Multivariate analysis of C-5 palsy incidence after cervical posterior fusion with instrumentation

Clinical article

View More View Less
  • 1 Departments of Orthopedic Surgery and
  • | 7 Preventive Medicine, Nagoya University Graduate School of Medicine;
  • | 2 Department of Orthopedic Surgery, Chubu Rosai Hospital, Nagoya;
  • | 3 Department of Orthopedic Surgery, Konan Kosei Hospital, Aichi;
  • | 4 Department of Orthopedic Surgery, Aichi Medical University Hospital, Aichi;
  • | 5 Department of Orthopedic Surgery, Nagoya Kyouritsu Hospital, Nagoya; and
  • | 6 Department of Orthopedic Surgery, Hamamatsu University School of Medicine, Shizuoka, Japan
Restricted access

Purchase Now

USD  $45.00

Spine - 1 year subscription bundle (Individuals Only)

USD  $376.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $612.00
Print or Print + Online

Object

Postoperative C-5 palsy is a significant complication resulting from cervical decompression procedures. Moreover, when cervical degenerative diseases are treated with a combination of decompression and posterior instrumented fusion, patients are at increased risk for C-5 palsy. However, the clinical and radiological features of this condition remain unclear. Therefore, the purpose of this study was to clarify the risk factors for developing postoperative C-5 palsy.

Methods

Eighty-four patients (mean age 60.1 years) who had undergone posterior instrumented fusion using cervical pedicle screws to treat nontraumatic lesions were independently reviewed. The authors analyzed the medical records of some of these patients who developed postoperative C-5 palsy, paying particular attention to their plain radiographs, MRI studies, and CT scans. Risk factors for postoperative C-5 palsy were assessed using multivariate logistic regression analysis. The cutoff values for the pre- and postoperative width of the intervertebral foramen (C4–5) were determined by receiver operating characteristic curve analysis.

Results

Ten (11.9%) of 84 patients developed postoperative C-5 palsy. Seven patients recovered fully from the neurological complications. The pre- and postoperative C4–5 angles showed significant kyphosis in the C-5 palsy group. The pre- and postoperative diameters of the C4–5 foramen on the palsy side were significantly smaller than those on the opposite side in the C-5 palsy group and those bilaterally in the non–C5 palsy group. Risk factors identified by multivariate logistic regression analysis were as follows: 1) ossification of the posterior longitudinal ligament (relative risk [RR] 7.22 [95% CI 1.03–50.55]); 2) posterior shift of the spinal cord (C4–5) (RR 1.73 [95% CI 1.00–2.98]); and 3) postoperative width of the C-5 intervertebral foramen (RR 0.33 [95% CI 0.14–0.79]). The cutoff values of the pre- and postoperative widths of the C-5 intervertebral foramen for C-5 palsy were 2.2 and 2.3 mm, respectively.

Conclusions

Patients with preoperative foraminal stenosis, posterior shift of the spinal cord, and additional iatrogenic foraminal stenosis due to cervical alignment correction were more likely to develop postoperative C-5 palsy after posterior instrumentation with fusion. Prophylactic foraminotomy at C4–5 might be useful when preoperative foraminal stenosis is present on CT. Furthermore, it might be useful for treating postoperative C-5 palsy. To prevent excessive posterior shift of the spinal cord, the authors recommend that appropriate kyphosis reduction should be considered carefully.

Abbreviations used in this paper:

AUC = area under the curve; CPS = cervical pedicle screw; CSA = cervical spine amyotrophy; CSM = cervical spondylotic myelopathy; JOA = Japanese Orthopaedic Association; MMT = manual muscle testing; OPLL = ossification of the posterior longitudinal ligament; ROC = receiver operating characteristic; RR = relative risk.

Spine - 1 year subscription bundle (Individuals Only)

USD  $376.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $612.00
  • 1

    Abumi K, , Ito M, & Kaneda K: Surgical treatment of cervical destructive spondyloarthropathy (DSA). Spine (Phila Pa 1976) 25:28992905, 2000

    • Search Google Scholar
    • Export Citation
  • 2

    Abumi K, , Itoh H, , Taneichi H, & Kaneda K: Transpedicular screw fixation for traumatic lesions of the middle and lower cervical spine: description of the techniques and preliminary report. J Spinal Disord 7:1928, 1994

    • Search Google Scholar
    • Export Citation
  • 3

    Abumi K, & Kaneda K: Pedicle screw fixation for nontraumatic lesions of the cervical spine. Spine (Phila Pa 1976) 22:18531863, 1997

  • 4

    Abumi K, , Shono Y, , Ito M, , Taneichi H, , Kotani Y, & Kaneda K: Complications of pedicle screw fixation in reconstructive surgery of the cervical spine. Spine (Phila Pa 1976) 25:962969, 2000

    • Search Google Scholar
    • Export Citation
  • 5

    Abumi K, , Shono Y, , Taneichi H, , Ito M, & Kaneda K: Correction of cervical kyphosis using pedicle screw fixation systems. Spine (Phila Pa 1976) 24:23892396, 1999

    • Search Google Scholar
    • Export Citation
  • 6

    Chiba K, , Toyama Y, , Matsumoto M, , Maruiwa H, , Watanabe M, & Hirabayashi K: Segmental motor paralysis after expansive open-door laminoplasty. Spine (Phila Pa 1976) 27:21082115, 2002

    • Search Google Scholar
    • Export Citation
  • 7

    Fan D, , Schwartz DM, , Vaccaro AR, , Hilibrand AS, & Albert TJ: Intraoperative neurophysiologic detection of iatrogenic C5 nerve root injury during laminectomy for cervical compression myelopathy. Spine (Phila Pa 1976) 27:24992502, 2002

    • Search Google Scholar
    • Export Citation
  • 8

    Fehlings MG, , Cooper PR, & Errico TJ: Posterior plates in the management of cervical instability: long-term results in 44 patients. J Neurosurg 81:341349, 1994

    • Search Google Scholar
    • Export Citation
  • 9

    Harrison DD, , Cailliet R, , Janik TJ, , Troyanovich SJ, , Harrison DE, & Holland B: Elliptical modeling of the sagittal lumbar lordosis and segmental rotation angles as a method to discriminate between normal and low back pain subjects. J Spinal Disord 11:430439, 1998

    • Search Google Scholar
    • Export Citation
  • 10

    Heller JG, , Silcox DH III, & Sutterlin CE III: Complications of posterior cervical plating. Spine (Phila Pa 1976) 20:24422448, 1995

  • 11

    Hirabayashi K, , Watanabe K, , Wakano K, , Suzuki N, , Satomi K, & Ishii Y: Expansive open-door laminoplasty for cervical spinal stenotic myelopathy. Spine (Phila Pa 1976) 8:693699, 1983

    • Search Google Scholar
    • Export Citation
  • 12

    Hojo Y, , Ito M, , Abumi K, , Kotani Y, , Sudo H, & Takahata M, et al.: A late neurological complication following posterior correction surgery of severe cervical kyphosis. Eur Spine J 20:890898, 2011

    • Search Google Scholar
    • Export Citation
  • 13

    Imagama S, , Matsuyama Y, , Yukawa Y, , Kawakami N, , Kamiya M, & Kanemura T, et al.: C5 palsy after cervical laminoplasty: a multicentre study. J Bone Joint Surg Br 92:393400, 2010

    • Search Google Scholar
    • Export Citation
  • 14

    Kaneyama S, , Sumi M, , Kanatani T, , Kasahara K, , Kanemura A, & Takabatake M, et al.: Prospective study and multivariate analysis of the incidence of C5 palsy after cervical laminoplasty. Spine (Phila Pa 1976) 35:E1553E1558, 2010

    • Search Google Scholar
    • Export Citation
  • 15

    Koller H, , Hempfing A, , Ferraris L, , Maier O, , Hitzl W, & Metz-Stavenhagen P: 4- and 5-level anterior fusions of the cervical spine: review of literature and clinical results. Eur Spine J 16:20552071, 2007

    • Search Google Scholar
    • Export Citation
  • 16

    Liu T, , Xu W, , Cheng T, & Yang HL: Anterior versus posterior surgery for multilevel cervical myelopathy, which one is better? A systematic review. Eur Spine J 20:224235, 2011

    • Search Google Scholar
    • Export Citation
  • 17

    O'Shaughnessy BA, , Liu JC, , Hsieh PC, , Koski TR, , Ganju A, & Ondra SL: Surgical treatment of fixed cervical kyphosis with myelopathy. Spine (Phila Pa 1976) 33:771778, 2008

    • Search Google Scholar
    • Export Citation
  • 18

    Sakaura H, , Hosono N, , Mukai Y, , Ishii T, & Yoshikawa H: C5 palsy after decompression surgery for cervical myelopathy: review of the literature. Spine (Phila Pa 1976) 28:24472451, 2003

    • Search Google Scholar
    • Export Citation
  • 19

    Suda K, , Abumi K, , Ito M, , Shono Y, , Kaneda K, & Fujiya M: Local kyphosis reduces surgical outcomes of expansive open-door laminoplasty for cervical spondylotic myelopathy. Spine (Phila Pa 1976) 28:12581262, 2003

    • Search Google Scholar
    • Export Citation
  • 20

    Takemitsu M, , Cheung KM, , Wong YW, , Cheung WY, & Luk KD: C5 nerve root palsy after cervical laminoplasty and posterior fusion with instrumentation. J Spinal Disord Tech 21:267272, 2008

    • Search Google Scholar
    • Export Citation
  • 21

    Tanaka N, , Nakanishi K, , Fujiwara Y, , Kamei N, & Ochi M: Postoperative segmental C5 palsy after cervical laminoplasty may occur without intraoperative nerve injury: a prospective study with transcranial electric motor-evoked potentials. Spine (Phila Pa 1976) 31:30133017, 2006

    • Search Google Scholar
    • Export Citation
  • 22

    Tsuzuki N, , Abe R, , Saiki K, & Zhongshi L: Extradural tethering effect as one mechanism of radiculopathy complicating posterior decompression of the cervical spinal cord. Spine (Phila Pa 1976) 21:203211, 1996

    • Search Google Scholar
    • Export Citation
  • 23

    Tsuzuki N, , Zhogshi L, , Abe R, & Saiki K: Paralysis of the arm after posterior decompression of the cervical spinal cord. I. Anatomical investigation of the mechanism of paralysis. Eur Spine J 2:191196, 1993

    • Search Google Scholar
    • Export Citation
  • 24

    Yanase M, , Matsuyama Y, , Mori K, , Nakamichi Y, , Yano T, & Naruse T, et al.: Intraoperative spinal cord monitoring of C5 palsy after cervical laminoplasty. J Spinal Disord Tech 23:170175, 2010

    • Search Google Scholar
    • Export Citation
  • 25

    Yukawa Y, , Kato F, , Yoshihara H, , Yanase M, & Ito K: Cervical pedicle screw fixation in 100 cases of unstable cervical injuries: pedicle axis views obtained using fluoroscopy. J Neurosurg Spine 5:488493, 2006

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 846 201 21
Full Text Views 278 51 5
PDF Downloads 223 44 5
EPUB Downloads 0 0 0