Medical Device Daily Contributing Writer

Clinicians at Hahnemann University Hospital (Philadelphia) recently hosted an interactive panel discussion and demonstration of minimally invasive (MIS) techniques to treat chronic neck pain. These techniques included physical therapy, pain management and a surgical option — laminoforaminotomy.

Panel members included television news reporter Karen Friedman as moderator. She was joined by Francis Kralick, DO, director of the Spine Center, who presented a laminoforaminotomy procedure he had performed at the hospital; Wes Prokop, MD, anesthesiologist and pain management specialist; and Kevin Gard, physical therapist.

Symptoms of pressure and irritation on cervical nerve roots can include neck pain, muscle weakness and numbness and tingling in the arms or legs. The patient may experience difficulty walking or loss of sensation in his fingers, with an MRI used to identify the compression of soft tissue structures.

Laminoforaminotomy is a posterior procedure offering patients with a laterally placed herniated disc, or osteophytes, a quicker post-operative recovery time than those undergoing the anterior procedure, known as anterior cervical discectomy and fusion.

“We generally begin an individual’s treatment regimen starting with the least invasive option,” Kralick said, “a combination of ample rest and reduction of physical activity. Non-prescription pain medication and physical therapy may be all a patient experiencing chronic neck pain needs to completely relieve their discomfort.”

According to Kralick, surgical intervention is always the last option recommended for patients suffering chronic neck pain.

Friedman opened the panel discussion: “Tonight we are looking at treatments for debilitating neck pain. Because of this pain, millions of people in this country are restricted from driving, gardening and even playing with their grandchildren. Tonight we will show this hospital’s multidisciplinary approach for those suffering cervical spine-related pain.”

Friedman then introduced Kralick, Gard and Prokoff, with Kralick opening the discussion: “The laminoforaminotomy relieves pressure from nerve roots by decompression — removal of overlying bone. Pressure on the root is what causes chronic neck pain and this decompression relieves the pressure. The cervical disk is not removed so the patient doesn’t need a cervical fusion.” He said that cervical spine disease can have a number of causes, including arthritis, genetics and occupational stresses. “It is essentially related to the wear and tear of the body that comes with age.”

A question from the Internet audience: “What do you look for to diagnose this problem?” Gard said that usually physical therapy reveals “impairments, weakness or loss of motion.”

“Does physical therapy prevent surgery?” the viewer asked.

“Sometimes this is true with physical therapy,” Gard said, “and for sure we can help the patient be better conditioned if he does have to have surgery.”

Prokoff explained the role of pain management: “If physical therapy doesn’t relieve the chronic neck pain the neurosurgeon may refer the patient to us for alleviation of the pain with medication or very simple interventional procedures. Pain treatment options include medications introduced by injections into the painful area.

“These are cervical epidural steroid injections. We place a needle into the epidural space around the nerve roots and inject the steroid. This decreases inflammation in the area. If these procedures are not effective, the patient returns to the neurosurgeon for surgery.”

Showing the video of a laminoforaminotomy, Kralick said, “Here we are in the operating room. The patient is under general anesthetic and is positioned face down. We’ve made a small incision up and down the back of neck — approximately one to two cm long, or about an inch. We’ve exposed the tissue down to vertebral bodies of the spine that overly the exiting nerve root. Now we’ll decrease the compression on the nerve root by removing tiny pieces of overlying bone.”

Kralick continued: “Now you can see a bone-cutting instrument we use to make a window in the bone where the nerve exits the spine. This relieves compression on the nerve. Bone wax is used to control the bleeding from the cut bone. This window will stay open.”

He said that an “angled instrument” is the used to feel the nerve where it moves through this window. “We can determine the free space and thus the degree of compression. A high-speed drill may also be used to shave down the bone.

“Now you can see the bones of neck and our circular bone opening,” he continued. “This procedure takes about 30 to 45 minutes to complete in the OR. We are very close to the spinal cord and moving the nerves can cause complications. We don’t drill too deeply. This is sort of like removing the eggshell and leaving the egg intact. You are seeing a magnified view through the surgical microscope.”

Another question from the audience: “What if you are fearful of the anesthesia and surgery?”

Prokoff answered, “That’s why we take a team approach. The patient will talk to all three of us so he has time to have all his questions answered and his fears allayed.”

Kralick concluded the video presentation, calling the video “very typical of most laminoforaminotomies. We’ve smoothed the rough edges of the bone, leaving no sharp edges to impinge on the nerve root. A patient’s morphology and anatomy is always different though. Older anatomy can be more complicated.”

He noted that the patient is in the recovery room for about an hour and that full recovery is a relatively long-term process.

“Sensory loss and muscle weakness takes months to resolve, but pain should be dramatically different due to the release of pressure. Our patients usually see immediate resolution of their chronic pain,” he said. “They will have post-op pain from the incision and will have a stiff neck for a few days. They go home that day. There’s no need for a cervical collar or X-rays or CAT scans. We tell them to take it easy for a week or two weeks until they are healed from the surgical injury.”

Kralick said that after a laminoforaminotomy 85% to 90% of patients will get “very good” relief, with some requiring post-op physical therapy for strengthening of their muscles.

The panel agreed that a future stage will include the use of artificial disks for cervical spine disease.

“They are now being used in the lumbar spine with modest results,” Kralick noted. “The artificial disk could allow the patient to retain mobility, avoid fusion and even more important the disk could decrease the stress on the adjacent levels in the spinal cord.”