The role of iatrogenic foraminal stenosis from lordotic correction in the development of C5 palsy after posterior laminectomy and fusion

Study Design: Systematic review. Objectives: C5 palsy (C5P) is a not uncommon and disabling postoperative complication with a reported incidence varying between 0% and 30%. Among others, one explanation for its occurrence includes foraminal nerve root tethering. Although different risk factors have been reported, controversy about its causation and prevention persists. Inconsistent study findings contribute to the persistent ambiguity leading to an assumption of a multifactorial nature of the underlying C5P pathophysiology. Here, we report the results of a systematic review on C5P with narrow inclusion criteria in the hope of elucidating risk factors for C5P due to a common pathophysiological mechanism. Methods: Electronic databases from inception to March 9, 2019 and references of articles were searched. Narrow inclusion criteria were applied to identify studies investigating demographic, clinical, surgical, and radiographic factors associated with postoperative C5P. Results: Sixteen studies were included after initial screening of 122 studies. Eighty-four risk factors were analyzed; 27 in ≥2 studies and 57 in single studies. The pooled prevalence of C5P was 6.0% (range: 4.2%-24.1%) with no consistent evidence that C5P was associated with demographic, clinical, or specific surgical factors. Of the radiographic factors assessed, specifically decreased foraminal diameter and preoperative cord rotation were identified as risk factors for C5P. Conclusion: Although risk factors for C5P have been reported, ambiguity remains due to potentially multifactorial pathophysiology and study heterogeneity. We found foraminal diameter and cord rotation to be associated with postoperative C5P occurrence in our meta-analysis. These findings support the notion that factors contributing to, and acting synergistically with foraminal stenosis increase the risk of postoperative C5P.

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A Case of Successful Foraminotomy for Severe Bilateral C5 Palsy following Posterior Decompression and Fusion Surgery for Cervical Ossification of Posterior Longitudinal Ligament

Case Reports in Orthopedics ◽

10.1155/2016/1250810 ◽

2016 ◽

Vol 2016 ◽

pp. 1-5 ◽

Cited By ~ 1

Author(s):

Yoshifumi Kudo ◽

Tomoaki Toyone ◽

Toshiyuki Shirahata ◽

Tomoyuki Ozawa ◽

Akira Matsuoka ◽

...

Keyword(s):

Standard Procedure ◽

Posterior Longitudinal Ligament ◽

Muscular Contraction ◽

Foraminal Stenosis ◽

Posterior Decompression ◽

Fusion Surgery ◽

C5 Palsy ◽

Postoperative Mri ◽

Cervical Surgery ◽

Complete Paralysis

We report a very rare (5~7%) case of bilateral C5 palsy after cervical surgery. A 71-year-old male patient with cervical ossification of posterior longitudinal ligament (OPLL) with foraminal stenosis at bilateral C4/5 underwent posterior decompression and fusion surgery. After surgery, muscle weakness in his both deltoid and biceps was detected and gradually deteriorated to complete paralysis. Postoperative MRI showed sufficient decompression of the spinal cord and posterior shifting. Subsequently, an additional bilateral foraminotomy at C4/5 was performed, with a suspicion that bilateral foraminal stenosis at C4/5 may have been the cause of the paresis. After foraminotomy, muscular contraction was seen in both deltoid and biceps. Finally, complete motor recovery was achieved in a year. Although the gold standard procedure for the prevention and treatment of postoperative C5 palsy has not yet been established, an additional foraminotomy may be recommended for severe C5 palsy in cases of foraminal stenosis even after the occurrence of palsy.

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Incidence and Prognostic Factors of C5 Palsy

Neurosurgery ◽

10.1227/neu.0000000000000322 ◽

2014 ◽

Vol 74 (6) ◽

pp. 595-605 ◽

Cited By ~ 57

Author(s):

Mohamad Bydon ◽

Mohamed Macki ◽

Paul Kaloostian ◽

Daniel M. Sciubba ◽

Jean-Paul Wolinsky ◽

...

Keyword(s):

Prognostic Factors ◽

Older Age ◽

Anterior Cervical Discectomy ◽

Upward Trend ◽

Prognostic Variables ◽

Cervical Discectomy ◽

C5 Palsy ◽

Logistical Regression ◽

Laminectomy And Fusion

ABSTRACT BACKGROUND: C5 palsy is a known cause of postoperative deltoid weakness. Prognostic variables affecting the incidence of the palsy have been poorly understood. OBJECTIVE: To determine the incidence and perioperative characteristics/predictors of C5 palsy after anterior vs posterior operations. METHODS: All patients undergoing C4-5 operations for degenerative conditions were retrospectively reviewed over 21 years. Anterior operations included an anterior cervical discectomy and fusion (ACDF) or a corpectomy, whereas posterior operations included laminectomy and fusion (± foraminotomies). RESULTS: Of the total 1001 operations, in 49.0% anterior and 51.0% posterior cases, there was an overall C5 palsy incidence of 5.2% (52 cases): 1.6% and 8.6%, respectively (P < .001). Of the 99 corpectomies, the palsy incidence of 4.0% was not only higher than ACDFs (1.0%), but also followed an upward trend with increasing corpectomy levels (P = .009). Of the 69 posterior and 83 anterior C4-5 foraminotomies, the incidence of C5 palsy was statistically higher in the posterior (14.5%) vs anterior (2.4%) cohort (P = .01). Multiple logistical regression identified older age as the strongest predictor of C5 palsy in the anterior (P = .02) and C4-5 foraminotomy in the posterior (P = .06) cohort. This condition improved within 3 to 6 months in 75% of patients in the anterior and 88.6% in the posterior cohort after a mean follow-up of 14.4 and 27.6 months, respectively. CONCLUSION: In one of the largest cohorts on C5 palsy, we found in anterior operations an increasing number of corpectomy levels had a higher incidence of C5 palsy; however, older age was the strongest predictor of C5 palsy. In posterior operations, C4-5 foraminotomy carried the strongest correlation.

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Surgical Management of Isolated Hemangioblastomas of the Spinal Cord

Neurosurgery ◽

10.1097/00006123-200108000-00012 ◽

2001 ◽

Vol 49 (2) ◽

pp. 321-328 ◽

Cited By ~ 13

Author(s):

Chanland Roonprapunt ◽

V. Michelle Silvera ◽

Avi Setton ◽

Diana Freed ◽

Fred J. Epstein ◽

...

Keyword(s):

Magnetic Resonance Imaging ◽

Magnetic Resonance ◽

Clinical Status ◽

Surgical Removal ◽

Resonance Imaging ◽

Characteristic Imaging ◽

Posterior Laminectomy ◽

Imaging Properties

Abstract OBJECTIVE Intramedullary hemangioblastomas are rare tumors, accounting for just 3% of all intraspinal neoplasms. The purpose of this study is to define the occurrence of isolated intramedullary hemangioblastomas and to analyze the role of the radiological studies and surgery for these lesions. METHODS The charts of 19 consecutive patients operated on for isolated spinal intramedullary hemangioblastoma were reviewed. Preoperatively, all patients underwent magnetic resonance imaging and nine underwent spinal angiography. For all patients, the surgical approach was via posterior laminectomy. RESULTS Our study sample comprised 6 women and 13 men, with an average age of 31.5 years (range, 16–75 yr). The mean prodrome was 20.8 months. Pain was the most common complaint. In all cases, the neoplasms were associated with a syrinx or edema. Gross total resection was achieved in all patients. At last follow-up examination (mean, 50.1 mo), 13 patients (68%) had improved and 6 patients (32%) had stabilized as compared with their preoperative clinical status. CONCLUSION Isolated intramedullary hemangioblastomas typically have an indolent clinical course. These tumors have characteristic imaging properties on magnetic resonance imaging and angiography. Surgical removal of these lesions results in excellent long-term functional outcome.

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Delayed C5 Palsy after Laminectomy and Fusion for Ossification of the Posterior Longitudinal Ligament

Journal of Spine ◽

10.4172/2165-7939.1000104 ◽

2011 ◽

Vol 01 (01) ◽

Author(s):

Darryl Lau ◽

Paul Park

Keyword(s):

Posterior Longitudinal Ligament ◽

C5 Palsy ◽

Laminectomy And Fusion

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123. Residual foraminal stenosis and increasing levels decompressed are risk factors for postoperative C5 palsy

The Spine Journal ◽

10.1016/j.spinee.2020.05.229 ◽

2020 ◽

Vol 20 (9) ◽

pp. S60-S61

Author(s):

Robert Brenner ◽

Carolyn Stickley ◽

Eaman Balouch ◽

Nicholas O'Malley ◽

Jack Zhong ◽

...

Keyword(s):

Risk Factors ◽

Foraminal Stenosis ◽

C5 Palsy

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Cervical Laminoplasty Versus Posterior Laminectomy and Fusion: A Cost Analysis of Perioperative Care in Cervical Spondylotic Myelopathy

The Spine Journal ◽

10.1016/j.spinee.2011.08.143 ◽

2011 ◽

Vol 11 (10) ◽

pp. S56-S57

Author(s):

Pedro Ricart-Hoffiz ◽

Daniel Warren ◽

Christian Hoelscher ◽

Themistocles Protopsaltis ◽

John Bendo

Keyword(s):

Cost Analysis ◽

Perioperative Care ◽

Cervical Spondylotic Myelopathy ◽

Cervical Laminoplasty ◽

Posterior Laminectomy ◽

Laminectomy And Fusion

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Contribution of Lordotic Correction on C5 Palsy Following Cervical Laminectomy and Fusion

Neurosurgery ◽

10.1227/neu.0000000000001199 ◽

2016 ◽

Vol 79 (6) ◽

pp. 816-822 ◽

Cited By ~ 11

Author(s):

Jacob Cherian ◽

Rory R. Mayer ◽

Kareem B. Haroun ◽

Lona R. Winnegan ◽

Ibrahim Omeis

Keyword(s):

Deformity Correction ◽

Plain Film ◽

Senior Author ◽

Control Group ◽

Cervical Alignment ◽

Cervical Spine Surgery ◽

Cervical Laminectomy ◽

C5 Palsy ◽

Spine Registry ◽

Laminectomy And Fusion

Abstract BACKGROUND: C5 palsy is a well-reported complication of cervical spine surgery. The implication of sagittal cervical alignment parameters and their changes after surgery on the incidence of C5 palsy remains unclear. OBJECTIVE: We review cervical alignment changes in our cases of C5 palsy after cervical laminectomy and fusion. METHODS: Cases of C5 palsy were retrospectively compared with a control group. Preoperative and postoperative upright plain film radiographs were analyzed in blinded fashion. RESULTS: Spine registry analysis identified 148 patients who underwent cervical laminectomy and fusion by the senior author over 5 years. There were 18 (12%) cases complicated by postoperative C5 palsy. Nine of these 18 patients had prerequisite upright films and were compared with a randomly constructed case control group of 20 patients. There were no statistically significant differences between the 2 groups in age, proportion of males, and preoperative Nurick score. Measures of sagittal alignment did not differ significantly between the 2 groups on preoperative and postoperative imaging. When comparing the amount of alignment change between preoperative and postoperative upright imaging, however, patients with C5 palsy had a statistically higher amount of average C4-C5 Cobb angle change (−2.53 vs 0.78°; P = .01). Logistic regression analysis demonstrated that lordotic change in both C4-C5 and C2-C7 Cobb angles were associated with development of palsy. CONCLUSION: Lordotic cervical correction, as measured on upright imaging, was statistically larger in patients who had C5 palsy. The role of deformity correction in C5 palsy deserves further study and may inform intraoperative decision making.

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