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Table of Contents    
COMMENTARY
Year : 2018  |  Volume : 66  |  Issue : 2  |  Page : 452-453

Endoscopic partial cervical corpectomy – Opening a new door to create a wider window


1 Department of Neurosurgery, Wockhardt Hospitals, Mumbai, Maharashtra, India
2 Division of Neurosurgery, Christian Medical College and Hospitals, Vellore, Tamil Nadu, India

Date of Web Publication15-Mar-2018

Correspondence Address:
Dr. Ari G Chacko
Division of Neurosurgery, Christian Medical College and Hospitals, Vellore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.227263

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How to cite this article:
Turel MK, Chacko AG. Endoscopic partial cervical corpectomy – Opening a new door to create a wider window. Neurol India 2018;66:452-3

How to cite this URL:
Turel MK, Chacko AG. Endoscopic partial cervical corpectomy – Opening a new door to create a wider window. Neurol India [serial online] 2018 [cited 2019 Dec 11];66:452-3. Available from: http://www.neurologyindia.com/text.asp?2018/66/2/452/227263




Cervical spondylotic myelopathy (CSM) is globally regarded as the commonest cause of spinal cord dysfunction in adults.[1] The term 'degenerative cervical myelopathy' (DCM) is now being widely used to encompass the entire spectrum of degenerative cervical spinal problems including spondylosis, disc herniation, facet arthropathy, and ligamentous aberrations such as ossification of the posterior longitudinal ligament (OPLL) and hypertrophy of the ligamentum flavum. However, CSM and OPLL might need to be studied separately as they vary with respect to the risk factors, natural history, global prevalence, management strategies and surgical prognosis.

The choice of approach for treating compressive cervical myelopathy continues to be debated. In a large cohort of 757 patients enrolled in 2 prospective multicenter AO Spine studies involving 26 international sites, anterior and posterior decompression for DCM resulted in similar postoperative outcomes and rates of complications.[2] The basic principle of addressing anterior pathology from the front and posterior pathology from behind prevails unless specific cases warrant otherwise. Circumferential procedures may be required to adequately accomplish surgical goals in patients with more complex pathology.

In this issue of Neurology India, Yadav YR, et al., push the edge of the envelope with regard to the surgical management of DCM describing an endoscopic partial cervical corpectomy.[3] They clearly elucidate the steps of surgery with excellent pictorial and video demonstration, where, through a traditional anterior cervical approach they attempt to make a midline trough in the vertebral body. The images show that the trough begins slightly off-centre that the authors say is due to the “natural medial angle of the working channel in the Destandau system”. Further posterior drilling widens the bone removal at the level of the dura to complete the corpectomy. The width of the trough or the amount of bone removed is not mentioned and this is crucial to determining future instability since they do not perform a fusion. It would indeed provide more clarity, particularly for readers wanting to adopt this technique, if the authors had mentioned the diameter and surface of the burrs used as well as the types of endoscopes used (0, 30 or 45 degrees) to facilitate lateral decompression to relieve the roots. Pre- and postoperative magnetic resonance imaging (MRI) scans to determine the extent of cord and nerve root decompression are lacking; however, from their postoperative axial computed tomographic (CT) images, the authors appear to have decompressed the ventral dural tube adequately. In addition, pre- and postoperative radiological assessments of C2-C7 lordosis, cervical sagittal alignment and T1 slope would aid in the understanding of sagittal balance/global spine alignment when they are evaluated in a larger cohort of patients with a longer follow-up who have been subjected to this innovative technique.

The authors compare their minimally invasive endoscopic central corpectomy with the oblique corpectomy described by Bernard George where the initial trough is situated far laterally in the region of the uncovertebral joint and bone removal is close to the posterior aspect of the vertebral body eliminating the need of a fusion procedure.[4] We described our experience with the oblique corpectomy in over 150 patients with degenerative ventral spinal cord compression and found this to be a useful technique with gratifying clinical improvement in over 75% of cases.[5] In addition, it avoids graft related complications associated with the central corpectomy, but is technically demanding, is associated with Horner's syndrome, puts the vertebral artery at risk and hence has not become popular. While this surgery was aimed to be motion preserving, we realised on a long term follow-up that there tends to be reduction in the range of motion which probably results from osteophytosis.[6] However, most patients remain asymptomatic and the incidence of adjacent segment disease is negligible.

Yadav YR, et al., wrongly attribute several complications as being exclusive to the oblique corpectomy that need to be clarified.[3] They say “The disadvantage of the oblique corpectomy are a progressive decrease in the range of movements, though without clinical worsening, difficulty in approaching pathology at the C1-C2 level, the occurrence of Horner's syndrome (5.9%), postoperative C5 radiculopathy (3.3%), dural tear with cerebrospinal fluid leak (0.7%), vertebral artery injury (0.7%), asymptomatic kyphosis (4.3%), and preoperative lordosis progressing to straightening of the spine (25.6%)”. Apart from Horner's syndrome and vertebral artery injury, all the other complications mentioned are equally seen in the central corpectomy and indubitably with their endoscopic minimally invasive technique as well if they were to follow their cases for a longer duration.

Yadav YR, et al., have demonstrated that their cost-effective, minimally invasive method of endoscopic partial cervical corpectomy in this small cohort provides excellent immediate postoperative clinical results,[3] and we congratulate them on their efforts. This technique can take a significant amount of time to master and might be useful in resource challenged environments, eliminating the need for expensive instrumentation and graft related complications. The minimally invasive approach might result in less blood loss, decreased postoperative pain, fewer infections, shorter hospital stay and faster recovery, all of which are advantageous not only for the patient but for the health care system in general.

While the authors mention the Nurick Grade and the Visual Analogue Scale (VAS) as the only objective tools by which they assessed outcomes, it might be prudent to include the modified Japanese Orthopedic Association Scale (mJOAS) to assess the upper limb function and some form of quality of life index. Furthermore, it has been sufficiently established that any form of cervical decompression for myelopathy not only arrests progression but also improves neurological outcomes, functional status and quality of life in patients, regardless of the disease severity. Thus, the addition of any new technique needs to be evaluated in the light of long term clinical and radiological outcomes and compared with the established methods. Of vital importance and interest will be the long term outcomes with regard to stability of the spine, progressive kyphosis and adjacent segment disease in this technique of endoscopic multilevel central corpectomy without spinal fusion.



 
  References Top

1.
Tetreault L, Goldstein CL, Arnold P, Harrop J, Hilibrand A, Nouri A, et al. Degenerative cervical myelopathy: A spectrum of related disorders affecting the aging spine. Neurosurgery 2015;77 Suppl 4:S51-67.  Back to cited text no. 1
    
2.
Kato S, Nouri A, Wu D, Nori S, Tetreault L, Fehlings MG. Comparison of anterior and posterior surgery for degenerative cervical myelopathy: An MRI-based propensity-score-matched analysis using data from the prospective multicenter AOSpine CSM North America and international studies. J Bone Joint Surg Am 2017;99:1013-21.  Back to cited text no. 2
    
3.
Yadav YR, Ratre S, Parihar V, Dubey A, Dubey MN. Endoscopic partial corpectomy using anterior decompression for cervical myelopathy. Neurol India 2018:66:444-51.  Back to cited text no. 3
    
4.
Chibbaro S, Mirone G, Makiese O, George B. Multilevel oblique corpectomy without fusion in managing cervical myelopathy: Long-term outcome and stability evaluation in 268 patients. J Neurosurg Spine 2009;10:458-65.  Back to cited text no. 4
    
5.
Chacko AG, Turel MK, Sarkar S, Prabhu K, Daniel RT. Clinical and radiological outcomes in 153 patients undergoing oblique corpectomy for cervical spondylotic myelopathy. Br J Neurosurg 2014;28:49-55.  Back to cited text no. 5
    
6.
Turel MK, Sarkar S, Prabhu K, Daniel RT, Jacob KS, Chacko AG. Reduction in range of cervical motion on serial long-term follow-up in patients undergoing oblique corpectomy for cervical spondylotic myelopathy. Eur Spine J 2013;22:1509-16.  Back to cited text no. 6
    




 

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