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Nishimura Percutaneous endoscopic cervical laminectomy

level can also be used safely at the level of the cervical side, because a right-handed surgeon stands on the
spine. Therefore, the use of such endoscopes has patient’s left side for surgery.
[3]
been expanded to the level of the cervical cord, and
surgeons have begun to carry out this procedure in In the interlaminar space between the affected
Japan. This procedure is expected to be adopted more vertebrae, a skin incision of 6 to 8 mm is made 5
widely in the future. Surgeon at the current institution mm outside the midline, with an incision of 6 to 8 mm
hasperformed percutaneous endoscopic cervical made on the fascia. While gently rotating and vertically
laminectomy (PECL) and has obtained good results. piercing the dilator to this incision, either the upper
Here, this surgical technique and treatment outcomes or lower margin of the arcus vertebrae is checked
are reported. by sensing contact with the bone using the tip of the
dilator. At this position, the operating sheath is replaced
METHODS using a dilator. [6,7] A small amount of muscle tissue in
the interlaminar space is retracted using the bipolar
Operative indication coagulator or resected with forceps to expose the face
Indication for the surgery included one vertebral disc of the yellow ligament of the interlaminar space. As this
level of cervical spinal canal stenosis, with the factor yellow ligament acts as a protector when the drill slips,
for stenosis being the thickening of the yellow ligament it should be preserved as much as possible until bone
from the posterior, or stenosis because of protrusion of removal is completed. Bone removal is started from
a cervical disc. This procedure has not been applied either the lower margin of the superior arcus vertebrae
to complicated and/or widely extended canal stenosis or the upper margin of the inferior arcus vertebrae.
and re-operative cases.
Because the purpose of decompression is release from
Preparation the pincer mechanism of the thickened yellow ligament
on the spinal cord, bone removal in the part covering
An angled endoscope (15 and 25 degrees: Karl Storz the thickened yellow ligament region is sufficient. [8]
GmbH, Tuttlingen, Germany) was used, which was
also used to treat lumbar diseases in this department. Although it depends on gender and physique, the
A square endoscopic sheath and a high-speed drill anatomical range of existence of the yellow ligament
(the burr head diameter is 2.5 mm or 3.5 mm, NSK- is usually exposed by removing 5-6 mm of the superior
Nakanishi Japan, Tokyo, Japan) were also used. vertebrae and 3-4 mm of the inferior vertebra. It is
For excision of the yellow ligament, a punch (cutter), normally unnecessary to remove the contralateral arcus
forceps, and curette, or a small bipolar radio-frequency vertebrae. Because the approach is 5 mm away from
electrode system (Elliquence, Baldwin, NY, USA) was the median, it is possible to pull down the operating
used. sheath so that the region under the contralateral arcus
vertebrae can be sufficiently observed. However, in
General anesthesia is recommended because the the event that it cannot be pulled down sufficiently, it is
surgery time and drill usage time are long and a strict necessary to remove the bone in the ventral inner edge
rest is necessary for safe surgery. Combined use of free of the contralateral arcus vertebrae [Figure 1I and J].
run motor evoked potential for transcranial irritation is
also recommended. [4] Leaving the yellow ligament on the approach side,
remove the yellow ligament on the contralateral side
Perfusion pressure is important because the surgery is at first, because if the ligament on the approach side
performed near the cranial epidural space. The optimal is removed first, the dura is exposed and expanded
perfusion pressure is 100 cmH O and the height of free and this is dangerous and also hinders the visual field.
2
drip is kept at 150 cm during the surgery. If the yellow ligament is resected by approximately 5
mm from the median to the contralateral side, the half
Operative procedure spinal cord on the contralateral side is decompressed.
The surgical position is similar to that of a cervical Subsequently, resection of the approach side yellow
laminoplasty. After fixation of the head using a Mayfield ligament is performed. Except for cases in which
clamp, the posture is the Concorde style. The cervical stenosis of the vertebral foramen on the approach side
spine is fixed in the neutral position. The approach is is complicated, the bone removal range and resection
outside-in from the back, similar to the percutaneous range for the yellow ligament on the approach side
endoscopic lumbar discectomy interlaminar approach. are sufficient up to the inside of the facet joint. If it
[5]
The approach side is the side where myelopathy is is difficult to stop bleeding, a head-up position is
dominant, but if there is no difference between the left effective. Surgery is completed after the placement of
and right, it is recommended to approach from the left an indwelling drain, which is considered essential. [9]

70 Mini-invasive Surgery ¦ Volume 1 ¦ June 30, 2017