Cervical microdiscectomy via posterior foraminotomy
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Cervical disc prolapse is a common spinal condition. Cervical spondylosis is present in the majority of general population, with an increasing prevalence with increasing age. The most commonly affected level is C5/6, followed by C6/7 and C4/5. The degenerative changes result in loss of disc height, bulging discs, and osteophyte formation from the uncovertebral joints and facet joints. It is often asymptomatic but can present with neck pain. If the degenerative changes start to press on the nerves, this can cause brachalgia which is radicular nerve pain radiating into the upper limbs.
Cervical disc prolapse, or herniation, is more common in the presence of cervical spondylosis although it is not as common as a lumbar disc prolapse. The exact incidence is poorly described in the literature but the incidence of cervical radiculopathy is around 60-100 per 100,000 and around 22% of patients presenting with a cervical radiculopathy have a disc prolapse (Radhakrishnan et al, 1994). The highest prevalence is in the 5th decade of life and may be related to activities and occupations that increase forces through the neck. In the cervical spine, disc prolapses are often located in the paracentral area which compresses the nerve root passing into the foramen.
Patients usually present with neck pain and brachalgia, which follows the dermatomal pattern associated with the compressed nerve. The pain can be severe and may be associated with weakness and loss of function. This is particularly relevant for activities of daily living and work-related activities where hand function is very important.
The vast majority of disc prolapses do resolve spontaneously over time and this can generally take between 3 and 12 months. As such, most patients will be able to follow a non-operative course of treatment using analgesia and activity modification. Steroid injections around the nerve may help with pain relief during this time.
For those patients who cannot tolerate the pain despite non-operative measures or those who have a progressive neurological deficit, surgery may be beneficial. Surgery in the cervical spine can be performed via anterior or posterior approaches; anterior approaches involve removing the disc and insertion of an implant, which has cost implications and risks of adjacent level disease in the future. Surgeons have previously performed anterior discectomies without cage or graft insertion but this reduces the disc height significantly and may increase the foraminal stenosis posteriorly; it may also theoretically increase load through the facet joints and increase neck pain in the longer term (although there are no high quality published studies assessing this). Posterior surgery may not require instrumentation but the surgeon needs to be aware that the spinal cord cannot be retracted and it is, therefore, essential that posterior approaches are only used where the compressive lesion can be accessed safely without injuring the spinal cord or nerve roots.
This case describes a lady with a C7/T1 disc prolapse compressing the C8 nerve root, which did not improve with non-operative measures.
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Author: Mr Stephen Morris FRCS(Tr & Orth)
Institution: Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
Clinicians should seek clarification on whether any implant demonstrated is licensed for use in their own country.