Impact of morphological restoration of the spinal cord from the preoperative to early postoperative periods on C5 palsy development

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  • 1 Department of Orthopedic Surgery, Osaka Medical College, Takatsuki, Japan
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OBJECTIVE

C5 palsy (C5P) is a known complication of cervical decompression surgery. The tethering effect of the C5 nerve root following the posterior shift of the spinal cord is the most accepted pathologic mechanism for C5P development; however, this mechanism cannot fully explain C5P by itself in clinical practice. Separately, some studies have suggested that preoperative severe spinal cord compression and postoperative morphological changes in the spinal cord affect C5P development; however, no previous study has quantitatively addressed these possibilities. The aim of this study was to examine whether spinal cord morphology and morphological restoration after surgery affect C5P development.

METHODS

The authors reviewed consecutive patients with degenerative cervical myelopathy who underwent laminoplasty including the C3–4 and C4–5 intervertebral disc levels. All participants underwent MRI both preoperatively and within 4 weeks postoperatively. To assess the severity of spinal cord compression, the compression ratio (CR; spinal cord sagittal diameter/transverse diameter) was calculated. As an index of morphological changes in the spinal cord during the early postoperative period, the change rate of CR (CrCR, %) was calculated as CRwithin 4 weeks postoperatively/CRpreoperatively × 100. These measurements were performed at both the C3–4 and C4–5 intervertebral disc levels. The study cohort was divided into C5P and non-C5P (NC5P) groups; then, CR and CrCR, in addition to other radiographic variables associated with C5P development, were compared between the groups.

RESULTS

A total of 114 patients (mean age 67.6 years, 58.8% men) were included in the study, with 5 and 109 patients in the C5P and NC5P groups, respectively. Preoperative CR at both the C3–4 and C4–5 levels was significantly lower in the C5P group than in the NC5P group (0.35 vs 0.44, p = 0.042 and 0.27 vs 0.39, p = 0.021, respectively). Patients with C5P exhibited significantly higher CrCR at the C3–4 level than those without (139.3% vs 119.0%, p = 0.046), but the same finding was not noted for CrCR at the C4–5 level. There were no significant differences in other variables between the groups.

CONCLUSIONS

This study reveals that severe compression of the spinal cord and its greater morphological restoration during the early postoperative period affect C5P development. These findings could support the involvement of segmental cord disorder theory, characterized as the reperfusion phenomenon, in the pathomechanism of C5P, in addition to the tethering effect.

ABBREVIATIONS

C5P = C5 palsy; CLP = cervical laminoplasty; CR = compression ratio (spinal cord sagittal diameter/transverse diameter); CrCR = change rate of CR (CRwithin 4 weeks postoperatively/CRpreoperatively × 100); Csev = most severely compressed spinal level (smaller CR among C3–4 and C4–5 levels); CSM = cervical spondylotic myelopathy; DCM = degenerative cervical myelopathy; ds = sagittal diameter of the spinal cord; dt = transverse diameter of the spinal cord; HIZ = high-intensity zone in the spinal cord on T2-weighted image; JOA = Japanese Orthopaedic Association; NC5P = non-C5P; OPLL = ossification of the posterior longitudinal ligament; rs = Spearman correlation coefficient.

Images from Shimizu et al. (pp 616–623).

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  • 1

    Hojo Y, Ito M, Abumi K, et al. A late neurological complication following posterior correction surgery of severe cervical kyphosis. Eur Spine J. 2011;20(6):890898.

    • Search Google Scholar
    • Export Citation
  • 2

    Baba S, Ikuta K, Ikeuchi H, et al. Risk factor analysis for C5 palsy after double-door laminoplasty for cervical spondylotic myelopathy. Asian Spine J. 2016;10(2):298308.

    • Search Google Scholar
    • Export Citation
  • 3

    Scoville WB. Cervical spondylosis treated by bilateral facetectomy and laminectomy. J Neurosurg. 1961;18:423428.

  • 4

    Stoops WL, King RB. Neural complications of cervical spondylosis: their response to laminectomy and foramenotomy. J Neurosurg. 1962;19:986999.

    • Search Google Scholar
    • Export Citation
  • 5

    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). 1996;21(2):203211.

    • Search Google Scholar
    • Export Citation
  • 6

    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. 1993;2(4):191196.

    • Search Google Scholar
    • Export Citation
  • 7

    Imagama S, Matsuyama Y, Yukawa Y, et al. C5 palsy after cervical laminoplasty: a multicentre study. J Bone Joint Surg Br. 2010;92(3):393400.

    • Search Google Scholar
    • Export Citation
  • 8

    Usami Y, Nakaya Y, Hayama S, et al. Impact of multifidus muscle swelling on C5 palsy after cervical laminoplasty. Spine (Phila Pa 1976). 2020;45(1):E10E17.

    • Search Google Scholar
    • Export Citation
  • 9

    Shinomiya K, Okawa A, Nakao K, et al. Morphology of C5 ventral nerve rootlets as part of dissociated motor loss of deltoid muscle. Spine (Phila Pa 1976). 1994;19(22):25012504.

    • Search Google Scholar
    • Export Citation
  • 10

    Katsumi K, Yamazaki A, Watanabe K, et al. Can prophylactic bilateral C4/C5 foraminotomy prevent postoperative C5 palsy after open-door laminoplasty?: a prospective study. Spine (Phila Pa 1976). 2012;37(9):748754.

    • Search Google Scholar
    • Export Citation
  • 11

    Nori S, Aoyama R, Ninomiya K, et al. Cervical laminectomy of limited width prevents postoperative C5 palsy: a multivariate analysis of 263 muscle-preserving posterior decompression cases. Eur Spine J. 2017;26(9):23932403.

    • Search Google Scholar
    • Export Citation
  • 12

    Chiba K, Toyama Y, Matsumoto M, et al. Segmental motor paralysis after expansive open-door laminoplasty. Spine (Phila Pa 1976). 2002;27(19):21082115.

    • Search Google Scholar
    • Export Citation
  • 13

    Hashimoto M, Mochizuki M, Aiba A, et al. C5 palsy following anterior decompression and spinal fusion for cervical degenerative diseases. Eur Spine J. 2010;19(10):17021710.

    • Search Google Scholar
    • Export Citation
  • 14

    Kaneko K, Hashiguchi A, Kato Y, et al. Investigation of motor dominant C5 paralysis after laminoplasty from the results of evoked spinal cord responses. J Spinal Disord Tech. 2006;19(5):358361.

    • Search Google Scholar
    • Export Citation
  • 15

    Minoda Y, Nakamura H, Konishi S, et al. Palsy of the C5 nerve root after midsagittal-splitting laminoplasty of the cervical spine. Spine (Phila Pa 1976). 2003;28(11):11231127.

    • Search Google Scholar
    • Export Citation
  • 16

    Ozawa H, Aizawa T, Tateda S, et al. Spinal cord swelling after surgery in cervical spondylotic myelopathy: relationship with intramedullary Gd-DTPA enhancement on MRI. Clin Spine Surg. 2018;31(7):E363E367.

    • Search Google Scholar
    • Export Citation
  • 17

    Nagashima H, Morio Y, Teshima R. Re-aggravation of myelopathy due to intramedullary lesion with spinal cord enlargement after posterior decompression for cervical spondylotic myelopathy: serial magnetic resonance evaluation. Spinal Cord. 2002;40(3):137141.

    • Search Google Scholar
    • Export Citation
  • 18

    Lee J, Koyanagi I, Hida K, et al. Spinal cord edema: unusual magnetic resonance imaging findings in cervical spondylosis. J Neurosurg. 2003;99 (1)(suppl):813.

    • Search Google Scholar
    • Export Citation
  • 19

    Seichi A, Takeshita K, Kawaguchi H, et al. Neurologic level diagnosis of cervical stenotic myelopathy. Spine (Phila Pa 1976). 2006;31(12):13381343.

    • Search Google Scholar
    • Export Citation
  • 20

    Shimizu T, Shimada H, Shirakura K. Scapulohumeral reflex (Shimizu). Its clinical significance and testing maneuver. Spine (Phila Pa 1976). 1993;18(15):21822190.

    • Search Google Scholar
    • Export Citation
  • 21

    Matsumoto M, Ishikawa M, Ishii K, et al. Usefulness of neurological examination for diagnosis of the affected level in patients with cervical compressive myelopathy: prospective comparative study with radiological evaluation. J Neurosurg Spine. 2005;2(5):535539.

    • Search Google Scholar
    • Export Citation
  • 22

    Cadotte DW, Cadotte A, Cohen-Adad J, et al. Characterizing the location of spinal and vertebral levels in the human cervical spinal cord. AJNR Am J Neuroradiol. 2015;36(4):803810.

    • Search Google Scholar
    • Export Citation
  • 23

    Choi YA, Kim K. Stenosis and neurologic level discrepancies in cervical spondylotic myelopathy. PM R. 2018;10(10):10511055.

  • 24

    Yonemura H, Kaneko K, Taguchi T, et al. Nerve root distribution of deltoid and biceps brachii muscle in cervical spondylotic myelopathy: a potential risk factor for postoperative shoulder muscle weakness after posterior decompression. J Orthop Sci. 2004;9(6):540544.

    • Search Google Scholar
    • Export Citation
  • 25

    Fujishiro T, Nakano A, Baba I, et al. Double-door cervical laminoplasty with suture anchors: evaluation of the clinical performance of the constructs. Eur Spine J. 2017;26(4):11211128.

    • Search Google Scholar
    • Export Citation
  • 26

    Nakajima H, Kuroda H, Watanabe S, et al. Risk factors and preventive measures for C5 palsy after cervical open-door laminoplasty. J Neurosurg Spine. 2020;32(4):592599.

    • Search Google Scholar
    • Export Citation
  • 27

    Yano T, Fujishiro T, Obo T, et al. Surgical outcomes of postural instability in patients with cervical myelopathy. Clin Spine Surg. 2020;33(10):E466E471.

    • Search Google Scholar
    • Export Citation
  • 28

    Nagai T, Takahashi Y, Endo K, et al. Analysis of spastic gait in cervical myelopathy: Linking compression ratio to spatiotemporal and pedobarographic parameters. Gait Posture. 2018;59:152156.

    • Search Google Scholar
    • Export Citation
  • 29

    Chen G, Li J, Wei F, et al. Short-term predictive potential of quantitative assessment of spinal cord impairment in patients undergoing French-door Laminoplasty for degenerative cervical myelopathy: preliminary results of an exploratory study exploiting intraoperative ultrasound data. BMC Musculoskelet Disord. 2020;21(1):336.

    • Search Google Scholar
    • Export Citation
  • 30

    Okada Y, Ikata T, Yamada H, et al. Magnetic resonance imaging study on the results of surgery for cervical compression myelopathy. Spine (Phila Pa 1976). 1993;18(14):20242029.

    • Search Google Scholar
    • Export Citation
  • 31

    Seichi A, Takeshita K, Kawaguchi H, et al. Postoperative expansion of intramedullary high-intensity areas on T2-weighted magnetic resonance imaging after cervical laminoplasty. Spine (Phila Pa 1976). 2004;29(13):14781482.

    • Search Google Scholar
    • Export Citation
  • 32

    Hirabayashi K, Miyakawa J, Satomi K, et al. Operative results and postoperative progression of ossification among patients with ossification of cervical posterior longitudinal ligament. Spine (Phila Pa 1976). 1981;6(4):354364.

    • Search Google Scholar
    • Export Citation
  • 33

    Guildford JP. Fundamental Statistics in Psychology and Education. McGraw-Hill; 1956.

  • 34

    Yoshihara H, Margalit A, Yoneoka D. Incidence of C5 palsy: meta-analysis and potential etiology. World Neurosurg. 2019;122:e828e837.

  • 35

    Shou F, Li Z, Wang H, et al. Prevalence of C5 nerve root palsy after cervical decompressive surgery: a meta-analysis. Eur Spine J. 2015;24(12):27242734.

    • Search Google Scholar
    • Export Citation
  • 36

    Gu Y, Cao P, Gao R, et al. Incidence and risk factors of C5 palsy following posterior cervical decompression: a systematic review. PLoS One. 2014;9(8):e101933.

    • Search Google Scholar
    • Export Citation
  • 37

    Pennington Z, Lubelski D, Westbroek EM, et al. Time to recovery predicted by the severity of postoperative C5 palsy. J Neurosurg Spine. 2019;32(2):191199.

    • Search Google Scholar
    • Export Citation
  • 38

    Hasegawa K, Homma T, Chiba Y. Upper extremity palsy following cervical decompression surgery results from a transient spinal cord lesion. Spine (Phila Pa 1976). 2007;32(6):E197E202.

    • Search Google Scholar
    • Export Citation
  • 39

    Turnbull IM. Microvasculature of the human spinal cord. J Neurosurg. 1971;35(2):141147.

  • 40

    Kolesár D, Kolesárová M, Pavel J, et al. Region-specific sensitivity of the spinal cord to ischemia/reperfusion: the dynamic of changes in catalytic NOS activity. J Physiol Sci. 2009;59(2):97103.

    • Search Google Scholar
    • Export Citation
  • 41

    Luo W, Li Y, Xu Q, et al. Cervical spondylotic amyotrophy: a systematic review. Eur Spine J. 2019;28(10):22932301.

  • 42

    Kaneko K, Taguchi T, Toyoda K, et al. Distal-type cervical spondylotic amyotrophy: assessment of pathophysiology from radiological findings on magnetic resonance imaging and epidurally recorded spinal cord responses. Spine (Phila Pa 1976). 2004;29(9):E185E188.

    • Search Google Scholar
    • Export Citation
  • 43

    Nakashima H, Yukawa Y, Suda K, et al. Abnormal findings on magnetic resonance images of the cervical spines in 1211 asymptomatic subjects. Spine (Phila Pa 1976). 2015;40(6):392398.

    • Search Google Scholar
    • Export Citation
  • 44

    Tetreault L, Lange SF, Chotai S, et al. A systematic review of definitions for neurological complications and disease progression in patients treated surgically for degenerative cervical myelopathy. Spine (Phila Pa 1976). 2019;44(18):13181331.

    • Search Google Scholar
    • Export Citation

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