C5 Nerve Palsy Research Articles

C5 Palsy after Cervical Disc Arthroplasty: Two Case Reports and Literature Review

Cervical disc arthroplasty (CDA), also known as cervical artificial disc replacement, has become an alternative for the treatment of cervical spondylosis with radicular or myelopathic symptoms. However, there is limited literature regarding its complications and outcomes. We present two cases that developed C5 nerve palsy (C5P) following two-level CDA. Both patients presented with C5P in a delayed fashion with 2/5 and 1/5 deltoid weakness on MMT, respectively. Postoperative imaging did not demonstrate any spinal cord compression and symptoms resolved (5/5 on MMT) with conservative management in both cases. To our knowledge, these represent the first cases of delayed C5P after cervical arthroplasty reported in the literature. We performed a literature review to further enhance our knowledge regarding CDA. By understanding its pathophysiology and response to treatment, these cases can serve as a guide for spine surgeons and improve their future outcomes.

C5 nerve root palsy (without prior cervical decompression) case series: 9 patients with critical delay to presentation.

Distinguishing between cervical nerve root and intrinsic shoulder pathology can be a difficult task given the overlapping and often coexisting symptoms. The objective of this study was to highlight the often-complicated presentation of these symptoms and the subsequent potential for delay in care regarding this subset of patients. A total of 9patients, managed by one of two different surgeons, were identified with a history of C5 nerve root palsy. A chart review was conducted, and the following information was recorded: presenting complaint, time from symptom onset to diagnosis, time from symptom onset to presentation to a spine surgeon, first specialist seen for symptoms, non-spinal advanced imaging and treatment conducted before diagnosis, preoperative and postoperative exam, time to recovery, and type of surgery. We observed an average time from onset of symptoms to presentation to a spine surgeon to be 31.6weeks. These patients' time to full recovery after cervical decompression was 15weeks. : We observed a critical delay to presentation in this series of patients with C5 nerve palsy. C5 nerve palsy should remain an elemental part of the differential diagnosis in the setting of any shoulder or neck pain presenting with weakness.

1068 Incidence and Recovery of C5 Nerve Palsy After Various Types of Cervical Spinal Surgery: A Systematic Review and Meta-Analysis of Over 14,834 Patients

INTRODUCTION: C5 nerve palsy is a debilitating operative complication of cervical surgery and occurs commonly as many surgical approaches operate near the exiting nerve root. No prior study has attempted to identify the recovery rate of C5 nerve palsy after cervical operations, and identify the rate of which this complication becomes permanent. METHODS: A literature search of the PubMed and Embase databases was completed to identify all papers focused on cervical surgery. Studies were excluded if they did not provide the rate of C5 palsy occurrence or if they did not define what type of cervical surgery was completed. A pooled, weighted prevalence rate of C5 palsy was calculated for each type of surgery, including the rate of these becoming permanent. RESULTS: A total of 118 studies were identified and met all inclusion criteria. Of these studies, 52 were focused on laminoplasties, 24 on anterior cervical discectomy fusions (ACDF), 22 on laminectomies without fusion, and 20 on posterior cervical fusions (PCF). Laminectomies had the highest incidence of C5 palsy at a pooled rate of 7.08% (95% Confidence Interval [CI], 4.74%-10.46%, I2 = 87%, P < .01), of which 0.05% (CI = 0.00%-0.90%) were permanent. This was followed by PCFs with a rate of 6.70% (CI = 4.50%-9.85%), with the effects being permanent at a rate of 0.04% (CI = 0.00%-1.20%). Laminoplasties had a C5 palsy incidence of 5.49% (CI = 4.65%-6.47%), of these 0.02% (CI = 0.00%-0.11%) were permanent. ACDFs had the lowest incidence at a rate of 4.50% (CI = 2.56%-7.79%), of which only 0.02% (CI = 0.04%-0.08%) were permanent. CONCLUSIONS: C5 nerve palsy is a relatively common complication after all types of cervical surgeries with increased rates in posterior approaches, however the rate of these becoming permanent is minimal.

411 Perioperative Complications and Radiographic Outcomes Following Cervical Laminoplasty: A Review of 105 Cases From a Single Academic Center

INTRODUCTION: With advancements in technology, the safety and efficacy of cervical laminoplasty have increased, leading to a reduction in complications frequently associated with posterior cervical surgical approaches, including C5 nerve palsy, axial neck pain, loss of lordosis, and loss of motion. However, the impact of these advancements on cervical radiographic parameters remains poorly documented, and the prevalence of complications in North American populations has not been adequately studied. METHODS: We evaluated patients undergoing cervical laminoplasty between 2011 to 2022 at an academic medical center. Patient demographics, intraoperative and postoperative complications, preoperative and post-operative radiographic parameters were recorded. RESULTS: 150 patients undergoing cervical laminoplasty during this study period were identified. 105 patients met the inclusion criteria. We identified a total of 22 (21.0%) adverse events in 20 patients. There were 4 intra-operative (3.8%), 10 peri-operative (9.5%), and 8 delayed post-operative (7.6%) adverse events. Amongst them, 13 (12.4%) were judged to be minor and 9 (8.6%) were judged to be major complications. Six (5.7%) patients required revision surgery. Forty-seven (44.8%) of the 105 patients had both pre-and post-operative cervical spine radiographic imaging. The average pre-and post-op C2-7 cobb angles were 14.7 degrees and 12.3 degrees (p-value of 0.04). The pre-and post-op SVA was 29.2 mm and 33.3 mm (p-value of 0.07). The pre-op and post-op T1 slopes were 32.3 and 30.2 deg (p-value of 0.07). CONCLUSIONS: Cervical laminoplasty carries a significant risk of adverse events, the majority of which are minor and has a low rate of re-operation (5.7%). The procedure does not result in significant changes in SVA or T1 slope. Cervical laminoplasty remains a valuable surgical option for selected patients with cervical myelopathy.

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

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. 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. 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. 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.

A case-control study:the clinical efficacy of total laminectomy with lateral mass screw fixation and single open-door laminoplasty for cervical spinal cord injury without fracture and dislocation

To compare the clinical effects of total laminectomy with lateral mass screw fixation and single open-door laminoplasty in the treatment of cervical spinal cord injury without fracture and dislocation. The clinical data of 75 patients with cervical spinal cord injury without fracture and dislocation treated from December 2014 to April 2020 were retrospectively analyzed, including 65 males and 10 females, aged from 33 to 83 years old with an average of (60.1±11.4) years. According to surgical method, the patients were divided into observation group (36 cases) and control group (39 cases). The observation group was treated with C3-C6 single open-door laminoplasty. In the control group, the C3-C6 whole lamina was opened by "uncovering", and the lateral mass screw was fixed and fused. The general conditions including operation time, intraoperative blood loss, hospital stay and complications such as axial pain, cerebrospinal fluid leakage, postoperative C5 nerve palsy were recorded. Visual analogue scale(VAS), Nurick pain scale, Japanese Orthopaedic Association(JOA) scores and American Spinal Injury Association(AISA) injury scale were used to evaluate the improvement of clinical symptoms and related functional recovery 12 months after operation. There were no statistically significant differences in operation time, intraoperative blood loss and hospital stay between two groups(P>0.05). There were statistically significant differences in JOA, VAS, ASIA and Nurick scores of the all patients between 12 months after surgery and before surgery (P<0.05), and there was no significant difference between groups. There was significant difference in the incidence of C5 nerve root palsy and axial pain between two groups(P<0.05), but there was no significant difference in the complications of cerebrospinal fluid leakage between two groups (P>0.05). Total laminectomy with lateral mass screw fixation and single open-door laminoplasty in treating cervical spinal cord injury without fracture and dislocation can obtain satisfactory results in restoring nerve function, alleviating pain and improving daily behavior, but single open-door laminoplasty has the advantages of less trauma and low incidence of complications.

Complications of the anterior cervical approach in spine surgery

The anterior cervical approach is a time-tested, minimally invasive procedure that is leveraged for some of the most common spine surgeries performed in the world. The use of natural muscle planes, specialized retractors, and meticulous attention to surrounding structures have enabled surgeons to treat patients with a variety of pathologies. Although associated with high success rates, recurring complications have been described. The goal of this literature review is to detail pertinent complications seen in such surgeries. Here we describe the incidence rates, risk factors, prevention, and treatment for commonly cited anterior cervical complications. These include dysphagia, esophageal perforation, C5 nerve palsy, recurrent laryngeal nerve injury, Horner's syndrome, hematoma, vascular injury, and infection. Our review suggests that while morbidity rates for these procedures are low, awareness of risk factors and preventative measures can further reduce such complications.

228. Complications following posterior cervical arthrodesis for cervical spondylotic myelopathy: a single institution's experience

<h3>BACKGROUND CONTEXT</h3> Posterior cervical fusion (PCF) is a frequently performed surgery for treatment of cervical spondylotic myelopathy (CSM). While incidences of these risks have been reported previously, prior studies on this topic either contain small sample sizes, pooled from multiple institutional or public databases, or have low follow-up duration. Here, we report the incidence of postoperative complications following PCF for CSM at a single institution with a large patient cohort. To review the rate of postoperative complications following primary posterior cervical fusion for cervical CSM at a single institution. <h3>PURPOSE</h3> To review the rate of postoperative complications following primary posterior cervical fusion for CSM at a single institution. <h3>STUDY DESIGN/SETTING</h3> Retrospective case series, single institution. <h3>METHODS</h3> Patients with a diagnosis of CSM treated with PCF over a 4-year period at a tertiary care center were identified. Exclusion criteria included: (1) cervical myelopathy secondary to trauma, spinal infection, or spinal neoplasm, (2) fusion constructs that proximally included occiput or C1, or distally extended below T2, and (3) revision PCF procedures. Postoperative data collected included incidence of superficial surgical site infection (SSI), deep wound infection, subsequent irrigation and debridement (I&D), postoperative pneumonia, venous thromboembolism (VTE), epidural hematoma, and C5 nerve palsy during course of follow-up. Multivariable regression analyses were performed to identify patient characteristics and comorbidities that were independent risk factors for these complications. <h3>RESULTS</h3> A total of 176 patients met inclusion criteria (mean age + standard deviation = 63.8 + 11.1 years). An average of four levels (range: 1-7) were fused per surgery. Mean follow-up was one year. Of 176 patients, 33 (18.7%) had at least one documented postoperative complication. There were six cases (3.4%) of superficial SSI and four cases (2.3%) of deep wound infection. One patient (0.57%) developed a postoperative epidural hematoma. There were five cases (2.8%) of VTE and six cases (3.4%) of postoperative pneumonia. Fifteen patients (8.5%) developed C5 nerve palsy, of which 12 of 15 cases were transient and improved. Diabetes was an independent risk factor for postoperative VTE (p=0.03) and pneumonia (p=0.03). <h3>CONCLUSIONS</h3> Almost 1 in 6 patients had some complication after posterior cervical fusion for treatment of CSM. The incidence of C5 nerve palsy at 8.5% was not trivial. Though PCF is a routine procedure, our results highlight the need for appropriate preoperative counseling, especially in patients with diabetes mellitus. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Late Postoperative Cervical Spinal Cord Herniation with Pseudomeningocele

We report a middle-aged man with a history of traumatic cervical spinal cord injury with extensive edema. Decompressive surgery of posterior laminectomy and fixation was performed. An irreparable dural rupture on dorsal-lateral side of the cord was found during operation. The patient was managed with a myofascial and fibrin glue assisted closure and underwent watertight closure of fascia and skin. No cerebrospinal fluid leakage was detected in the postoperative period and the wound was healing, thus the patient was discharged. Clinical symptoms resolved. Half a year later, however, the patient presented with C5 nerve palsy. Magnetic resonance imaging revealed cervical spinal cord herniation with pseudomeningocele. Late postoperative cervical spinal cord herniation with pseudomeningocele may occur in any cervical spine trauma cases with dural rupture and/or defect, and close follow-up and observation are needed in the postoperative period.

Patterns of neurological deficits and recovery of postoperative C5 nerve palsy.

Paresis of the C5 nerve is a well-recognized complication of cervical spine surgery. Numerous studies have investigated its incidence and possible causes, but the specific pattern and character of neurological deficits, time course, and relationship to preoperative cord signal changes remain incompletely understood. Records of patients undergoing cervical decompressive surgery for spondylosis, disc herniation, or ossification of the longitudinal ligament, including the C4-5 level, were reviewed from a 15-year period, identifying C5 palsy cases. Data collected included age, sex, diabetes and smoking statuses, body mass index, surgical levels, approach, presence of increased cord signal intensity, and modified Japanese Orthopaedic Association (mJOA) scores. Narrative descriptions of the patterns and findings on neurological examination were reviewed, and complications were noted. The minimum follow-up requirement for the study was 12 months. Of 642 patients who underwent cervical decompressive surgery, 18 developed C5 palsy (2.8%). The incidence was significantly lower following anterior surgery (6 of 441 [1.4%]) compared with that following cervical laminectomy and fusion (12 of 201 [6.0%]) (p < 0.001). There were 10 men and 8 women whose mean age was 66.7 years (range 54-76 years). The mean preoperative mJOA score of 11.4 improved to 15.6 at the latest follow-up examination. There were no differences between those with and without C5 palsy with regard to sex, age, number of levels treated, or pre- or postoperative mJOA score. Fifteen patients with palsy (83%) had signal changes/myelomalacia on preoperative T2-weighted imaging, compared with 436 of 624 (70%) patients without palsy; however, looking specifically at the C4-5 level, signal change/myelomalacia was present in 12 of 18 (67%) patients with C5 palsy, significantly higher than in the 149 of 624 (24%) patients without palsy (p < 0.00003). Paresis was unilateral in 16 (89%) and bilateral in 2 (11%) patients. All had deltoid weakness, but 15 (83%) exhibited new biceps weakness, 8 (44%) had triceps weakness, and 2 (11%) had hand intrinsic muscle weakness. The mean time until onset of palsy was 4.6 days (range 2-14 days). Two patients (11%) complained of shoulder pain preceding weakness; 3 patients (17%) had sensory loss. Recovery to grade 4/5 deltoid strength occurred in 89% of the patients. No patient had intraoperative loss of somatosensory or motor evoked potentials or abnormal intraoperative C5 electromyography activity. Postoperative C5 nerve root dysfunction appears in a delayed fashion, is predominantly a motor deficit, and weakness is frequently appreciated in the biceps and triceps muscles in addition to the deltoid muscle. Preoperative cord signal change/myelomalacia at C4-5 was a significant risk factor. No patient had a detectable deficit in the immediate postoperative period or changes in intraoperative neuromonitoring status. Neurological recovery to at least that of grade 4/5 occurred in nearly 90% of the patients.

Comparison of clinical outcomes and safety between laminectomy with instrumented fusion versus laminoplasty for the treatment of multilevel cervical spondylotic myelopathy.

Study design:Systematic review and meta-analysis.Objectives:Posterior laminectomy with instrumented fusion and laminoplasty are widely used for the treatment of multilevel cervical spondylotic myelopathy (MCSM). There is great controversy over the preferred surgical method. The purpose of this study is to evaluate the clinical outcomes and safety between laminectomy with instrumented fusion and laminoplasty for the treatment of MCSM.Methods:Related studies that compared the effectiveness of laminectomy with instrumented fusion and laminoplasty for the treatment of MCSM were acquired by a comprehensive search in PubMed, Embase, the Cochrane library, CNKI, VIP, and WANFANG up to April 2018. Included studies were evaluated according to eligibility criteria. The main endpoints included: preoperative and postoperative Japanese Orthopedic Association (JOA) scores, preoperative and postoperative visual analog scale (VAS), preoperative and postoperative cervical range of motion (ROM), preoperative and postoperative cervical curvature index (CCI), overall complication rate, C5 nerve palsy rate, axial symptoms rate, operation time and blood loss.Results:A total of 15 studies were included in this meta-analysis. All of the selected studies were of high quality as indicated by the Newcastle–Ottawa scale (NOS). Among 1131 patients, 555 underwent laminectomy with instrumented fusion and 576 underwent laminoplasty. The results of this meta-analysis indicated no significant difference in preoperative and postoperative JOA scores, preoperative and postoperative VAS, preoperative and postoperative CCI, preoperative ROM and axial symptoms rate. However, compared with laminoplasty, laminectomy with instrumented fusion exhibited a higher overall complication rate [RR = 1.99, 95% confidence intervals (CI) (1.24, 3.21), P <.05], a higher C5 palsy rate [RR = 2.22, 95% CI (1.30, 3.80), P <.05], a decreased postoperative ROM [SMD = −1.51, 95% CI (−2.14, −0.88), P <.05], a longer operation time [SMD = 0.51, 95% CI (0.12, 0.90), P <.05] and increased blood loss [SMD = 0.47, 95% CI (0.30, 0.65), P <.05].Conclusion:These results suggested that both posterior laminectomy with instrumented fusion and laminoplasty were determined to be effective for MCSM. However, laminoplasty appeared to allow for a greater ROM, lower overall complication and C5 palsy rates, shorter operation time and lower blood loss. Future well-designed, randomized controlled trials are still needed to further confirm our results.

Anterior cervical ossified posterior longitudinal ligament en bloc resection for the treatment of cervical ossification of posterior longitudinal ligament

Objective To evaluate theclinical efficacy and safety of anterior cervical ossified posterior longitudinal liga-ment en bloc resection (ACOE), and analyze the advantages of ACOE compared to the traditionally anterior cervical surgery. Methods The clinical datawith more than one year follow-up of 96 patients suffered from cervical ossification of the posterior longitu-dinal ligament(OPLL) from April 2010 to March 2017 was retrospectively analyzed, including 57 males and 39 females, aged 32-69 years, average 54.6±8.7 years. There were 29 cases of nodular type (30.2%), 48 cases of segmental type (50.0%), 5 cases of con-tinuous type(5.2%), and 14 cases of mixed type (14.6%). The neurological function assessments before and after operation were performed using the Japanese Orthopaedic Association (JOA) scoring system and the visual analogue scale (VAS) scoring system.The effect of ossified mass resection was observed by three-dimensional reconstruction CT scan. The spinal cord decompression was evaluated by MRI. The cervical curvature was compared before and after surgery by cervical lateral radiograph. The operation time, intraoperative blood loss, recovery rates of the JOA scores and complication rates of this group were compared with the cases of anterior cervical ossified posterior longitudinal ligament piecemeal resection (ACOP) reported by the recent literature to analyze the clinical efficacy, safety and advantages of ACOE. Results All the surgeries of 96 cases were successfully performed, in-cluding 57 cases (59.4%) with subtotal resectionof single vertebra, 31 cases (32.3%) with subtotal resectionof doublevertebras, 1 case (1.0%) with expanded intervertebral decompression, 4 cases (4.2%) with + subtotal resection,1 case (1.0%) with semi-vertebra + vertebra + subtotal resection, 2 cases with double vertebras + semi-verte-bra subtotal resection (2.1%). Ninty-six cases were followed up for 12 to 78 months, with an average of 28.0±9.3 months. The preoperative JOA score with (11.38±2.80) scores was increased to 15.32±1.62 scores at the last follow-up, and the recovery rate of JOA score was 74.63%±13.18%. The preoperative VAS score with 6.00±1.41 scores was reduced to 2.35±1.11 scores at the last follow-up. The cervical curvature increased from 10.4°±9.0° before surgery to 15.8°±8.1° at the last follow-up. CT showed that the ossified masses of the surgical segments were completely excised without residue; MRI showed that the com-pressionsof spinal cords and dural sacs were completely relieved, with nice morphology recovery. There was no neurological de-terioration in this group. There were 6cases of cerebrospinal fluid leakage (CSFL), 3 cases of C5 nerve palsy, 1 case of Horner syndrome, 2 cases of dysphagia and hoarseness, 1 case of titanium mesh subsidence with screw loosing. At the final follow-ups, except one case of occasional throat foreign body sensation, the above complications were all remittedat different follow-up periods. Compared with the cases of ACOP reported by the recent meta-analysis, the operation time, the intraoperative blood loss, the complication rate of dysphagia with hoarseness and neurological deterioration were lower than those reported in the literature. The recovery rate of JOA scorewas higher than which reported in the literature. Conclusion ACOE is safe and effective for the treatment of cervical OPLL, which may be superior to traditional anterior cervical surgery in terms of surgical safe-ty, controllability of cerebrospinal fluid leakage and improvement of neurological function. Key words: Cervical vertebrae; Ossification of posterior longitudinal ligament; Decompression, surgical; Spinal fusion

Comparison of anchor screw fixation versus mini-plate fixation in unilateral expansive open-door laminoplasty for the treatment of multi-level cervical spondylotic myelopathy

Study design:Systematic review and meta-analysis.Background:Anchor screw fixation and mini-plate fixation are widely used in unilateral open-door laminoplasty. There is a great controversy over the preferred fixation method. The purpose of this study is to evaluate the clinical outcomes between anchor screw fixation and mini-plate fixation for the treatment of multilevel cervical spondylotic myelopathy (MCSM).Methods:Related studies that compared the clinical effectiveness of anchor screw fixation and mini-plate fixation in cervical laminoplasty for the treatment of MCSM were acquired by a comprehensive search in PubMed, Embase, the Cochrane library, CNKI, VIP, and WANFANG up to March, 2018. Included studies were evaluated according to eligibility criteria. The main end points included: preoperative Japanese Orthopedic Association (JOA) scores, postoperative JOA scores, JOA scores improvement rate, preoperative and postoperative cervical range of motion (ROM), preoperative and postoperative cervical curvature index (CCI), lamina open angle, operation time, blood loss, C5 nerve palsy rate and axial symptoms rate.Results:Papers in English and Chinese were searched for the initial review, but only 12 articles in Chinese were included in this meta-analysis. All of the selected studies were of high quality as indicated by the Newcastle–Ottawa scale (NOS). Among 809 patients, 372 underwent anchor screw fixation and 437 underwent mini-plate fixation. The results of this meta-analysis indicated that no significant difference was found in preoperative JOA score, JOA scores improvement rate, preoperative CCI, preoperative ROM, C5 palsy rate and blood loss. However, compared with mini-plate fixation, anchor screw fixation patients showed higher axial symptoms rate [RR = 1.75, 95% CI (1.31, 2.35), P <.05], lower postoperative JOA scores [SMD = −0.38, 95% CI (−0.62, −0.15), P <.05], lower postoperative CCI [SMD = −0.64, 95% CI (−0.94, −0.33), P <.05], lower postoperative ROM [SMD = −1.11, 95% CI (−2.18, −0.04), P <.05], smaller lamina open angle [SMD = −1.98, 95% CI (−3.71, −0.24), P <.05], shorter operation time [SMD = −0.33, 95% CI (−0.59, −0.07), P <.05].Conclusions:Compared with anchor screw fixation, mini-plate fixation in cervical laminoplasty appears to achieve better clinical and radiographic outcomes with fewer surgical complications. However, future well-designed, randomized controlled trials are still needed to further confirm our results.

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.

An algorithmic strategy of surgical intervention for cervical degenerative kyphosis

PurposeCorrection surgery for cervical degenerative kyphosis (CDK) may carry a greater risk of causing neural complications such as spinal cord injury and C5 nerve palsy because spinal canal stenosis, osteoarthritis of the facet, and consequent foraminal stenosis may coexist with CDK. We have produced an algorithmic strategy of surgical intervention for CDK, and report the outcome. MethodsThirty-one patients who underwent correction surgery for CDK, with a kyphotic angle of 20° or more (from 20 to 74) were involved. An algorithmic surgical strategy is shown. Clinical and radiological outcomes were examined amongst the groups. ResultsRecovery rate of the JOA score was a mean of 44%. Preoperative kyphotic angle and correction angle were; 24.4°and 26.5°in P, 38.4°and 41.1°in AP, and 42.0°and 46.9°in PAP respectively. No spinal cord injury was found. Five cases of C5 nerve palsy occurred in P, and one in AP. Four cases of C5 palsy occurred in seven patients in PAP, although prophylactic foraminotomy was performed. All C5 palsy patients recovered fully at follow-up. ConclusionsThis study showed that our algorithmic surgical strategy for CDK is acceptable because we obtained good outcomes, and no catastrophic complications occurred. Although we did not intend to obtain excessive postoperative lordosis, we still had several incidence of C5 nerve palsy. We have to be aware of this incidence in PAP, which required a massive range of realignment. The incidence occurred even after we performed prophylactic foraminotomy, however, this procedure may lessen the severity of C5 palsy because those were all transient.

In Situ Decompression to Spinal Cord During Anterior Controllable Antedisplacement Fusion Treating Degenerative Kyphosis with Stenosis: Surgical Outcomes and Analysis of C5 Nerve Palsy Based on 49 Patients

To observe outcomes of anterior controllable antedisplacement fusion (ACAF) in treatment of degenerative kyphosis with stenosis (DKS) and analyze probability of C5 nerve palsy. From 2016 to 2017, a consecutive cohort of adults with DKS underwent ACAF. All patients underwent cervical radiography, computed tomography, and magnetic resonance imaging. Operative duration, blood loss, and hospital stay were estimated. Radiologic assessment included kyphotic correction, decompression width, and spinal canal area. Postoperative curvature of spinal cord was observed on sagittal magnetic resonance imaging. Japanese Orthopaedic Association score was used to evaluate neurologic status. C5 nerve palsy and other complications were recorded. The study included 49 patients. There was significant kyphosis correction postoperatively (-19.4° vs. 3.5°, P < 0.01). On cross-sectional computed tomography, mean decompression width was 19.0 mm, and spinal canal area was 218.5 mm2. On sagittal magnetic resonance imaging, spinal cord curvature was classified into 5 types: type I, lordosis; type II, straight with no shifting; type III, straight with shifting; type IV, sigmoid; and type V, kyphosis. After ACAF, the spinal cord was maintained in good curvature with no shifting in all patients. No patient presented with C5 nerve palsy. Mean postoperative Japanese Orthopaedic Association score was significantly better than preoperatively (14.9 points vs. 9.0 points, P < 0.01), with mean improvement rate of 79.8%. ACAF provides in situ decompression and good curvature to the spinal cord. Good neurologic recovery is obtained with lower incidence of C5 nerve palsy when ACAF is used to treat DKS.

Cervical Laminoplasty: Indications, Surgical Considerations, and Clinical Outcomes.

Cervical laminoplasty was initially described for the management of cervical myelopathy resulting from multilevel stenosis secondary to ossification of the posterior longitudinal ligament. The general concepts are preservation of the dorsal elements, preservation of segmental motion, and expansion of the spinal canal via laminar manipulation. No clear evidence suggests that laminoplasty is superior to either posterior laminectomy or anterior cervical diskectomy and fusion. However, laminoplasty has its own advantages, indications, and complications. Surgeons have refined the technique to decrease complication rates and improve efficacy. Recent efforts have highlighted less invasive approaches that are muscle sparing and associated with less postoperative morbidity. Although the long-term outcomes suggest that cervical laminoplasty is safe and effective, continued research on the development of novel modifications that decrease common complications, such as C5 nerve palsy, axial neck pain, and loss of lordosis, is required.

Potential Mechanism for Some Postoperative C5 Palsies: An Anatomical Study.

Anatomical Study. Determine if shoulder depression (eg, taping the shoulders) might result in C5 nerve traction and subsequent injury. Postoperative C5 nerve palsy is a recognized entity that is still often enigmatic. Inferior shoulder depression is usually employed to assist with surgical visualization during cervical spine procedures. In the supine position, 10 adult fresh frozen human cadavers underwent dissection of the spinal cord and its adjacent dorsal, ventral roots, and spinal nerves from C4 to T1. In the supine position, the head was rotated ipsilaterally, contralaterally, and in lateral flexion. The shoulder was elevated, retracted, protracted, and depressed all with direct observation of nerve roots, intradural ventral/dorsal rootlets, or the spinal cord. The effects of these movements upon the cervical nerve rootlets were measured. The greatest displacement of nervous tissue was generated by shoulder depression and occurred primarily at the intradural rootlet level. The nerve rootlets that underwent the greatest average displacement were found at C5, with a decreasing gradient to C7 and no gross motion at C8 or T1. With maximal shoulder depression, C5-C7 rootlet tension produced cord movement to the ipsilateral side, touching the dura mater covering the lateral vertebral column with the C5 nerve root moving farthest. Shoulder depression is often used during cervical spine surgery. In cadavers, shoulder depression causes significant tension and displacement of the C5 nerve rootlets, and in the extreme, cord displacement to the ipsilateral side. This could be a mechanism for injury, putting patients at greater risk for postoperative C5 palsy. 5.

Does Resection of the Posterior Longitudinal Ligament Impact the Incidence of C5 Palsy After Cervical Corpectomy Procedures?: A Review of 459 Consecutive Cases.

Retrospective review. To evaluate key risk factors for the development of C5 palsy after cervical corpectomy, including resection of the posterior longitudinal ligament (PLL). Postoperative C5 palsy is a well-known complication after cervical spine surgery. It is unknown whether resection of the PLL affects the incidence of C5 palsy. We performed a retrospective review of 459 consecutive patients undergoing anterior cervical corpectomies over a 15-year period. Medical records were reviewed to gather demographic data, operative details, and the incidence of C5 palsy. We performed regression analyses to identify variables that predicted the development of C5 palsy. Our final analysis included 397 patients (females 51.4%, mean age 55.6 ± 11.6 yrs). Anterior corpectomy alone was performed in 255 (64.2%) patients, and combined anterior and posterior fusion was performed in 142 (35.8%) patients. Twenty-four patients (6.0%) developed C5 nerve palsy. Univariable regression demonstrated age greater than 65 (odds ratio, OR 2.7, 95% confidence interval, CI 1.2 to 6.3), corpectomy of three or more levels (OR 6.3, 95% CI 2.1 to 18.9), presence of ossification of the PLL (OR 4.3, 95% CI 1.6 to 11.7), and complete or partial resection of the PLL (OR 2.6, 95% CI 1.0 to 6.7) predicted development of C5 palsy. Multivariable regression demonstrated that the odds of getting C5 palsy with complete or partial resection of the PLL is 4.0 times (95% CI 1.5 to 10.5) higher compared with patients with an intact PLL. There were no significant differences in C5 palsy rates based on surgical approach (anterior vs. anterior plus posterior), sex, smoking status, or diabetes. Age greater than 65 years, corpectomy of three or more levels, presence of ossification of the PLL, and complete or partial resection of the PLL significantly predicted the development of C5 palsy. 4.

Long-term outcomes and prognostic analysis of modified open-door laminoplasty with lateral mass screw fusion in treatment of cervical spondylotic myelopathy.

ObjectivesThe purpose of the present study was to explore and analyze the long-term outcomes and factors that affect the prognosis of expansive open-door laminoplasty with lateral mass screw fusion in treatment of cervical spondylotic myelopathy (CSM).MethodsWe retrospectively reviewed 49 patients with multilevel CSM who had undergone expansive open-door laminoplasty with lateral mass screws fixation and fusion in our hospital between February 2008 and February 2012. The average follow-up period was 4.6 years. The clinical data of patients, including age, sex, operation records, pre- and postoperation Japanese Orthopedic Association (JOA) scores, cervical spine canal stenosis, and cervical curvature, were collected. Increased signal intensity (ISI) on T2-weighted magnetic resonance imaging and ossification of the posterior longitudinal ligament were also observed. Paired t-test was used to analyze the treatment effectiveness and recovery of neuronal function. The prognostic factors were analyzed with multivariable linear regression model.ResultsForty-nine patients with CSM with a mean age of 59.44 years were enrolled in this study. The average of preoperative JOA score was 9.14±2.25, and postoperative JOA score was 15.31±1.73. There was significant difference between the pre- and postoperative JOA scores. The clinical improvement rate was 80.27%. On follow-up, five patients had complaints of neck and shoulder pain, but no evidence of C5 nerve palsy was found. Developmental cervical spine canal stenosis was present in all patients before surgery. Before surgery, ISI was observed in eight patients, while ossification of the posterior longitudinal ligament was found in 12 patients. The average of preoperative cervical curvature was 21.27°±8.37° and postoperative cervical curvature was 20.09°±1.29°, and there was no significant difference between the pre- and postoperative cervical curvatures. Multivariable linear regression analysis results showed that the postoperation JOA scores were significantly affected by age, preoperative JOA scores, and preoperative ISI. Except one case of epidural hematoma, there were no complications associated with the surgery.ConclusionTreatment of CSM with posterior open-door laminoplasty with lateral mass screw fusion is effective with few complications. In addition, the normal cervical lordosis was well maintained. Age, preoperative JOA scores, and preoperative ISI were the independent factors that significantly affect disease prognosis and surgical outcomes.