Great. We'll do two more, and then we'll do the question and answers. Next one will be by Tim Adamson. Outpatient unilateral cervical radiculopathy, posterior foraminotomy as a procedure choice. Good afternoon. I apologize in advance. This is not the talk that I brought to present, so it's not as abbreviated as the one that was supposed to be presented. After an hour in the speaker-ready room, I gave up on the last one. Disclosure, spine wave, not applicable to this talk. Let's see. It just clicks through. I'm having troubles again. Focusing just on cervical radiculopathy today and the argument of whether a posterior and anterior approach is going to be adequate to manage that. We know that the anterior approach kind of treats everything, but if we localize just down to radiculopathy, posterior approach can be really, really beneficial. This series is based on the system created by Kevin Foley and Moe Smith 20 years ago. It was modified to cervical treatment within a year after that started. We're focusing on unilateral radiculopathy. It may involve one or two levels. We look for concordant symptoms. I'm sorry, we look for associated neck pain. With the radiculopathy, contraindication would be a bilateral radiculopathy. Any sign of myelopathy or any history of prior foraminotomy that would make it risky to expose through that same approach. Radiographic indications, foraminal spondylotic stenosis, soft disc herniations. Use a lot of CT and myelography sometimes to discriminate those. And I apologize for the speed. I'm trying to get through all these as quick as I can. Contraindications, alignment abnormalities or instability. Spondylotic canal stenosis, central disc herniations, which I think fall back to the disc replacement technology. And then again, frequently unclear until we can get a myelogram. We actually have a pretty good series now of post-artificial disc replacement patients who've developed foraminal spondylotic stenosis related to facet disease. I think Dom and I are up to about 12 or 15 that we've been able to successfully treat with secondary foraminotomy. A quick overview of the technique. It's done in the sitting position, head secured in the Mayfield. Localizing with C-arm. The C-arm is actually draped into the field so you can take shots all the way through. And then there's a series of technical steps of localizing where you are, getting the palpation of the facet step with the first dilator and then introducing the rest of the dilators. Now looking at the current series, and this series is a few years old, but we went after about 1,000 patients. We were able to get in touch with almost 800. And then we got responses back from, I think I'm coming up here, about 500 or 600. Average age was 48 years. It was about half soft disc, half spondylotic disease. Distribution of the levels. I'm sorry, we had 565 responses. Of those in the follow-up query, this was an average of 10 years post-op. Ninety-one percent would have the surgery again. Eighty-seven percent felt that it fulfilled expectations. Eighty-six percent were able to return to their pre-radiculopathy activity level. Ninety-four percent weakness returned to baseline. Numbness returned to baseline at 91 percent. Ninety-two percent back to normal neck discomfort. And one of the key features of this is the ability to return to work very, very quickly. We're not bracing these folks. They have literally a half-inch incision, some muscle soreness. And 75 percent returned to work within three weeks. Eighty-five percent off of prescription drugs in three weeks or less. That's a huge factor in today's climate. Major complications in that first series, 0.4 percent. One Brown-Saccard syndrome, one C8 reflex sympathetic dystrophy, and one wound infection that required a secondary surgery. Minor complications, making up about 3 percent. Dural tears, that was more prevalent early in the series. Twelve minor wound infections treated with oral antibiotics only. And five cases of increased radicular weakness with the symptoms resolving at six months. We look at the complication rate, anterior versus posterior. One of the biggest differences is we don't have to deal with the issues of anterior hematomas, airway issues, swallowing difficulties, dysphagia that persists long-term. All things that really make it unique when approaching from the back. There are the usual infection, pematoma, durotomy issues, root issues. And the questions always raised about air embolism, the way we do them in the sitting position, we're now over 2,000 in our outpatient center with not a single incidence of air embolism. Looking at the course to reoperation in some of these folks, the average time for follow-up operation was about four years or four weeks to nine years. When we look at the same level, we treated 47 of them with ACDF, or about 8.3% of the total series. 5.6% had been treated for soft disc herniations. Their mean recurrence rate was at about 2.8 years, with one occurring within the first few weeks after surgery. That one was actually treated with a repeat posterior foraminotomy. 9.5% of those in the spondylotic foraminal stenosis range ended up having same-level ACDFs with a mean time to reoperation at about three years. The soft disc herniations tended to reoccur earlier, but the recurrence rate was much lower than the spondylotics. Looking at some of the literature on this, our series total was about 8.3%, but we split it into 5.6% for soft disc recurrences versus 9.5% for the spondylotics. Open posterior discectomy, which a series of Clark focused mostly on soft disc herniations, was 5%, so we feel pretty comparable to that. And the total disc replacement series of PICOT was about 4%. ACDF rate is closer to 10%. We look at the adjacent level surgery rate. 19% or 3.4% of the cases required adjacent level surgery. We're able to treat the vast majority of these with a secondary foraminotomy at the new level, and three of that are 0.6% required additional ACDF. Overall, comparing the adjacent level reoperation rates, current series is 3.4%. Clark series is 6.7, 5.2 from Henderson. Those are both open posterior studies. The TDR series of Grasso was 5%. At the very bottom, the ACDF rate is about 25%, as we all know, at 10 years. Small series that Matt McGirt put together for me. Looking at some of the outcomes going forward from our QOD database, we really focused on is there equivalency between the two approaches and what were the differences. As you can see, very similar groups of patients. I'm sorry, jumped ahead there quicker than I wanted. Really no difference in the major or minor morbidities. But one of the things that's interesting to look at is the return to work rate. The posterior foraminotomy, the lion's share of them are returning within the first week, as opposed to two to three weeks with the anterior approach. Overall, looking at cost reduction without an implant required, we're seeing about a $7,700 difference in whether it can be done through a posterior foraminotomy or an anterior discectomy or total disc replacement that requires the implant cost. In conclusion, cervical foraminotomy continues to be a very good option for the treatment of unilateral adiculopathy. It's very effective in the outpatient setting. All of these are done strictly outpatient. It's useful in both soft disc herniations and foraminal spondylotic stenosis. Very low rate of adjacent level breakdown disease or even reoperation at the index level. Complication rate is low. Routinely, it could be changed to always done on an outpatient basis now and a significantly lower cost than an anterior discectomy infusion or total disc replacement. Thank you.

outpatient unilateral cervical radiculopathy posterior foraminotomy

radiculopathy

technique

patient outcomes

complications