Chapter 23 Percutaneous Endoscopic Cervical Discectomy and Stabilization

Percutaneous endoscopic cervical discectomy (PECD) is a relatively new surgical method for treating soft cervical disc herniations [1–7]. The goal of the procedure is decompression of the spinal nerve root by percutaneous removal of the herniated mass under local anesthesia. A holmium:yttrium-aluminum-garnet (Ho:YAG) laser is generally used to ablate and shrink the herniated disc [1–7].

The WSH cervical endoscopy set (Karl Storz, Tuttlingen, Germany) consists of a high-resolution endoscope, illumination, and two irrigation channels [7]. The working channel allows passage of a side-firing Ho:YAG laser and microforceps. The excellent visualization via the endoscope permits the surgeon to selectively remove a portion of the herniated nucleus pulposus. After the anular anchorage has been loosened by the side-firing laser, the herniated fragment can be removed easily with the microforceps. With circumferential rotation of the working cannula and the endoscope, the side-firing laser can also ablate the thickened ligamentum flavum, remnant bone fragment, and shoulder osteophyte.

Although PECD is effective and can be an alternative to open anterior cervical discectomy and fusion, it has limitations. For example, it is ineffective in patients with segmental instability or cervical discogenic pain syndromes. However, the specially designed WSH Cervical B-Twin expandable holder (Disc-O-Tech Medical Technologies Ltd., Herzliya, Israel), which is made of titanium, can be used as an interbody spacer to achieve stability without open discectomy and fusion.

The major advantages of PECD and PECD stabilization (PECDS) with the B-Twin spacer are as follows [8–12]:

Minimal insult to anterior anulus, anterior longitudinal ligament, longus colli muscle, and anterior vertebral body

Provision of cervical stability

Prevention of postoperative kyphosis

Avoidance of complications of open surgery

Rapid functional recovery

Excellent cosmetic effect

In cases of failure, this minimally invasive procedure does not preclude further conventional surgical approaches. It also offers numerous other advantages, such as the absence of risk of epidural bleeding and periradicular fibrosis, maintenance of stability of the intervertebral mobile segment, and reduced risk for recurrence after creating an anterior discal window. PECD or PECDS provides an excellent cosmetic effect, and the shorter operation time and hospital stay allow the patient to recover to normal daily activity more rapidly.

Indications and contraindications

The indication for PECD or PECDS (Box 23.1) is a soft cervical disc herniation that shows no response to conservative treatment for 6 weeks.

BOX 23.1 Indications for Percutaneous Endoscopic Cervical Discectomy With and Without Stabilization

Percutaneous Endoscopic Cervical Discectomy

Noncontained disc herniation

Radiculopathy

Percutaneous Endoscopic Cervical Discectomy and Stabilization

Disc herniation with vertical instability

Axial neck pain with or without radiculopathy

Spondylotic radiculopathy

Discogenic neck pain

Contraindications to these procedures are as follows:

Cervical spondylotic myelopathy

Hard disc or sequestrated disc fragment

Definite segmental instability

Advanced spondylosis with disc space narrowing

Central canal stenosis or severe osteophytosis

Neurologic or vascular diseases mimicking herniated disc

Preoperative preparation

The primary patient complaint is cervical radiculopathy or neck pain.

Imaging diagnosis consists of the following modalities and findings:

Magnetic resonance imaging (MRI) findings correspond with the physical findings.

Computed tomography (CT) must depict a soft disc herniation.

Plain films are used to confirm segmental instability and intervertebral space measurement preoperatively.

Discography can be performed during the preoperative or intraoperative period to check for the provocation of pain; the surgeon must note the disc shape, degree of resistance upon media injection, and volume of media injected.

Instrumentation

Equipment

The following instruments and modalities are required in the operating room for PECD/PECDS:

WSH cervical endoscopy set (Karl Storz) (Fig. 23-1)

Side-firing Ho:YAG laser (Fig. 23-2)

WSH cervical B-Twin expandable spacer (Disc-O-Tech Medical Technologies Ltd.) (Fig. 23-3)

Fluoroscope (Fig. 23-4)

Figure 23–1 A set of percutaneous endoscopic cervical discectomy (PECD) instruments. (Karl Storz, Germany)

Figure 23–2 An Ho:YAG laser (VeraPulse PowerSuite, Lumenis, Germany). A main computer body of powersuite (A) and side-firing delivery device (B).

Figure 23–3 (A) The single-use delivery system of the WSH cervical B-Twin expandable holder (Disc-O-Tech Medical Technologies Ltd., Herzliya, Israel). (B) Unexpanded end. (C) Expanded end.

(From Choi WC, Lee SH, Ahn Y, et al. Percutaneous cervical stabilization using the WSH cervical B-Twin. Joint Dis Relat Surg 2005;16:82-87.)

Figure 23–4 Fluoroscopic (A) and endoscopic (B) monitors used during percutaneous endoscopic cervical discectomy.

Anesthesia and Other Medications

To decrease the risk of infection, preoperative antibiotics (usually 1.0 g of cefazolin) should be given the day before operation. Preoperative sedatives are recommended.

Sterile preparation of the anterior neck skin and a shower with iodized antiseptics are usual. PECD must be performed in the operating room under strict asepsis.

A solution of 1% lidocaine is usually used to infiltrate the skin and subcutaneous tissue.

Procedure

Patient Preparation

1. The patient’s written informed consent is obtained.

2. The patient is placed supine on a radiolucent table. The neck is kept slightly extended by keeping a towel roll under the shoulder blades, and the head is stabilized by application of a plaster tape across the forehead that is then secured to the table. Both the patient’s arms are fixed to the table by application of plaster tape after the shoulders have been pulled down for better viewing of the lower cervical spine via the fluoroscope (Fig. 23-5).

3. Anterior cervical skin is aseptically prepared and draped. A C-arm (fluoroscope) is brought in, and with the help of a metallic needle, skin markings are made with a marking pen to indicate the midline and the correct surgical level with anteroposterior and lateral fluoroscopic views. The surgeon marks lesion by counting the cervical vertebrae downward, then up from the bottom. For better visualization of the C6–C7 level, a slight slope of the fluoroscope may be necessary.

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