Patterns of neurological deficits and recovery of postoperative C5 nerve palsy

View More View Less
  • 1 Division of Neurosurgery and
  • 2 Department of Orthopedic Surgery, Maimonides Medical Center, Brooklyn; and
  • 3 Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, New York
Restricted access

Purchase Now

USD  $45.00

Spine - 1 year subscription bundle (Individuals Only)

USD  $369.00

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

USD  $600.00
Print or Print + Online

OBJECTIVE

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

ABBREVIATIONS ACDF = anterior cervical discectomy and fusion; BMI = body mass index; CLF = cervical laminectomy and fusion; EMG = electromyography; MEP = motor evoked potential; mJOA = modified Japanese Orthopaedic Association; PEEK = polyetheretherketone; SSEP = somatosensory evoked potential.

Spine - 1 year subscription bundle (Individuals Only)

USD  $369.00

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

USD  $600.00

Contributor Notes

Correspondence John K. Houten: Maimonides Medical Center, Brooklyn, NY. jkhmd@yahoo.com.

INCLUDE WHEN CITING Published online July 31, 2020; DOI: 10.3171/2020.5.SPINE20514.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

  • 1

    Jack A, Ramey WL, Dettori JR, Factors associated with C5 palsy following cervical spine surgery: a systematic review. Global Spine J. 2019;9(8):881894.

    • Search Google Scholar
    • Export Citation
  • 2

    Kurakawa T, Miyamoto H, Kaneyama S, C5 nerve palsy after posterior reconstruction surgery: predictive risk factors of the incidence and critical range of correction for kyphosis. Eur Spine J. 2016;25(7):20602067.

    • Search Google Scholar
    • Export Citation
  • 3

    Nassr A, Eck JC, Ponnappan RK, The incidence of C5 palsy after multilevel cervical decompression procedures: a review of 750 consecutive cases. Spine (Phila Pa 1976). 2012;37(3):174178.

    • Search Google Scholar
    • Export Citation
  • 4

    O’Toole JE, Olson TJ, Kaiser MG. Surgical management of dissociated motor loss following complex cervical spine reconstruction. Spine (Phila Pa 1976). 2004;29(3):E56E60.

    • Search Google Scholar
    • Export Citation
  • 5

    Houten JK, Cooper PR. Laminectomy and posterior cervical plating for multilevel cervical spondylotic myelopathy and ossification of the posterior longitudinal ligament: effects on cervical alignment, spinal cord compression, and neurological outcome. Neurosurgery. 2003;52(5):10811088.

    • Search Google Scholar
    • Export Citation
  • 6

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

    • Search Google Scholar
    • Export Citation
  • 7

    Klement MR, Kleeman LT, Blizzard DJ, C5 palsy after cervical laminectomy and fusion: does width of laminectomy matter? Spine J. 2016;16(4):462467.

    • Search Google Scholar
    • Export Citation
  • 8

    Liu T, Zou W, Han Y, Wang Y. Correlative study of nerve root palsy and cervical posterior decompression laminectomy and internal fixation. Orthopedics. 2010;33(8):10.3928/01477447-20100625-08.

    • Search Google Scholar
    • Export Citation
  • 9

    Sakaura H, Hosono N, Mukai Y, C5 palsy after decompression surgery for cervical myelopathy: review of the literature. Spine (Phila Pa 1976). 2003;28(21):24472451.

    • Search Google Scholar
    • Export Citation
  • 10

    Gandhoke G, Wu JC, Rowland NC, Anterior corpectomy versus posterior laminoplasty: is the risk of postoperative C-5 palsy different? Neurosurg Focus. 2011;31(4):E12.

    • Search Google Scholar
    • Export Citation
  • 11

    Shou F, Li Z, Wang H, 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
  • 12

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

    • Search Google Scholar
    • Export Citation
  • 13

    Minoda Y, Nakamura H, Konishi S, 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
  • 14

    Radcliff KE, Limthongkul W, Kepler CK, Cervical laminectomy width and spinal cord drift are risk factors for postoperative C5 palsy. J Spinal Disord Tech. 2014;27(2):8692.

    • Search Google Scholar
    • Export Citation
  • 15

    Shinomiya K, Okawa A, Nakao K, 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
  • 16

    Shiozaki T, Otsuka H, Nakata Y, Spinal cord shift on magnetic resonance imaging at 24 hours after cervical laminoplasty. Spine (Phila Pa 1976). 2009;34(3):274279.

    • Search Google Scholar
    • Export Citation
  • 17

    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
  • 18

    Katsumi K, Yamazaki A, Watanabe K, 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
  • 19

    Bydon M, Macki M, Aygun N, Development of postoperative C5 palsy is associated with wider posterior decompressions: an analysis of 41 patients. Spine J. 2014;14(12):28612867.

    • Search Google Scholar
    • Export Citation
  • 20

    Nakajima H, Kuroda H, Watanabe H, 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
  • 21

    Odate S, Shikata J, Yamamura S, Soeda T. Extremely wide and asymmetric anterior decompression causes postoperative C5 palsy: an analysis of 32 patients with postoperative C5 palsy after anterior cervical decompression and fusion. Spine (Phila Pa 1976). 2013;38(25):21842189.

    • Search Google Scholar
    • Export Citation
  • 22

    Saunders RL. On the pathogenesis of the radiculopathy complicating multilevel corpectomy. Neurosurgery. 1995;37(3):408413.

  • 23

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

    • Search Google Scholar
    • Export Citation
  • 24

    Fan D, Schwartz DM, Vaccaro AR, Intraoperative neurophysiologic detection of iatrogenic C5 nerve root injury during laminectomy for cervical compression myelopathy. Spine (Phila Pa 1976). 2002;27(22):24992502.

    • Search Google Scholar
    • Export Citation
  • 25

    Liu T, Kong J, Zou W, The correlation study of C5 nerve root palsy and common body position in posterior total laminectomy decompression and instrumentation. Turk Neurosurg. 2016;26(2):280285.

    • Search Google Scholar
    • Export Citation
  • 26

    Woodroffe RW, Helland LC, Bryant A, Intraoperative shoulder traction as cause of C5 palsy: magnetic resonance imaging study. World Neurosurg. 2020;136:e393e397.

    • Search Google Scholar
    • Export Citation
  • 27

    Hosono N, Miwa T, Mukai Y, Potential risk of thermal damage to cervical nerve roots by a high-speed drill. J Bone Joint Surg Br. 2009;91(11):15411544.

    • Search Google Scholar
    • Export Citation
  • 28

    Takenaka S, Hosono N, Mukai Y, Significant reduction in the incidence of C5 palsy after cervical laminoplasty using chilled irrigation water. Bone Joint J. 2016;98-B(1):117124.

    • Search Google Scholar
    • Export Citation
  • 29

    Alafifi T, Kern R, Fehlings M. Clinical and MRI predictors of outcome after surgical intervention for cervical spondylotic myelopathy. J Neuroimaging. 2007;17(4):315322.

    • Search Google Scholar
    • Export Citation
  • 30

    Yagi M, Ninomiya K, Kihara M, Horiuchi Y. Long-term surgical outcome and risk factors in patients with cervical myelopathy and a change in signal intensity of intramedullary spinal cord on Magnetic Resonance imaging. J Neurosurg Spine. 2010;12(1):5965.

    • Search Google Scholar
    • Export Citation
  • 31

    Fischer I, Haas C, Raghupathi R, Jin Y. Spinal cord concussion: studying the potential risks of repetitive injury. Neural Regen Res. 2016;11(1):5860.

    • Search Google Scholar
    • Export Citation
  • 32

    Jin Y, Bouyer J, Haas C, Fischer I. Evaluation of the anatomical and functional consequences of repetitive mild cervical contusion using a model of spinal concussion. Exp Neurol. 2015;271:175188.

    • Search Google Scholar
    • Export Citation
  • 33

    Fassett DR, Harrop JS, Maltenfort M, Mortality rates in geriatric patients with spinal cord injuries. J Neurosurg Spine. 2007;7(3):277281.

    • Search Google Scholar
    • Export Citation
  • 34

    Iverson GL, Gaetz M, Lovell MR, Collins MW. Cumulative effects of concussion in amateur athletes. Brain Inj. 2004;18(5):433443.

  • 35

    Lombard FW, Mathew JP. Neurocognitive dysfunction following cardiac surgery. Semin Cardiothorac Vasc Anesth. 2010;14(2):102110.

  • 36

    Matser JT, Kessels AG, Jordan BD, Chronic traumatic brain injury in professional soccer players. Neurology. 1998;51(3):791796.

  • 37

    Brown JM, Yee A, Ivens RA, Post-cervical decompression parsonage-turner syndrome represents a subset of C5 palsy: six cases and a review of the literature: case report. Neurosurgery. 2010;67(6):E1831E1844.

    • Search Google Scholar
    • Export Citation
  • 38

    Tanaka N, Nakanishi K, Fujiwara Y, 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). 2006;31(26):30133017.

    • Search Google Scholar
    • Export Citation
  • 39

    Jimenez JC, Sani S, Braverman B, Palsies of the fifth cervical nerve root after cervical decompression: prevention using continuous intraoperative electromyography monitoring. J Neurosurg Spine. 2005;3(2):9297.

    • Search Google Scholar
    • Export Citation
  • 40

    Currier BL. Neurological complications of cervical spine surgery: C5 palsy and intraoperative monitoring. Spine (Phila Pa 1976). 2012;37(5):E328E334.

    • Search Google Scholar
    • Export Citation
  • 41

    Matsunaga S, Sakou T, Imamura T, Morimoto N. Dissociated motor loss in the upper extremities. Clinical features and pathophysiology. Spine (Phila Pa 1976). 1993;18(14):19641967.

    • Search Google Scholar
    • Export Citation
  • 42

    Levin KH, Maggiano HJ, Wilbourn AJ. Cervical radiculopathies: comparison of surgical and EMG localization of single-root lesions. Neurology. 1996;46(4):10221025.

    • Search Google Scholar
    • Export Citation
  • 43

    Marzo JM, Simmons EH, Kallen F. Intradural connections between adjacent cervical spinal roots. Spine (Phila Pa 1976). 1987;12(10):964968.

    • Search Google Scholar
    • Export Citation
  • 44

    Park P, Lewandrowski KU, Ramnath S, Benzel EC. Brachial neuritis: an under-recognized cause of upper extremity paresis after cervical decompression surgery. Spine (Phila Pa 1976). 2007;32(22):E640E644.

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 859 859 859
Full Text Views 70 70 70
PDF Downloads 41 41 41
EPUB Downloads 0 0 0