C5 palsy after cervical laminectomy: natural history in a 10-year series

An innovative approach to assess spinal canal expansion following French-door cervical laminoplasty by intraoperative ultrasonography

OBJECTIVE

To investigate the feasibility and effectiveness of applying intraoperative ultrasound (IOUS) to evaluate spinal canal expansion in patients undergoing French-door cervical laminoplasty (FDCL).

MATERIALS AND METHODS

Twenty-five patients who underwent FDCL for multilevel degenerative cervical myelopathy were prospectively recruited. Formulae describing the relationship between laminoplasty opening angle (LOA) and laminoplasty opening size, the increase in sagittal canal diameter and the spinal canal area were deduced with trigonometric functions. The LOA was measured with IOUS imaging during surgery, and other spinal canal parameters were assessed. Actual spinal canal enlargement was verified on postoperative CT images. Linear correlation analysis and Bland‒Altman analysis were used to evaluate correlation and agreement between the intraoperative and postoperative measurements.

RESULTS

The LOA at C5 measured with IOUS was 27.54 ± 3.12°, and it was 27.23 ± 3.02° on postoperative CT imaging. Linear correlation analysis revealed a significant correlation between IOUS and postoperative CT measurements (r = 0.88; p < 0.01). Bland-Altman plots showed good agreement between these two methods, with a mean difference of 0.30°. For other spinal canal expansion parameter measurements, correlation analysis showed a moderate to a high degree of correlation (p < 0.01), and Bland-Altman analysis indicated good agreement.

CONCLUSION

In conclusion, during the French-door cervical laminoplasty procedure, application of IOUS can accurately evaluate spinal canal expansion. This innovative method may be helpful in improving surgical accuracy by enabling the operator to measure and determine canal enlargement during surgery, leading to ideal clinical outcomes and fewer postoperative complications.

CLINICAL RELEVANCE STATEMENT

The use of intraoperative ultrasonography to assess spinal canal expansion following French-door cervical laminoplasty may improve outcomes for patients undergoing this procedure by providing more accurate measurements of spinal canal expansion.

KEY POINTS

• Spinal canal expansion after French-door cervical laminoplasty substantially influences operative prognosis; insufficient or excessive lamina opening may result in unexpected outcomes. • Prediction of spinal canal expansion during surgery was previously impracticable, but based on this study, intraoperative ultrasonography offers an innovative approach and strongly agrees with postoperative CT measurement. • Since this is the first research to offer real-time canal expansion guidance for cervical laminoplasty, it may improve the accuracy of the operation and produce ideal clinical outcomes with fewer postoperative complications.

Treatment of C5 Palsy: An International Survey of Peripheral Nerve Surgeons

STUDY DESIGN

International survey.

OBJECTIVES

C5 palsy (C5P) is a neurological complication affecting 5-10% of patients after cervical decompression surgery. Most cases improve with conservative treatment; however, nearly 20% of patients may be left with residual deficits. Guidelines are lacking on C5P management and timing of surgical intervention. Therefore, we sought to survey peripheral nerve surgeons on their management of C5P.

METHODS

An online survey was distributed centered around a patient with C5P after posterior cervical decompression and fusion. Questions included surgeon demographics, diagnostic modalities, and timing and choice of operation. Responses were summarized and the chi-squared and Kruskal-Wallis H tests were used to examine differences across specialties.

RESULTS

A total of 154 surgeons responded to the survey, of which 59 (38%) indicated that they manage C5P cases. Average time prior to operating was 4.5 ± 2.2 months for complete injuries and 6.6 ± 3.2 months for partial injuries, with neurosurgeons significantly more likely to wait longer periods for complete (P = .01) and partial injuries (P = .03). Foraminotomies were selected by 19% of surgeons, while 92% selected nerve transfers. Transfer of the ulnar nerve to the musculocutaneous nerve was the most common choice (81%), followed by transfer of the radial nerve to the axillary nerve (58%).

CONCLUSION

Consensus exists among peripheral nerve surgeons on the use of nerve transfers for surgical treatment in cases with severe motor weakness failing to improve. Most surgeons advocate for early intervention in complete injuries. Disagreement concerns the type of nerve transfer employed, timing of surgery, and efficacy of foraminotomy.

Optimal timing of referral for nerve transfer surgery for postoperative C5 palsy

OBJECTIVE

Cervical nerve 5 palsy can occur following surgery for cervical spine pathology. The prognosis of C5 palsy is generally favorable, and most patients recover useful function. However, some patients do not recover useful strength. Nerve transfers are a potential effective treatment of postoperative severe C5 palsy. This study aimed to further delineate the natural history of recovery from postoperative C5 palsy, determine whether lack of recovery at specific time points predicts poor recovery prognosis, and thereby determine a reasonable time point for referral to a complex peripheral nerve specialist.

METHODS

The authors conducted a retrospective review of 72 patients who underwent surgery for cervical spondylosis and stenosis complicated by C5 palsy. Medical Research Council (MRC) motor strength grades were recorded preoperatively; immediately postoperatively; at discharge; and at 2 weeks, 3 months, 6 months, and 12 months postoperatively. Univariate and multivariate logistic regression models were used to identify demographic and clinical risk factors associated with recovery of useful strength after severe C5 palsy.

RESULTS

The mean patient age was 62.5 years, and 36.1% of patients were female. Thirty patients (41.7%) experienced severe C5 palsy with less than antigravity strength (MRC grade 2 or less) at discharge. Twenty-one (70%) of these patients recovered useful strength (MRC grade 3 or greater) at 12 months postoperatively, and 9 patients (30%) did not recover useful strength at 12 months. Of those patients with persistent severe C5 palsy at 3 months postoperatively, 50% recovered useful strength at 12 months. Of those patients with persistent severe C5 palsy at 6 months postoperatively, 25% recovered useful strength at 12 months. No patient with MRC grade 0 or 1 strength at 6 months postoperatively recovered useful strength. A history of diabetes was associated with the occurrence of severe C5 palsy. On multivariate analysis, female sex was associated with recovery of useful strength.

CONCLUSIONS

Most patients with severe C5 palsy recover useful strength in their C5 myotome within 12 months of onset. However, at 3 months postoperatively, patients with persistent severe C5 palsy had only a 50% chance of recovering useful strength by 12 months. Lack of recovery of useful strength at 3 months postoperatively is a reasonable time point for referral to a complex peripheral nerve center to establish care and to determine candidacy for nerve transfer surgery if severe C5 palsy persists.

Analysis of the Risk Factors for C5 Nerve Palsy After Cervical Posterior Open-Door Laminoplasty for Patients with Cervical Spondylotic Myelopathy-From the Perspective of Cervical Sagittal Parameters

OBJECTIVE

This study was performed to explore the sagittal radiological parameters related to the occurrence of C5 nerve palsy after cervical posterior open-door laminoplasty for the patients with cervical spondylotic myelopathy.

METHODS

Sixty-two patients who underwent cervical posterior open-door laminoplasty were reviewed retrospectively from March 2017 to March 2022. The C2-7 Cobb angle, C2-7 sagittal vertex axis, thoracic inlet angle, neck tilt, T1 slope, and encroachment ratio of ossification were measured on X-rays. The enrolled patients were divided into C5 nerve palsy and control groups. Logistic regression was performed to analyze the potential risk factors for the occurrence of C5 nerve palsy. The receiver operating characteristic (ROC) curve and the area under the ROC curve (AUC) were used to evaluate the significance of the results and the optimal diagnostic value.

RESULTS

The results of logistic regression showed that only the T1 slope and encroachment ratio were variables that were responsible for C5 nerve palsy (P = 0.024; P = 0.04). The ROC curve analysis for the T1 slope showed that the cutoff value was 21.3° and the AUC was 0.796. The ROC curve analysis for the encroachment ratio revealed that the cutoff value was 0.21 and the AUC was 0.763. Both analyses demonstrated good diagnostic value for C5 nerve palsy.

CONCLUSIONS

The preoperative T1 slope and encroachment ratio were variables that were risk factors for C5 nerve palsy in patients who underwent cervical posterior open-door laminoplasty.

Traumatic Cervical Facet Fractures and Dislocations

»

Flexion-distraction, axial loading, and rotational forces can cause various degrees of osseoligamentous disruption of the cervical spine, leading to traumatic cervical facet fractures and dislocations.

»

Low-energy forces lead to minimally displaced facet fractures that often can be treated with immobilization only. High-energy forces are more likely to cause unstable injuries with or without neurologic compromise, which may require surgical intervention.

»

The initial treatment of cervical facet injuries requires patient evaluation and management through the Advanced Trauma Life Support (ATLS) protocols, while definitive management varies based on the biomechanical components of the injury, the neurologic status of the patient, and additional patient factors.

»

Cervical facet injuries often require a multidisciplinary approach to optimize long-term functional outcomes and minimize serious complications.