Abstract
Introduction
The surgical management of cervical brachialgia utilizing anterior cervical discectomy (ACD) and posterior cervical foraminotomy (PCF) is a controversial area of spine surgery. Few studies have compared the effectiveness of both interventions. These studies were however flawed by utilization of nonvalidated outcome measures, nonstatistical analysis, and importantly lack of preoperative analysis to ensure both groups were matched. Taking this into account, the authors aimed to compare the effectiveness of both surgical interventions using validated outcome measures. It will be the first study in the literature to be doing this.
Material and Methods
The authors conducted a 5-year retrospective review (2008–2013) of outcome following both the above surgeries and also compared the effectiveness of both techniques. Patients with previous neck surgery, myelopathy, and large central discs were excluded. The main outcome variables measured were Neck Disability Index (NDI), Visual analogue scores (VAS) for neck and arm pain. Wilcoxon signed rank test and student t test were used to test differences.
Results
A total of 150 ACDs and 51 PCFs were performed for brachialgia. Overall, 26 (17.3%) and 13 (25.5%) patients with ACD and PCF were lost to follow-up, respectively. Median follow-up for the ACD and PCF group were 5 months (range, 1–45 months) and 1 month (range, 1–30 months), respectively. There were no differences in the preoperative NDI, VAS neck, and arm scores between the groups (p > 0.05). As expected, both ACD and PCF delivered statistically significant improvement in NDI and VAS neck and arm scores. The degree of improvement of NDI, VAS neck, and VAS arm were similar between both the groups of patients (p > 0.05) with a trend favoring the PCF group. The amount of blood loss and length of operation were comparable between both the groups (p > 0.05). There was a nonsignificant trend that ACD was effective in compression related to disc and PCF being more effective in foraminal pathology. In the ACD group, two (1.3%) patients needed repeat ACD due adjacent segment disease. One (0.7%) needed further decompression via PCF. Four (2.7%) and seven (4.7%) patients with ACD had hoarse voice and dysphagia respectively all of which improved on follow-up. In the PCF group, one (2.0%) patient needed ACD because of the persistent brachialgia.
Conclusion
Our study shows that PCF is an alternative to ACD for treating patients with brachialgia with both modalities being equally effective. There were no differences in postoperative neck pain nor need for further surgery between the two procedures however the risks of hoarse voice, dysphagia, and adjacent segment disease could be avoided with PCF. This is the first study to utilize validated outcome measures to prove the effectiveness of PCF and that it is comparable to ACD. This is a medium-sized, single center, unrandomized, and retrospective study. Nevertheless, it is the authors' belief that this study, interpreted in association with previously published studies, provides strong justification for conducting a large multicenter, randomized controlled trial comparing these two treatment options. The authors are currently setting up a prospective clinical trial to help address this question further.