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Hideaki Nakajima, Hiroyuki Kuroda, Shuji Watanabe, Kazuya Honjoh, and Akihiko Matsumine

OBJECTIVE

The pathomechanism of C5 palsy after cervical open-door laminoplasty is unknown despite the relatively common occurrence of this condition postoperatively. The aim of this study was to review clinical and imaging findings in patients with C5 palsy and to propose countermeasures for prevention of this complication.

METHODS

Between 2001 and 2018, 326 patients with cervical myelopathy underwent cervical laminoplasty at the authors’ hospital, 10 (3.1%) of whom developed C5 palsy. Clinical features and radiological findings of patients with and without C5 palsy were analyzed.

RESULTS

In patients with C5 palsy, the width of the C5 intervertebral foramen was narrower and the position of the bony gutter was wider beyond the medial part of the C5 facet joint. The distance between the lateral side of the spinal cord and bony gutter was significantly greater in patients with C5 palsy. Patient characteristics, disease, cervical alignment, spinal canal expansion rate, anterior protrusion of the C5 superior articular process, high-intensity area in the spinal cord on T2-weighted MR images, posterior shift of the spinal cord, and operative time did not differ significantly between patients with and without C5 palsy.

CONCLUSIONS

The position of the bony gutter may have a central role in the pathomechanism of postoperative C5 palsy, especially in patients with a narrow C5 intervertebral foramen. Making an excessively lateral bony gutter might be a cause of C5 nerve root kinking at the intervertebral foramen. To prevent the occurrence of C5 palsy, it is important to confirm the medial line of the facet joint on the preoperative CT scan, and a high-speed burr should be started from inside of the facet joint and manipulated in a direction that allows the ligamentum flavum to be identified.

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Hideaki Nakajima, Kazuya Honjoh, Shuji Watanabe, Arisa Kubota, and Akihiko Matsumine

OBJECTIVE

The development of diffuse idiopathic skeletal hyperostosis (DISH) often requires further surgery after posterior decompression without fusion because of postoperative intervertebral instability. However, there is no information on whether fusion surgery is recommended for these patients as the standard surgery. The aim of this study was to review the clinical and imaging findings in lumbar spinal canal stenosis (LSS) patients with DISH affecting the lumbar segment (L-DISH) and to assess the indication for fusion surgery in patients with DISH.

METHODS

A total of 237 patients with LSS underwent 1- or 2-level posterior lumbar interbody fusion (PLIF) at the authors’ hospital and had a minimum follow-up period of 2 years. Patients with L-DISH were classified as such (n = 27, 11.4%), whereas those without were classified as controls (non-L-DISH; n = 210, 88.6%). The success rates of short-level PLIF were compared in patients with and those without L-DISH. The rates of adjacent segment disease (ASD), pseudarthrosis, postoperative symptoms, and revision surgery were examined in the two groups.

RESULTS

L-DISH from L2 to L4 correlated significantly with early-onset ASD, pseudarthrosis, and the appearance of postsurgical symptoms, especially at a lower segment and one distance from the segment adjacent to L-DISH, which were associated with the worst clinical outcome. Significantly higher percentages of L-DISH patients developed ASD and pseudarthrosis than those in the non-L-DISH group (40.7% vs 4.8% and 29.6% vs 2.4%, respectively). Of those patients with ASD and/or pseudarthrosis, 69.2% were symptomatic and 11.1% underwent revision surgery.

CONCLUSIONS

The results highlighted the negative impact of short-level PLIF surgery for patients with L-DISH. Increased mechanical stress below the fused segment was considered the reason for the poor clinical outcome.