CERVICAL HEMILAMINECTOMY FOR EXCISION OF A HERNIATED DISC

ROBERT H. WILKINS, M.D. SARAH J. GASKILL, M.D.

INTRODUCTION A cervical disc herniation usually occurs in a posterolateral direction, compressing the ipsilateral exiting nerve root (Fig. 1). The most commonly affected cervical disc is the one between the C-6 and C-7 vertebrae, and this C6-7 disc herniation compresses the C-7 nerve root. The patient with a suspected cervical disc herniation usually presents with pain in the neck that extends into one upper extremity in a radicular fashion. Loss of neurological function appropriate to the affected nerve root may also be present. Such a patient is managed first by rest, analgesics, a muscle relaxant, and/or cervical traction. The usual criteria for proceeding with further diagnostic tests and therapy are: 1) absence of improvement with the measures just mentioned, 2) significant weakness or marked hypesthesia in an important area (e.g., the dominant thumb and index finger), or 3) evidence of myelopathy. PREOPERATIVE CONSIDERATIONS Plain x-ray films of the cervical spine are helpful in assessing the presence and degree of cervical spondylosis and in identifying another cause of neck and arm pain such as a metastatic carcinoma. In our opinion, magnetic resonance imaging is not as sensitive in the identification of a cervical disc herniation as is cervical myelography followed by computed tomography scanning, so we ordinarily obtain the latter studies to verify the clinical diagnosis. The usual posterolateral cervical disc herniation can be exposed either through an anterior approach, which involves removing the intervertebral disc, or through a posterior approach, which involves removing lateral portions of -two adjacent laminae and the medial portion of the facet joint. If a disc herniation has occurred with a direct posterior (central) vector, and is causing myelopathy, the anterior approach is preferred because the surgeon can remove the herniated disc without manipulating

the spinal cord (and possibly increasing the myelopathy). However, for the more common posterolateral disc herniation that is causing a radiculopathy and no myelopathy, we prefer the posterior approach because of its simplicity: it does not involve risk of injury to the anterior structures of the neck, such as the esophagus and the ipsilateral recurrent laryngeal nerve; it does not involve bone grafting or a second surgical incision; and, in our hands, it takes less time than an anterior cervical discectomy and the patient recovers more quickly. The posterior approach to a cervical herniated disc through a partial hemilaminectomy can be performed with the patient in a prone, lateral, or sitting position. We prefer the sitting position because there is less venous congestion, the anatomical alignment of the spine is easy for the surgeon to visualize mentally after the patient is draped, and the blood and irrigation solution run out of the exposure rather than pooling within it. However, when the sitting position is used, we think that Doppler monitoring should be performed for venous air embolism and that an intra-atrial catheter should be placed before the operation is begun, to permit the aspiration of any air that might enter the right atrium through the venous system. In actuality, venous air embolism seldom occurs during operations for cervical disc herniation, although it is common during posterior fossa operations in the sitting position. We may be overly cautious in using the Doppler monitor and the intra-atrial catheter. SURGICAL TECHNIQUE The patient usually arrives in the anesthesia induction room wearing elastic antiembolism stockings which were ordered the previous day as part of the routine preoperative orders. If not, the patients lower extremities are wrapped with elastic wraps to prevent the pooling (and thrombosis) of venous blood in the lower extremities during the operation and in the immediate postoperative period. A restraining strap is placed across the patient to prevent a fall off the oper-

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WILKINS AND GASKILL : CERVICAL HERNIATED DISC EXCISION

1991 The American Association of Neurological Surgeons

Figure 1. Posterolaterally herniated cervical disc compressing a nerve root.

ating table. A catheter is inserted into an upper extremity vein and intravenous fluids are begun. Prophylactic antibiotics are also given. We follow the Malis regimen, giving 1 g of vancomycin intravenously in 250 ml of 5% dextrose in distilled water or in 0.25 N saline over at least one hour and giving 80 mg of tobramycin intramuscularly. In addition, streptomycin is added to the irrigating fluid used during the operation, at a concentration of 50 Lg/ml. An intra-atrial catheter is inserted, usually via the basilic or cephalic vein. When these veins cannot be used successfully, the catheter is inserted via the internal jugular vein. Its position is verified by a portable x-ray film of the chest. A vascular catheter is also placed in the radial artery to permit the direct monitoring of arterial blood pressure. A urinary catheter is usually not inserted because of the relatively short duration of the operation.
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After the induction of anesthesia, the patients eyes are protected by ophthalmic ointment and eyelid tapes or adhesive plastic eyelid covers. A three-point head clamp is applied, and the operating table is adjusted such that the patient comes into a sitting position, with a bolster under the buttocks. Pillows are placed beneath the knees so the hips and knees are each flexed to about 100 to 120 degrees. The patients arms are usually placed in the lap, and the head clamp is fixed to the table with the patients head in straight alignment and flexed somewhat forward. The normal headrest is removed from the table to expose the posterior surface of the neck and upper thorax. Care is taken to prevent direct pressure against any superficial nerve, such as the u1nar nerve at the elbow and the common peroneal nerve at the knee. The posterior surface of the neck is prepared with antiseptic solutions and dried. The spinous processes

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1991 The American Association of Neurological Surgeons

Figure 2. The skin incision (dotted line) used to expose a herniated disc between the C-6 and C-7 vertebrae.

are palpated by the surgeon to aid in planning the incision. The spinous process of the seventh cervical vertebra is ordinarily the most prominent, which can be verified on the lateral x-ray film that was made during the patients diagnostic workup. The line of the proposed incision is marked on the skin (Fig. 2). The operative area is then draped as a sterile field, using, along with the towels and drapes, an adhesive transparent plastic skin covering. Just before the operation is begun, a portable x-ray machine is positioned on the same side of the table as the anesthesiologist, to permit a lateral localization film to be made after the ipsilateral laminae are exposed. The incision is carried through the skin and subcutaneous tissues down to the posterior aspects of the spinous processes. The fascia is divided along the side of the
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spinous processes with cutting cautery, and the ipsilateral paravertebral muscles are stripped away from the spines and laminae by subperiosteal dissection using a periosteal elevator. Adherent muscle strands and tendons are divided with curved Mayo scissors. A Williams or Scoville retractor is then inserted to maintain the exposure of the laminae and the facet joint (Fig. 3A). A metallic marker, such as a No. 4 Penfield dissector, is placed at the facet joint and a lateral x-ray film is made to verify the level. If the marked joint is the correct one, the surgeon proceeds; otherwise the surgeon enlarges the exposure to arrive at the proper facet joint. With a cup curette, soft tissue is removed from the lateral aspects of the appropriate laminae and from the facet joint. The inferior edge of the superior lamina is exposed in this way, and a portion of it is removed

WILKINS AND GASKILL : CERVICAL HERNIATED DISC EXCISION

1991 The American Association of Neurological Surgeons

Figure 3. A, the paravertebral muscles have been stripped away from the laminae and spinous processes of C-6 and C-7 and a selfretaining retractor has been inserted. The area within the dotted keyhole line represents the extent of bone removal. B, a portion

of the inferior edge of the superior lamina is removed with Kerrison rongeurs. C, the medial aspect of the facet joint is drilled away using a diamond burr. D, herniated disc material is removed from under the axilla of the C-7 nerve root.

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with Kerrison rongeurs (Fig. 3B). The superior rim of the inferior lamina is removed laterally in similar fashion. The medial aspect of the facet joint is removed along the exiting nerve root, to expose its posterior surface. This can be done with a small Kerrison rongeur, but if the nerve root is already compressed within the intervertebral foramen it maybe compressed further by the insertion of the footplate of the rongeur. Thus, it is safer to expose the nerve root with a diamond burr (Fig. 3C), using constant irrigation during the drilling to avoid thermal injury to the nerve. The bone is drilled down to a thin remaining shell, which is then removed with a small cup curette. The ligamentum flavum is removed to expose the lateral aspect of the dura mater within the spinal canal and the medial aspect of the nerve root. The epidural veins may be coagulated with bipolar current (with care taken to avoid thermal or electrical injury to the nerve root and spinal cord) or may be compressed temporarily by cottonoid pledgets with radiopaque markers (having attached strings that extend out of the wound as a reminder to the surgeon to remove them before the closure). The disc herniation is usually best approached under the axilla of the nerve root (Fig. 3D). With gentle superomedial retraction by an instrument such as a No. 4 Penfield dissector, the herniated disc material is exposed. If the posterior longitudinal ligament is still intact over the disc protrusion, it should be incised with a No. 11 scalpel blade. The disc herniation is removed with a small pituitary rongeur. Additional disc fragments can sometimes be squeezed into view by pressing forward on the posterior longitudinal ligament with a blunt nerve hook or small dissector. These fragments are then removed as well. The disc space itself is not entered. Before closure, the area anterior to the nerve root and the adjacent dura mater is palpated with a blunt nerve hook or a small dissector to verify that all obtainable disc fragments have been removed and that the nerve root has been decompressed (i.e., is slack). The surgeon must be careful to avoid vigorous or prolonged manipulation of the nerve root, which may injure the

root and result in unnecessary postoperative pain or neurological dysfunction. Occasionally the disc herniation is best approached at the shoulder of the nerve root rather than the axilla; the steps in exposure and removal of the disc fragments are essentially the same. With either route the surgeon must be certain that the protruding material is the disc herniation. At times, the nerve root will be found to be in two parallel parts; the risk is that the surgeon may retract one part and incise the other, thinking it is the disc herniation. We usually cover the exposed dura and nerve root with absorbable gelatin sponge, but this step can be omitted. The muscles are reapproximated to the interspinous ligament or ligaments with interrupted sutures, and the fascia is closed with similar sutures. After closure of the subcutaneous tissues and skin, a sterile dressing is applied and the patients head holder is detached from its support. The operating table is flattened to bring the patient again into a supine position. The head holder is removed from the patients head, and the pin puncture sites are covered with an antibiotic ointment. The anesthetic is reversed. The eye covers are removed. The patient is extubated and sent to the recovery room. The intra-arterial and intravenous catheters and the leg wraps or stockings are removed subsequently, as appropriate. POSTOPERATIVE COURSE After the anesthetic has worn off, the patient may be out of bed as comfort permits. Medication is given as needed to provide adequate pain relief. We ordinarily do not recommend the use of a cervical collar. The patient is encouraged to begin restoring the range of neck movement to normal. An exercise program is initiated to reverse any residual upper extremity weakness. The patient is discharged from the hospital when sufficient comfort has been achieved, usually on about the fifth postoperative day. The skin sutures are removed before discharge. The patient increases activity gradually at home and returns in one month for reevaluation. Ordinarily, the patient is released to return to work at that time.

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