterior arch component, the posterior approach is more feasible. Despite this, the topic is still little discussed in the literature. Bergamaschi et al.1 described in detail the central decompression and over-the-top cervical in 2023, but some authors discuss its use in cases of myelopathy4.
In this context, we aim to report a case of central stenosis with cervical spinal cord compression and myelopathy treated by the endoscopic technique of central decompression and over-the-top.
CASE REPORT
The patient signed the informed consent form (ICF) and the report was approved by the Ethics Committee (CAAE 70416223.8.0000.5487, opinion number 6.339.106).
Female patient, 53 years old, with a condition of bilateral cervicobrachialgia associated with hand paresthesia for 12 months. It evolved with significant worsening of the pain condition and with loss of strength in the upper limbs, associated with loss of fine motor skills with difficulty in grasping objects. Conservative treatment was carried out with multimodal analgesia, acupuncture, and physiotherapy for more than 8 months, without improvement.
The patient had previously undergone C4-C5 and C5-C6 discectomy and arthrodesis surgery via the anterior approach, associated with posterior cervical decompression and arthrodesis from C3 to C7 three years ago, due to cervical spondylotic myelopathy.
The patient had grade IV muscle strength in shoulder abduction and extension bilaterally, according to the Medical Research Council muscle strength grading scale. It also presented a positive Spurling test and a positive bilateral Hoffmann test.
In the plain radiographs of the cervical spine, the fixation of the anterior arthrodesis C4-C5 and C5-C6 and posterior fixation from C3 to C7 with lateral mass screws were noted (Figures 1a and 1b). Dynamic cervical spine X-rays did not show instability at adjacent levels.
Magnetic resonance imaging (MRI) of the cervical spine showed severe central stenosis at C2-C3 due to hypertrophy of the yellow ligament, medullary compression, and myelomalacia (Figures 1e and 1f). In the computed tomography (CT) scan, no discal calcifications of the yellow ligament were evidenced, however, stenosis and medullary compression were confirmed (Figures 1c and 1d).
The score on the modified Japanese Orthopaedic Association (mJOA) preoperative scale was 10. The intensity of the pain was assessed using the visual analog scale (VAS), being 9/10 in the cervical region and 8/10 in the upper limbs, with a predominance of pain complaints in the left upper limb.
Due to the patient’s neurological deterioration, surgical treatment of central decompression and cervical over-the-top via posterior endoscopic approach was chosen.
The procedure was performed under general anesthesia with intraoperative neurophysiological monitoring (IONM). The confirmation of the C2-C3 level was performed with radioscopy. The access was made on the left side, as it represented the most symptomatic side of the patient (Figure 2a).
Fluoroscopy confirming posterior left access (A); fluoroscopy with decompression of the contralateral lateral recess with Kerrison (B), and final appearance of the surgical incision (C).
The step-by-step of the technique was performed according to the description of the technique by Bergamaschi et al.1. Bone decompression was performed with a cutting and diamond drill. After removal of the entire yellow ligament, satisfactory decompression of the spinal cord was observed, from pedicle to pedicle, bilaterally (Figure 2b). The surgical wound measured 8 mm and was closed with a simple stitch (Figure 2c)
The surgical time was 62 minutes, with no persistent MNIO shocks. The patient remained hospitalized for 24 hours.
Four weeks after the surgery, there was an 80% improvement in the paresthesia of the upper limbs. Cervical VAS went to 3/10 and VAS in the upper limbs to 2/10 (Figure 3).
Evolution of cervical VAS and in the upper limbs in the pre-operative, 4 weeks post-operative, and 6 months post-operative periods.
After six months of follow-up, an improvement in motor function and activities of daily living was observed, with an increase in mJOA to 14 (Figure 4).
RM and TC controls can be seen in Figure 5, with satisfactory decompression of the channel.
DISCUSSION
Cervical endoscopy represents a challenge for the spine surgeon. Serious and irreversible complications can occur with inadvertent manipulation of the spinal cord or injury to the vertebral artery. Nevertheless, the endoscopic technique offers advantages over posterior foraminotomy5 and anterior approach arthrodesis6 in the treatment of disc herniations, such as: less soft tissue injury, less intraoperative bleeding, shorter hospitalization time, and early rehabilitation7.
The endoscopic treatment of cervical disc hernias can be performed via the anterior or posterior approach. In cases of stenosis, where the spinal cord compression is mainly due to the hypertrophy of the yellow ligament, the posterior or postero-lateral approach for decompression is the most effective treatment8.
In the classic open posterior cervical laminectomy surgery, if the ligamentous structures, laminae, and articular processes are completely removed, they can cause iatrogenic instability, possibly requiring arthrodesis9. With this, specific complications of arthrodesis can occur, such as misplacement, displacement, breakage or failure of implants, infection, and pseudoarthrosis10.
The endoscopic technique follows the same principles of preserving at least 50% of the integrity of the facet joint of the micro-foraminotomy9. Zdeblick et al. showed in a mechanical study on cadavers that the removal of 50% or more of the facet joint can cause segmental hypermobility and, consequently, microinstability11. Posterior endoscopic foraminotomy shows good results in cases of disc herniations12 and foraminal stenosis12, regarding pain improvement and the individual’s functional capacity.
Continuous training is recommended to reduce surgical time and the complication rate in endoscopic spine technique. In this way, new indications arise and more complex cases can benefit from this new technique13,14. The endoscopic treatment of cervical stenoses is still little discussed in the literature1. Bergamaschi et al.1 presented a technical note with details of the step-by-step central decompression and endoscopic over-the-top to treat central stenoses. With this, cases with spinal cord compressions or more severe neurological deficits began to be treated using the endoscopic technique1. Our report confirms this possibility, with the use of endoscopy in a patient with previous cervical spine surgery, severe spinal cord compression, and clinical signs of myelopathy, with a favorable outcome of improved pain and neurological function.
CONCLUSION
The posterior cervical decompression over-the-top endoscopic showed satisfactory results in the reported case. However, new studies must be conducted to confirm the effectiveness of the technique and its advantages over other treatment options for cervical central stenosis with myelopathy.
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Study conducted by the Atualli Spine Care Clinic, São Paulo, SP, Brazil.
REFERENCES
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Edited by
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Reviewed by:
Erasmo Zardo
