C5 Palsy After Cervical Spine Surgery: A Multicenter Retrospective Review of 59 Cases

Management of C5 Palsy After Anterior Cervical Decompression Using Oberlin Nerve Transfer: A Case Report

C5 palsy is a potential complication of cervical decompression surgery from which many patients do not recover or partially recover function. We present the case of a 48-year-old patient who developed elbow flexion paralysis after anterior decompression surgery with fusion of the C5-C7 levels. Muscle function was not spontaneously restored until eight months after surgery. In this case, we performed an Oberlin procedure to restore the function of the arm. Muscle strength (5/5) and volume were obtained 13 months after surgery. A reasonable waiting period is required after C5 palsy in case spontaneous recovery occurs. Treatment decision should be based on the patient's symptoms. Nerve transfers have been shown to be effective when performed after six months, especially in Oberlin transfer.

Hirayama's disease associated with cervical deformity and spinal cord compression: a case report from Sweden

BACKGROUND

Hirayama's disease (HD) is most common in young males, and previous studies are predominantly from Asian countries. The cause of HD is unknown but the most common theory about the pathology speculates on forward bending that causes a compression of the dura mater and the anterior horn of the spinal cord against the vertebra during an overstretch flexion that may result in myelopathy. Both anterior and posterior cervical surgical approaches have been shown to be effective in stopping the disease and improving function; however, HD is also reported to be a self-limited disease, and treatment with a cervical collar may be an alternative for these patients.

CASE REPORT

We report HD in a 17-year-old male from Sweden who underwent surgical treatment with a 2 level anterior cervical discectomy and fusion (ACDF) due to neurological progression from HD after conservative treatment.

CONCLUSION

HD is rare and is easily overlooked. Surgical intervention shows promising results for neurological progression, but HD is also reported to be a self-limited disease.

Combining Laminoplasty With Artificial Disc Replacement for the Treatment of Cervical Spondylotic Myelopathy With Congenital Cervical Stenosis

BACKGROUND

Cervical spondylotic myelopathy (CSM) is a very common and devastating spinal disease. Congenital cervical stenosis (CCS) is the most common cause. We aimed to elucidate the security, effectivity, and feasibility of surgery combining laminoplasty with artificial disc replacement (ADR) to treat CSM patients with radiculopathy, especially for preserving the range of motion (ROM) of the cervical spine.

METHOD

Between August 2008 and April 2019, 39 patients with multiple CSM caused by CCS were enrolled in the present study. All patients received laminoplasty first and then ADR. We used a retrospective collection of data for evaluating the functional and radiologic outcomes, especially regarding preservation of ROM.

RESULTS

Each patient underwent at least a 2-year postoperative follow-up. The Japanese Orthopedic Association score showed great improvements at 6 months. The ADR index-level ROM was preserved during follow-up. The subaxial Cobb angle could also be retained in the whole cervical spine, and the spinal canal diameter could be expanded by more than 52.6%. There were no severe complications or side effects, and no patients needed secondary surgery.

CONCLUSIONS

We aimed to treat multiple levels of CSM with adequate decompression without too many intervertebral disc replacements. We were able to expand the spinal canal directly for these patients with CCS and needed only 1- or 2-level ADR to treat them with associated radiculopathy. This combined surgical strategy was secure, effective, and was able to preserve the ROM of the cervical spine.

LEVEL OF EVIDENCE: 4

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.

Posterior division of ipsilateral C7 transfer to C5 for shoulder abduction limitation

Background

Reparation of C5 by proximal selective ipsilateral C7 transfer has been reported for the treatment of neurogenic shoulder abduction limitation as an alternative to the reparation of the suprascapular nerve (SSN) and the axillary nerve (AXN) by distal nerve transfers. However, there is a lack of evidence to support either strategy leading to better outcomes based on long-term follow-up.

Objective

The purpose of the study was to investigate the safety and long-term outcomes of the posterior division of ipsilateral C7 (PDIC7) transfer to C5 in treating neurogenic shoulder abduction limitation.

Methods

A total of 27 cases with limited shoulder abduction caused by C5 injury (24 cases of trauma, 2 cases of neuritis, and 1 case of iatrogenic injury) underwent PDIC7 transfer to the C5 root. A total of 12 cases (11 cases of trauma and 1 case of neuritis) of C5 injury underwent spinal accessory nerve (SAN) transfer to SSN plus the triceps muscular branch of the radial nerve (TMBRN) transfer to AXN. The patients were followed up for at least 12 months for muscle strength and shoulder abduction range of motion (ROM).

Results

In cases that underwent PDIC7 transfer, the average shoulder abduction was 105.9° at the 12-month follow-up. In total, 26 of 27 patients recovered at least M3 (13 reached M4) (Medical Research Council Grading) of the deltoid. In cases that underwent SAN transfer to SSN plus TMBRN to AXN, the average shoulder abduction was 84.6° at the 12-month follow-up. In total, 11 of 12 patients recovered at least M3 (4 reached M4) of the deltoid.

Conclusion

Posterior division of ipsilateral C7 transfer is a one-stage, safe, and effective surgical procedure for patients with neurogenic shoulder abduction limitation.

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.

Postoperative C5 Palsy Following Cervical Laminectomy With Instrumented Fusion Versus Cervical Laminoplasty With Reconstruction: Single Surgeon and National Inpatient Cohort Analyses

STUDY DESIGN

This was a retrospective cohort study.

OBJECTIVE

The objective of this study was to investigate whether cervical laminectomy with instrumented fusion (LF) and cervical laminoplasty with reconstruction (LP) are associated with different rates C5 palsy (C5P) at 1-month follow-up in a single surgeon and nationally representative cohort.

SUMMARY OF BACKGROUND DATA

LF and LP both carry a well-known risk of nerve root injury that most commonly presents as C5P which can reduce patient satisfaction, patient function, and impede patient recovery. The procedure type that is more frequently associated with C5P remains largely unclear.

METHODS

We identified patients undergoing primary LF or LP procedures for the treatment of cervical myelopathy in both a single-surgeon series cohort (2004-2018; Mount Sinai Hospital) and a nationally representative cohort drawn from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database (2006-2017). For the single-surgeon cohort, C5P within 1 month of surgery was recorded. For the NSQIP cohort, peripheral nerve injury (PNI) within 1 month of surgery was recorded and used as a proxy for C5P. Postoperative complications including C5P were compared between cohorts. Multivariable logistic regression was used to evaluate the association between procedure type and postoperative C5P or PNI.

RESULTS

Without adjusting for covariates, LF patients had a higher rate of 1-month C5P in the single-surgeon cohort (8% vs. 0%, P=0.01). An adjusted odds ratio could not be obtained due to the absence of C5P in the LP group. In the national cohort, LP patients had a significantly higher rate of 1-month PNI on unadjusted analysis (11% vs. 16%, P<0.001). After adjusting for covariates, we found no significant difference in odds of 1-month PNI between LF and LP (adjusted odds ratio=0.84, P=0.07).

CONCLUSIONS

Overall, the single-surgeon series suggest that cervical LF is associated with significantly higher rates of postoperative C5P as compared with LP. These findings are not corroborated by nationally representative data, which showed no difference in PNI rates between LF and LP. A surgeon's training and experience likely contribute to which procedure has a higher propensity for a C5P as a complication. Regardless, both LF and LP patients should be closely monitored for new-onset C5P during follow-up visits.

LEVEL OF EVIDENCE

Level III.

Morphology of cervical periradicular fibrous sheath and nerve roots in relation to postoperative C5 palsy

BACKGROUND CONTEXT

C5 palsy is a major complication of cervical spine surgery, however, its exact pathogenesis remains unclear. Some studies have shown that the superficial layer of the posterior longitudinal ligament extends laterally and forms the periradicular fibrous sheath (PFS), and envelopes the nerve roots. However, the anatomical relationship between the PFS and nerve root at each cervical level has not been fully revealed.

PURPOSE

To examine the difference of the PFS that covers the nerve root at each cervical level, and to consider its potential in the onset of postoperative C5 palsy.

STUDY DESIGN

Anatomical study of cervical dissection of 13 embalmed cadavers.

METHODS

Thirteen human formalin-fixed cadavers were dissected from posterior approach, and were observed their cervical nerves bilaterally from C3 to C8 (the total number of nerves was 156). The bare area length (BAL), which is the distance between the medial posterior edge of the PFS and the bifurcation of the nerve and dura mater, was measured by using electronic calipers. Thus, BAL is the uncovered area of the nerve root by the PFS. We examined whether BAL significantly varied at each cervical level.

RESULTS

We confirmed the PFS macro- and/or microanatomically in all cadavers. The average BAL gradually increased craniocaudally, and there was a significant step between that of C5 and C6 level.

CONCLUSION

The average BAL of the C5 root was significantly shorter than that of C6, C7, and C8, suggesting that C5 root was more tightly anchored. This could be one reason for C5 palsy, making C5 nerve root vulnerable to the traction caused by the postoperative spinal cord shift.

CLINICAL SIGNIFICANCE

This study provides clinicians an additional understanding of the anatomical factor of C5 palsy. Consideration of the anchoring effect of the PFS for nerve roots, release of the PFS could be a preventive procedure for C5 palsy.

Insufficient Recovery From C5 Palsy Following Anterior Cervical Decompression and Fusion

STUDY DESIGN

Retrospective study.

OBJECTIVE

To determine the risk factors for insufficient recovery from C5 palsy (C5P) following anterior cervical decompression and fusion (ADF).

SUMMARY OF BACKGROUND DATA

Postoperative C5P is a frequent but unsolved complication following cervical decompression surgery. Although most patients gradually recover, some recover only partially. When we encounter new-onset C5P following ADF, the question that often arises is whether the palsy will sufficiently resolve.

METHODS

We retrospectively reviewed consecutive patients who underwent ADF at our institution. We defined C5P as postoperative deterioration of deltoid muscle strength by two or more grades determined by manual muscle testing (MMT). We evaluated the following demographic data: patient factors, surgical factors, and radiological findings. C5P patients were divided into two groups: sufficient recovery (MMT grade≧4) and insufficient recovery (MMT grade < 4). Each parameter was compared between the two groups.

RESULTS

Of 839 patients initially included in the study, 57 experienced new-onset C5P (6.8%). At the final follow-up (mean, 55 ± 17 months), 41 patients experienced sufficient recovery, whereas 16 (28%) still exhibited insufficient recovery. Compared with the sufficient recovery group, patients with insufficient recovery exhibited a higher decompression combination score, a larger anterior shift in preoperative cervical sagittal balance, less lordosis of the pre- and postoperative C4/C5 segment, more frequent stenosis at the C3/C4 segment, lower deltoid strength at C5P onset, more frequent co-occurrence of biceps weakness, greater postoperative expansion of the dura mater, and more frequent presence of postoperative T2 high-intensity areas. Multivariate analysis revealed that co-occurrence of biceps muscle weakness, less lordosis at the preoperative C4/C5 segment, and postoperative expansion of the dura mater were independent predictors of insufficient recovery.

CONCLUSION

The combination of unfavorable conditions, such as potential spinal cord disorder, cervical malalignment, and excessive expansion of the dura mater after corpectomy, predicts insufficient recovery from C5P.Level of Evidence: 4.

Nerve Transfers After Cervical Spine Surgery: Multi-Institutional Case Series and Review of the Literature

BACKGROUND

Up to 10% of cervical spine surgeries are complicated by postoperative weakness. Although many patients recover with nonoperative management, some require surgery for restoration of function.

OBJECTIVE

To present the indications and outcomes of patients undergoing nerve transfers after developing weakness secondary to cervical spine decompression.

METHODS

A retrospective review of patients from 2 academic medical centers who underwent nerve transfer for C5-6 root injury after cervical spine surgery was performed.

RESULTS

Of the 10 treated patients, 9 experienced recovery at last follow-up, demonstrating improvements in strength and motion in the affected muscles. Successful nerve transfers occurred between 3 and 8 months after the index spinal surgery and included spinal accessory nerve to suprascapular nerve, triceps branch to anterior division of the axillary nerve, and/or ulnar or median fascicles to motor branches of the musculocutaneous nerve. The unsuccessful patient underwent nerve transfer surgery approximately 11 months after the index operation and failed to obtain functional recovery.

CONCLUSIONS

Patients who experience C5-6 weakness after cervical spine surgery should be evaluated and considered for nerve transfer surgery if they have continued severe functional deficits at 6 months postoperatively. Earlier referral for nerve transfer is associated with improved functional outcomes in this cohort.

Timing of referral to peripheral nerve specialists in patients with postoperative C5 palsy

The objective of this study was to examine the association between electrophysiology data post-C5-palsy and referral to peripheral nerve surgeons (PNS) using a 15-year cohort of patients who underwent posterior cervical decompression. Endpoints included the associations of postoperative treatments employed with functional recovery and abnormal electrophysiology data. Of 77 included patients (median 64 yr; 68% male), 48% completely recovered. The most common treatments were physical therapy (90%), occupational therapy (34%), oral corticosteroids (18%), and PNS referral (17%). Baseline weakness did not associate with PNS referral or postoperative treatment strategy. None of the treatments predicted recovery, though patients with no [versus complete] recovery were more likely to be recommended for nerve transfers (22.2 vs 0%; p = 0.03). Abnormal electromyography data associated with PNS referral (p < 0.01), nerve transfer recommendation (p < 0.01), occupational therapy referral, and oral corticosteroid therapy. Abnormal findings on EMG obtained between 6-weeks and 6-months post-injury were the most strongly associated with peripheral nerve surgeon referral (p = 0.02) and nerve transfer recommendation (p < 0.01). These data suggest strategies for postoperative C5 palsy management are highly heterogeneous. None of the treatments employed significantly predicted the extent of functional recovery. However, patients with abnormal electrophysiology results were most likely to receive multimodal treatment, suggesting these results may significantly alter medical management of patients with postoperative C5 palsy. Early (6-week to 6-month) electrophysiology data may help to ensure that patients likely to benefit from nerve transfer procedures are referred to a PNS within the 9-12-month time frame associated with the best recovery of function.

Operative treatment of cervical radiculopathy: anterior cervical decompression and fusion compared with posterior foraminotomy: study protocol for a randomized controlled trial

Background

Cervical radiculopathy is the most common disease in the cervical spine, affecting patients around 50–55 year of age. An operative treatment is common clinical praxis when non-operative treatment fails. The controversy is in the choice of operative treatment, conducting either anterior cervical decompression and fusion or posterior foraminotomy. The study objective is to evaluate short- and long-term outcome of anterior cervical decompression and fusion (ACDF) and posterior foraminotomy (PF)

Methods

A multicenter prospective randomized controlled trial with 1:1 randomization, ACDF vs. PF including 110 patients. The primary aim is to evaluate if PF is non-inferior to ACDF using a non-inferiority design with ACDF as “active control.” The neck disability index (NDI) is the primary outcome measure, and duration of follow-up is 2 years.

Discussion

Due to absence of high level of evidence, the authors believe that a RCT will improve the evidence for using the different surgical treatments for cervical radiculopathy and strengthen current surgical treatment recommendation.

Trial registration

ClinicalTrials.gov NCT04177849. Registered on November 26, 2019

Analysis of risk factors for C5 nerve root paralysis after posterior cervical decompression

BACKGROUND

C5 nerve root paralysis is a nonnegligible complication after posterior cervical spine surgery (PCSS). The cause of its occurrence remains controversial. The purpose of this study was to analyse the incidence of and risk factors for C5 nerve root paralysis after posterior cervical decompression.

METHODS

We retrospectively analysed the clinical data of 640 patients who underwent PCSS in the Department of Orthopaedics, Affiliated Hospital of Qingdao University from September 2013 to September 2019. According to the status of C5 nerve root paralysis after surgery, all patients were divided into paralysis and normal groups. Univariate and multivariate analyses were used to determine the independent risk factors for C5 nerve root paralysis. A receiver operating characteristic (ROC) curve was used to demonstrate the discrimination of all independent risk factors.

RESULTS

Multivariate logistic regression analysis revealed that male sex, preoperative cervical spine curvature, posterior longitudinal ligament ossification, and preoperative C4/5 spinal cord hyperintensity were independent risk factors for paralysis, whereas the width of the intervertebral foramina was an independent protective factor for paralysis. The area under the curve (AUC) values of the T2 signal change at C4-C5, sex, cervical foramina width, curvature and posterior longitudinal ligament ossification were 0.706, 0.633, 0.617, 0.637, and 0.569, respectively.

CONCLUSIONS

Male patients with C4-C5 intervertebral foramina stenosis, preoperative C4-C5 spinal cord T2 high signal, combined with OPLL, and higher preoperative cervical spine curvature are more likely to develop C5 nerve root paralysis after surgery. Among the above five risk factors, T2 hyperintensity change in C4-C5 exhibits the highest correlation with C5 paralysis and strong diagnostic power. It seems necessary to inform patients who have had cervical spine T2 hyperintensity before surgery of C5 nerve root paralysis after surgery, especially those with altered spinal cord T2 signals in the C4-C5 segment.

Cervical laminoplasty with unilateral C4-5 foraminotomy: Technical note and case series

OBJECTIVE

The open-door laminoplasty technique is widely used in the treatment of multilevel cervical myelopathy. Despite the satisfactory functional and radiological results of this technique, postoperative C5 palsy is still a severe and disabling complication with a variable incidence in the literature. The objective of this article is to describe and demonstrate the surgical technique step by step with the addition of unilateral C4-5 foraminotomy and to evaluate the results obtained to date, with special emphasis on C5 palsy.

MATERIAL AND METHODS

Retrospective study of 20 patients operated on for cervical myelopathy using the "extended" laminoplasty technique, which is described step by step.

RESULTS

Between January 2013 and April 2019, 20 patients were operated on using the extended laminoplasty technique. Only one patient (5%) presented postoperative C5 palsy. The postoperative recovery rate of the modified JOA (Japanese Orthopaedic Association) score was 54.5%, similar to that observed in other series.

CONCLUSION

The extended cervical laminoplasty technique with unilateral C4-5 foraminotomy was developed and demonstrated for the prevention of C5 palsy. The results were analysed and an incidence of C5 palsy coinciding with the lowest percentage reported in the literature was obtained. A prospective randomised study would be useful to assess the role of preventive unilateral C4-5 foraminotomy.

Radiographic Measures of Spinal Alignment Are Not Predictive of the Development of C5 Palsy Following Anterior Cervical Discectomy and Fusion Surgery

BACKGROUND

Postoperative C5 palsy is a common complication following cervical decompression, occurring more frequently after posterior-based procedures. It has been theorized that this is the result of C5 nerve stretch resulting from spinal cord drift with these procedures. As such, it is thought to be less common after anterior cervical decompression and fusion (ACDF). However, no consensus has been reached on its true etiology. The purpose of this study is to assess the rate of C5 palsy following ACDF and to determine whether any radiographic or demographic parameters were predictive of its development.

METHODS

Two hundred and twenty-six patients who received ACDF between September 2015 and September 2016 were reviewed, and 122 were included in the final analysis. Patient demographic, surgical, and radiographic data were analyzed, including preoperative and postoperative radiographic and motor examination results. The Mann-Whitney U test was used to compare continuous variables between independent groups, and Fisher's exact test was used to compare categorical variables between groups.

RESULTS

Seven patients developed a C5 palsy in the postoperative period, an incidence rate of 5.7%. Among the radiographic parameters evaluated, there were no statistically significant differences between the C5 palsy and nonpalsy groups. Additionally, there were no statistically significant differences in age, patient sex, or numbers of vertebral levels fused between groups.

CONCLUSIONS

Ultimately, we did not identify any statistically significant demographic or radiographic predictive factors for the development of C5 palsy following ACDF surgery.

LEVEL OF EVIDENCE

3.

Biomechanics of Circumferential Cervical Fixation Using Posterior Facet Cages: A Cadaveric Study

OBJECTIVE

Anterior cervical discectomy and fusion (ACDF) is a common procedure for the treatment of cervical disease. Circumferential procedures are options for multilevel pathology. Potential complications of multilevel anterior procedures are dysphagia and pseudarthrosis, whereas potential complications of posterior surgery include development of cervical kyphosis and postoperative chronic neck pain. The addition of posterior cervical cages (PCCs) to multilevel ACDF is a minimally invasive option to perform circumferential fusion. This study evaluated the biomechanical performance of 3-level circumferential fusion with PCCs as supplemental fixation to anteriorly placed allografts, with and without anterior plate fixation.

METHODS

Nondestructive flexibility tests (1.5 Nm) performed on 6 cervical C2-7 cadaveric specimens intact and after discectomy (C3-6) in 3 instrumented conditions: allograft with anterior plate (G+P), PCC with allograft and plate (PCC+G+P), and PCC with allograft alone (PCC+G). Range of motion (ROM) data were analyzed using 1-way repeated-measures analysis of variance.

RESULTS

All instrumented conditions resulted in significantly reduced ROM at the 3 instrumented levels (C3-6) compared to intact spinal segments in flexion, extension, lateral bending, and axial rotation (p < 0.001). No significant difference in ROM was found between G+P and PCC+G+P conditions or between G+P and PCC+G conditions, indicating similar stability between these conditions in all directions of motion.

CONCLUSION

All instrumented conditions resulted in considerable reduction in ROM. The added reduction in ROM through the addition of PCCs did not reach statistical significance. Circumferential fusion with anterior allograft, without plate and with PCCs, has comparable stability to ACDF with allograft and plate.

Use of electromyography to predict likelihood of recovery following C5 palsy after posterior cervical spine surgery

BACKGROUND

C5 palsy affects approximately 5% to 10% of patients undergoing cervical spine surgery. It has a significant negative impact on patient quality-of-life outcomes and healthcare costs. Although >80% of patients improve, some are left with persistent, debilitating deficits. Our objective was to examine if electrodiagnostic testing could be used to successfully identify patients likely to experience complete, partial, and no recovery.

METHODS

Patients undergoing posterior cervical decompression and fusion at a single institution over a 10-year period were identified. Those experiencing postoperative C5 palsy were included. Outcomes examined included motor recovery of the affected deltoid as a function of time, and changes in electrodiagnostic testing as a function of time since injury. Electrodiagnostic testing included electromyography and was sub-analyzed by time of acquisition postinjury. Deltoid strength was graded on manual motor testing using the 5-point medical research council grading system.

RESULTS

Of 77 patients experiencing C5 palsy, 29 had postoperative electrodiagnostic testing. Patients experiencing complete recovery on average achieved functional (4/5) strength by 6-weeks post injury and 4+ per 5 strength by 6-months. Those experiencing partial recovery only achieved antigravity strength (3/5) by 6-weeks and low-function (4-/5) strength by 6-months. Electrodiagnostic testing performed 6-weeks to 6-months postinjury demonstrated that those experiencing complete recovery were more likely to have normal motor unit (MU) recruitment than those experiencing partial (p<.001) or no recovery (p=.008). The presence of ≥2+ fibrillation on tests acquired ≤6-weeks of injury identified patients unlikely to experience any recovery with a positive predictive value (PPV) of 88.9%. The presence of normal MU recruitment on tests acquired 6-weeks to 6-months postinjury identified patients likely to experience complete recovery with a PPV of 87.5%.

CONCLUSIONS

Electrodiagnostic testing may be a valuable means of differentiating between patients with C5 palsy likely to experience complete, partial, or no recovery. Testing between 6-weeks and 6-months post onset may aid in identifying those least likely to have a complete recovery. No MUs at 4 to 6-months, or reduced units with strength that is not improving, portends a poor long-term outcome. In this population, peripheral nerve transfers may be considered sooner.

Cervical laminoplasty with unilateral C4-5 foraminotomy: Technical note and case series

OBJECTIVE

The open-door laminoplasty technique is widely used in the treatment of multilevel cervical myelopathy. Despite the satisfactory functional and radiological results of this technique, postoperative C5 palsy is still a severe and disabling complication with a variable incidence in the literature. The objective of this article is to describe and demonstrate the surgical technique step by step with the addition of unilateral C4-5 foraminotomy and to evaluate the results obtained to date, with special emphasis on C5 palsy.

MATERIAL AND METHODS

Retrospective study of 20 patients operated on for cervical myelopathy using the "extended" laminoplasty technique, which is described step by step.

RESULTS

Between January 2013 and April 2019, 20 patients were operated on using the extended laminoplasty technique. Only one patient (5%) presented postoperative C5 palsy. The postoperative recovery rate of the modified JOA (Japanese Orthopaedic Association) score was 54.5%, similar to that observed in other series.

CONCLUSION

The extended cervical laminoplasty technique with unilateral C4-5 foraminotomy was developed and demonstrated for the prevention of C5 palsy. The results were analysed and an incidence of C5 palsy coinciding with the lowest percentage reported in the literature was obtained. A prospective randomised study would be useful to assess the role of preventive unilateral C4-5 foraminotomy.

Neuromonitoring in Cervical Spine Surgery: When Is a Signal Drop Clinically Significant?

Study Design

Retrospective cohort study.

Purpose

To identify the clinical significance of different patterns of intraoperative neuromonitoring (IONM) signal alerts.

Overview of Literature

IONM is a long-established valuable adjunct to complex spine surgeries. IONM for cervical spine surgery is in the form of somatosensory evoked potential (SSEP) and motor evoked potential (MEP). The efficacy of both modalities (individually or in combination) to detect clinically significant neurological compromise is constantly being debated and requires conclusive suggestions.

Methods

Clinical and neuromonitoring data of 207 consecutive adult patients who underwent cervical spine surgeries at multiple surgical centers using bimodal IONM were analyzed. Signal changes were divided into three groups. Group 0 had transient signal changes in either MEPs or SSEPs, group 1 had sustained unimodal changes, and group 2 had sustained changes in both MEPs and SSEPs. The incidences of true neurological deficits in each group were recorded.

Results

A total of 25% (52/207) had IONM signal alerts. Out of these signal drops, 96% (50/52) were considered to be false positives. Groups 0 and 1 had no incidence of neurological deficits, while group 2 had a 29% (2/7) rate of true neurological deficits. The sensitivities of both MEP and SSEP were 100%. SSEP had a specificity of 96.6%, while MEP had a lower specificity at 76.6%. C5 palsy rate was 6%, and there was no correlation with IONM signal alerts (p=0.73).

Conclusions

This study shows that we can better predict its clinical significance by dividing IONM signal drops into three groups. A sustained, bimodal (MEP and SSEP) signal drop had the highest risk of true neurological deficits and warrants a high level of caution. There were no clear risk factors for false-positive alerts but there was a trend toward patients with cervical myelopathy.

Therapeutic Impact of Traction Release After C5 Nerve Root Motor Evoked Potential (MEP) Alerts in Cervical Spine Surgery

STUDY DESIGN

A retrospective review of 40,919 cervical spine surgeries monitored with motor evoked potentials (MEPs) from a multi-institutional intraoperative neuromonitoring database.

OBJECTIVE

The objective of this study was to determine the clinical impact of interventions prompted by C5 spinal nerve root MEP alerts.

SUMMARY OF BACKGROUND DATA

MEPs have been shown to diagnose acute C5 palsies, but additional data are needed regarding the clinical impact of interventions in response to C5 MEP alerts.

MATERIALS AND METHODS

Procedures with isolated C5 MEP alerts were categorized as fully resolved, partially resolved, or unresolved based on the status of signals at closure. Clinical outcomes were based on neurological assessment in the immediate postoperative period. The sensitivity, specificity, likelihood ratios, and odds ratios (ORs) of C5 MEP alerts for acute C5 palsies were calculated.

RESULTS

The odds of an acute C5 palsy greatly increased if there was a C5 MEP alert [OR=340.9; 95% confidence (CI): 173.0, 671.6; P<0.0001], and increased further if the alert persisted through closure (OR=820.8; 95% CI: 398.1, 1692.0; P<0.0001). Relative to procedures with unresolved C5 MEP alerts, the risk of an acute C5 palsy significantly decreased if a C5 MEP alert was fully resolved by closure (OR=0.07; 95% CI: 0.02, 0.25; P<0.0001). For alerts resolved during positioning or exposure, 90.9% were resolved with the release of positional traction, and for resolved alerts that occurred after exposure, 36.3% involved just traction release, 14.1% involved both traction release and surgical action, and 30.3% involved just surgical action. The sensitivity of C5 MEP alerts for acute C5 palsies was anesthetic dependent: 89.7% (26/29) in the total intravenous regimen cohort but just 50.0% (10/20) in the inhalational anesthesia cohort.

CONCLUSIONS

The timely release of positional traction is an effective intervention for resolving C5 MEP alerts and reducing the odds of an acute postoperative C5 palsy. Surgical maneuvers, such as the release of distraction or graft adjustment, should be attempted in conjunction with traction release depending on the surgical context of the alert.

LEVEL OF EVIDENCE

Level IV.

Complications following posterior cervical decompression and fusion: a review of incidence, risk factors, and prevention strategies

Posterior cervical decompression and fusion (PCF) is a common surgical technique used to treat various cervical spine pathologies. However, there are various complications associated with PCF that can negatively impact patient outcome. We performed a comprehensive literature review to identify the most common complications following PCF using PubMed, Cochrane Database of Systematic Reviews, and Google Scholar. The overall complication rates of PCF are estimated to range from about 15% to 25% in the current literature. The most common immediate complications include acute blood loss anemia, surgical site infection (SSI), C5 palsy, and incidental durotomy; the most common long-term complications include adjacent segment degeneration, junctional kyphosis, and pseudoarthrosis. Three principal mechanisms are thought to contribute to complications. First, higher number of fusion levels, obesity, and more complex pathologies can increase the invasiveness of the planned procedure, thus increase complications. Second, wound healing and arthrodesis may be impaired due to poor blood flow due to various patient factors such as smoking, diabetes, increased frailty, steroid use, and other medical comorbidities. Finally, increased biomechanical stress on the upper instrumented vertebra (UIV) and lowest instrumented vertebra (LIV) may predispose patient to chronic degeneration and result in adjacent level degeneration and/or junctional problems. Reducing the modifiable risk factors pre-operatively can decrease the overall complication rate. Neurologic deficits may be reduced with adequate intraoperative decompression of neural elements. SSI may be reduced with meticulous wound closure that minimizes dead space, drain placement, and the use of intra-wound antibiotics. Careful design of the fusion construct with consideration in spinal alignment and biomechanics can help to reduce the rate of junctional problems. Spine surgeons should be aware of these complications associated with PCF and the corresponding prevention strategies optimize patient outcomes.

Time to recovery predicted by the severity of postoperative C5 palsy

OBJECTIVE

Postoperative C5 palsy affects 7%–12% of patients who undergo posterior cervical decompression for degenerative cervical spine pathologies. Minimal evidence exists regarding the natural history of expected recovery and variables that affect palsy recovery. The authors investigated pre- and postoperative variables that predict recovery and recovery time among patients with postoperative C5 palsy.

METHODS

The authors included patients who underwent posterior cervical decompression at a tertiary referral center between 2004 and 2018 and who experienced postoperative C5 palsy. All patients had preoperative MR images and full records, including operative note, postoperative course, and clinical presentation. Kaplan-Meier survival analysis was used to evaluate both times to complete recovery and to new neurological baseline—defined by deltoid strength on manual motor testing of the affected side—as a function of clinical symptoms, surgical maneuvers, and the severity of postoperative deficits.

RESULTS

Seventy-seven patients were included, with an average age of 64 years. The mean follow-up period was 17.7 months. The mean postoperative C5 strength was grade 2.7/5, and the mean time to first motor examination with documented C5 palsy was 3.5 days. Sixteen patients (21%) had bilateral deficits, and 9 (12%) had new-onset biceps weakness; 36% of patients had undergone C4–5 foraminotomy of the affected root, and 17% had presented with radicular pain in the dermatome of the affected root. On univariable analysis, patients’ reporting of numbness or tingling (p = 0.02) and a baseline deficit (p < 0.001) were the only predictors of time to recovery. Patients with grade 4+/5 weakness had significantly shorter times to recovery than patients with grade 4/5 weakness (p = 0.001) or ≤ grade 3/5 weakness (p < 0.001). There was no difference between those with grade 4/5 weakness and those with ≤ grade 3/5 weakness. Patients with postoperative strength < grade 3/5 had a < 50% chance of achieving complete recovery.

CONCLUSIONS

The timing and odds of recovery following C5 palsy were best predicted by the magnitude of the postoperative deficit. The use of C4–5 foraminotomy did not predict the time to or likelihood of recovery.

Postsurgical Neuropathy: A Descriptive Review

Postsurgical neuropathies represent an infrequent but potentially devastating complication of surgery that may result in significant morbidity with medicolegal implications. Elucidation of this phenomenon has evolved over the past few decades, with emerging evidence for not only iatrogenic factors contributing to this process but also inflammatory causes. This distinction can be important; for instance, cases in which inflammatory etiologies are suspected may benefit from further investigations including nerve biopsy and may benefit from treatment in the form of immunotherapy. In contrast, postsurgical neuropathies due to perioperative causes including anesthesia, traction, compression, and transection will not benefit in the same manner. This article summarizes early and current literature surrounding the frequency of new neurologic deficits after various surgical types, potential causes including anatomical and inflammatory considerations, and roles for treatment. To capture the scope of the issue, a literature review was conducted for human studies in English via MEDLINE and EMBASE from January 1, 1988 to March 31, 2018. Search terms included anesthesia and/or surgical procedures, operative, peripheral nervous system diseases, trauma, mononeuropathy, polyneuropathy, peripheral nervous system, nerve compression, neuropathy, plexopathy, postoperative, postsurgical, perioperative, complication. We excluded case series with less than 10 patients and review papers. We then narrowed the studies to those presented highlighting key concepts in postsurgical neuropathy.

Impact of Multifidus Muscle Swelling on C5 Palsy After Cervical Laminoplasty

STUDY DESIGN

Retrospective radiological analysis OBJECTIVE.: The aim of this study was to identify the effects of posterior cervical muscle swelling on C5 palsy (C5P) by evaluating early postoperative magnetic resonance (MR) images.

SUMMARY OF BACKGROUND DATA

Cervical laminoplasty is an established technique, but the risk of C5P after surgery has not been fully resolved. Studies have reported that lateral stretching and postoperative swelling of the multifidus muscle may cause stretching of the medial branches and cervical nerves.

METHODS

A total of 214 C5 nerves of 107 consecutive patients who underwent laminoplasty were examined. We reviewed their demographic and surgical data and radiographic and MR images as parameters, including the axial cross-sectional area (CSA) of the posterior muscles. The patients and C5 nerves were divided into C5P and non-C5P groups. The parameters and changes were compared between the two groups to examine correlations with C5P.

RESULTS

In demographic data, age, sex, history of smoking, diabetes mellitus, and preoperative Japanese Orthopedic Association scores were not significantly different between the groups. Only body mass index (BMI) was significantly higher in the C5P group. Regarding the surgical and imaging data, the number of laminoplasty, operative time, decompression trough width, cervical sagittal alignment, preoperative spinal cord rotation, and posterior shift of the spinal cord were not significantly different, but the multifidus CSA change ratio was significantly higher in the C5P group. Multiple logistic regression analyses revealed that the multifidus CSA change ratio and BMI were significant independent factors.

CONCLUSION

Multifidus swelling is associated with C5P, possibly through traction of the C5 nerve via the medial branches of the cervical dorsal rami. The medial branch is the shortest of the dorsal rami and may have the largest effect by traction force. Therefore, a gentle maneuver of the deep posterior muscles during surgery is a potential countermeasure to prevent C5P.

LEVEL OF EVIDENCE

3.

Epidemiology of C5 Palsy after Cervical Spine Surgery: A 21-Center Study

Objective

C5 palsy is a severe complication after cervical spine surgery, the pathophysiology of which remains unclear. This multicenter study investigated the incidence of C5 palsy following cervical spine surgery in Korea.

Methods

We conducted a retrospective multicenter study involving 21 centers from the Korean Cervical Spine Study Group. The inclusion criteria were cervical spine surgery patients between 2012 and 2016, excluding cases of neck surgery. In patients with C5 palsy, the operative methods, disease category, onset time of C5 palsy, recovery time, C5 manual muscle testing (MMT) grade, and post-C5 palsy management were analyzed.

Results

We collected 15,097 cervical spine surgery cases from 21 centers. C5 palsy occurred in 88 cases (0.58%). C5 palsy was more common in male patients (p=0.019) and after posterior approach procedures (p<0.001). C5 palsy usually occurred within 3 days after surgery (77 of 88, 87.5%) and most C5 palsy patients recovered within 6 months (51 of 88, 57.95%). Thirty C5 palsy patients (34.09%) had motor weakness, with an MMT grade≤2. Only four C5 palsy patients (4.5%) did not recover during follow-up. Posterior cervical foraminotomy was performed in 7 cases (7.95%), and steroids were used in 56 cases (63.63%). Twenty-six cases (29.55%) underwent close observation only.

Conclusion

The overall incidence of C5 palsy was relatively low (0.58%). C5 palsy was more common after posterior cervical surgery and in male patients. C5 palsy usually developed within 3 days after surgery, and more than half of patients with C5 palsy recovered within 6 months.

Surgical Reconstruction Using a Flanged Mesh Cage without Plating for Cervical Spondylotic Myelopathy and a Symptomatic Ossified Posterior Longitudinal Ligament

OBJECTIVE

We introduce innovative method of cervical column reconstruction and performed the reconstruction with a flanged titanium mesh cage (TMC) instead of a plate after anterior corpectomy for cervical spondylotic myelopathy (CSM) and an ossified posterior longitudinal ligament (OPLL).

METHODS

Fifty patients with CSM or OPLL who underwent anterior cervical reconstruction with a flanged TMC were investigated retrospectively. Odom's criteria were used to assess the clinical outcomes. The radiographic evaluation included TMC subsidence, fusion status, and interbody height. Thirty-eight patients underwent single-level and 12 patients underwent two-level corpectomy with a mean follow-up period of 16.8 months.

RESULTS

In all, 19 patients (38%) had excellent outcomes and 25 patients (50%) had good outcomes. Two patients (4%) in whom C5 palsy occurred were categorized as poor. The fusion rate at the last follow-up was 98%, and the severe subsidence rate was 34%. No differences in subsidence were observed among Odom's criteria or between the single-level and two-level corpectomy groups.

CONCLUSION

The satisfactory outcomes in this study indicate that the flanged TMC is an effective graft for cervical reconstruction.

Incidence and Outcomes of C5 Palsy and Axial Pain After Open-Door Laminoplasty or Laminectomy and Fusion: A Meta-Analysis

OBJECTIVE

C5 palsy and axial pain are significant factors affecting the quality of life after posterior cervical surgery; however, there has been no clear and supportive conclusion on which method is more suitable in a certain case. As a result, we compare the clinical outcomes, complication rates, and anatomical changes between open-door laminoplasty (ODL) and laminectomy and fusion (LF) for cervical spondylotic myelopathy. This is a systematic literature review and meta-analysis.

METHODS

A comprehensive literature search was conducted using PubMed, Embase, and the Cochrane library. The following outcomes were extracted and analyzed: the cases of C5 palsy and axial pain patients, Japanese Orthopaedic Association, range of motion (ROM), and cervical curvature. Data analysis was conducted with RevMan 5.3. The I² statistics were used to evaluate heterogeneity.

RESULTS

A total of 9 studies were included in the final analysis, all of which were prospective or retrospective cohort studies. The pooled data showed that the incidences of C5 palsy and axial pain in LF were higher than those in ODL. The study indicated that there was no significant difference in pre- and postoperative Japanese Orthopaedic Association scores, preoperative cervical ROM, pre- and postoperative cervical curvature between the 2 groups, but there was significant difference in ROM after operation. These results indicate that ODL was superior to LF in maintaining cervical ROM.

CONCLUSIONS

Our results demonstrate that the lower incidence of C5 palsy and axial pain can be achieved by using ODL compared with LF. However, current data only provide weak support, if any, favoring ODL over for clinical improvement in reduce these 2 complications.

Anterior and Posterior Approaches for Cervical Myelopathy: Clinical and Radiographic Outcomes

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

The aim of this study was to identify advantages and disadvantages of the anterior and posterior approaches in the treatment of cervical stenosis and myelopathy.

SUMMARY OF BACKGROUND DATA

Both anterior and posterior surgical approaches for cervical stenosis and myelopathy have been shown to result in improvement in health-related outcomes. Despite the evidence, controversy remains regarding the best approach to achieve decompression and correct deformity.

METHODS

We retrospectively reviewed patients with cervical stenosis and myelopathy who had undergone anterior cervical fusion and instrumentation (n = 38) or posterior cervical laminectomy and instrumentation (n = 51) with at least 6 months of follow-up. Plain radiographs, magnetic resonance imaging, and computed tomography scans, as well as health-related outcomes, including Visual Analog Scale for neck pain, Japanese Orthopedic Association score for myelopathy, Neck Disability Index, and Short Form-36 Health Survey, were collated before surgery and at follow-up (median 12.0 and 12.1 months for anterior and posterior group, respectively).

RESULTS

Both anterior and posterior approaches were associated with significant improvements in all studied quality of life parameters with the exception of general health in the anterior group and energy and fatigue in the posterior group. In the anterior group, follow-up assessment revealed a significant increase in C2-7 lordosis. Both approaches were accompanied by significant increases in C2-7 sagittal balance [sagittal vertical axis (SVA)]. There were two complications in the anterior group and nine complications in the posterior group; the incidence of complications between the two groups was not significantly different.

CONCLUSION

When the benefits of one approach over the other are not self-evident, the anterior approach is recommended, as it was associated with a shorter hospital stay and more successful restoration of cervical lordosis than posterior surgery.

LEVEL OF EVIDENCE

3.

C5 Motor Palsy After Single- and Multi-level Anterior Cervical Diskectomy and Fusion: A Retrospective Review

INTRODUCTION

Postoperative C5 nerve root palsy is a known complication after cervical surgery. The effect of increasing number of levels fused on the prevalence of C5 palsy after anterior cervical diskectomy and fusion (ACDF) is unclear.

METHODS

Medical records of ACDF patients that included the C4-5 level at one institution were retrospectively reviewed. C5 palsy was defined as motor decline of the deltoid and/or biceps brachii muscle function by at least 1 level on standard manual muscle testing.

RESULTS

A total of 196 patients met the inclusion criteria, with no significant differences noted between groups undergoing single- or multi-level ACDF. The overall C5 palsy rate was 5.1%. Palsy rates were not statistically significant based on the number of levels fused. Six of the 10 patients with C5 palsy had complete recovery of motor strength, whereas 2 patients had at least some level of strength recovery.

CONCLUSION

The overall C5 palsy rate was 5.1% for all patients undergoing up to four-level ACDF. The rate of postoperative motor decline was lowest in the patients undergoing two-level ACDF and highest in the single-level group, but this finding did not reach statistical significance. The prognosis for strength recovery by final follow-up is excellent.

LEVEL OF EVIDENCE

Level III, Case-control.

Post-operative nerve injuries after cervical spine surgery

Although relatively rare, post-operative nerve injuries may occur after cervical spine procedures. The most common post-operative neural disorder is C5 nerve palsy. The risk factors for C5 nerve palsy are male gender, OPLL, and posterior cervical approaches. It generally presents with deltoid and/or biceps weakness, and may present immediately or several days after surgery. Treatment is generally conservative due to transient duration of symptoms, but evaluation of residual compression at C4-5 is essential. PTS (Parsonage-Turner syndrome) is an idiopathic plexopathy generally presenting with severe neuropathic pain in the shoulder, neck, and arms, followed by neurological deficits involving the upper brachial plexus. The deficits typically present in a delayed fashion after the onset of pain. Once residual nerve compression is ruled out, initial treatment is based on pain control and physical therapy. Post-operative C8-T1 nerve palsies occur with weakness of the five intrinsic muscles of the hand innervated by the medial nerve, with sensory symptoms in the territory innervated by the ulnar nerve (ulnar two digits of the hand), and also the medial forearm. The risk factors for C8-T1 nerve injuries after surgery are C7 pedicle subtraction osteotomies and posterior fixation of the cervico-thoracic junction, especially in patients with preoperative C7-T1 stenosis. A wide foraminal decompression at C7-T1 region is necessary to minimize risk of this complication. Finally, Horner's syndrome can occur post-operatively, especially after anterolateral approaches to the middle and lower levels of the cervical spine. It is characterized by ipsilateral papillary miosis, facial anhydrosis, and ptosis secondary to injury of the cervical sympathetic nerves. Avoid using the cautery on the lateral border of the longus colli muscle, where the sympathetic chain lies and place the retractors properly underneath the muscle to decrease the chance of sympathetic injuries. It can also occur from iatrogenic compression or injury to the T1 nerve root, as the sympathetic chain gets some of its fibers from that level. Understanding the most common potential nerve injuries after cervical spine procedures is helpful in prevention, early diagnosis, and appropriate management.

Case report of C5 palsy after C3-C6 posterior decompression and instrumented fusion in a patient undergoing inpatient rehabilitation

We report on a patient who had neurological deterioration attributed to C5 palsy post C3-C6 posterior decompression and instrumented fusion. A 60-year old man was admitted after a fall from an electric scooter. MRI of the cervical spine confirmed severe cervical spondylosis causing cord compression at C4/5 with associated cord oedema. He underwent posterior cervical decompressive surgery, and he remained neurologically stable post operatively. However, he subsequently developed acute left upper limb weakness limited to the C5 myotome 1 week after surgery whilst undergoing inpatient rehabilitation. A repeat MRI of the cervical spine did not reveal any new changes that may explain his symptoms. He was started on intravenous dexamethasone. C5 palsy after cervical decompressive surgery is not uncommon. There is no specific evidence-based treatment and it carries a generally good prognosis. The aim of this case report is to highlight this complication and raise awareness amongst physicians.

Cervical spondylotic myelopathy: A two decade experience

Context Cervical myelopathy occurs as a result of compression of the cervical spinal cord. Symptomatology includes, but is not limited to, pain, weakness, paresthesias, or gait/balance difficulties. Objective To present a two-decade experience with the management of cervical myelopathy. Methods Literature was reviewed to provide current guidelines for management as well as accompanying clinical presentations. Results Surgical decompression, if necessary, may be achieved from either an anterior, a posterior, or a combined anterior-posterior (AP) approach. The indications for each approach, as well as the surgical techniques, are described. Conclusion Several etiologies may lead to cord compression and cervical myelopathy. The best vector of approach with regard to anterior versus posterior surgical intervention is still under investigation. Regardless, management via surgical decompression has been demonstrated repeatedly to improve the CSM patients' quality of life.

[C5 palsy after multi-segmental cervical decompression : How can it be avoided?]

BACKGROUND

Anterior cervical discectomy and fusion (ACDF) as well as posterior instrumentation of the cervical spine are frequently performed surgeries for cervical disc prolapse or spinal stenosis. Surgery itself harbors a very low risk of adverse events. Postoperative palsy of the C5 nerve root, however, is a severe complication and its origin is still not fully understood. The risk of such a C5 palsy is reported to be between 0 and 30%; 5% on average according to the literature.

OBJECTIVES

To describe underlying pathomechanisms and to recommend strategies for risk reduction.

MATERIALS AND METHODS

An extensive literature research via Medline was performed.

RESULTS

Potential risk factors are male gender, sagittal diameter below 5.6 mm, anterior approach, and higher age.

CONCLUSIONS

Currently available data only originates from retrospective or anatomical studies. A prospective register study with the goal to put light on the pathogenesis is currently being performed.