Preoperative Radiographic Simulation for Partial Uncinate Process Resection during Anterior Cervical Discectomy and Fusion to Achieve Adequate Foraminal Decompression and Prevention of Vertebral Artery Injury

Study Design: Retrospective radiographic study. Purpose: This study aims to demonstrate the proper resection trajectory of a partial posterior uncinate process resection combined with anterior cervical discectomy and fusion (ACDF) and evaluate whether foraminal stenosis or uncinate process degeneration increases the risk of vertebral artery (VA) injury. Overview of Literature: Appropriate resection trajectory that could result in sufficient decompression and avoid vertebral artery injury is yet unknown. Methods: We retrospectively reviewed patients who underwent cervical magnetic resonance imaging and computed tomography angiography for preoperative ACDF evaluation. The segments were classified according to the presence of foraminal stenosis. The height, thickness, anteroposterior length, horizontal distance from the uncinate process to the VA, and vertical distance from the uncinate process baseline to the VA of the uncinate process were measured. The distance between the uncinate anterior margin and the resection trajectory (UAM-to-RT) was measured. Results: There were no VA injuries or root injuries among the 101 patients who underwent ACDF (163 segments, mean age of 56.3 +/- 12.2). Uncinate anteroposterior length was considerably longer in foramens with foraminal stenosis, whereas uncinate process height, thickness, and distance between the uncinate process and VA were not significantly associated with foraminal stenosis. There were no significant differences in radiographic parameters based on uncinate degeneration. The UAM-to-RT distances for adequate decompression were 1.6 +/- 1.4 mm (range, 0-4.8 mm), 3.4 +/- 1.7 mm (range, 0-7.1 mm), 4.0 +/- 1.7 mm (range, 0-9.0 mm), and 4.5 +/- 1.2 mm (range, 2.5-7.5 mm) for C3-C4, C4-C5, C5-C6, and C6-C7, respectively. Conclusions: More than half of the uncinate process in the anteroposterior plane should be removed for adequate neural foramen decompression. Foraminal stenosis or uncinate degeneration did not alter the relative anatomy of the uncinate process and the VA and did not impact VA injury risk.