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Patterns of Neurological Deficits and Recovery of Postoperative C5 Nerve Palsy

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Patterns of Neurological Deficits and Recovery of Postoperative C5 Nerve Palsy CLINICAL ARTICLE J Neurosurg Spine 33:742–750, 2020 Patterns of neurological deficits and recovery of postoperative C5 nerve palsy John K. Houten, MD,1–3 Joshua R. Buksbaum, BS,1 and Michael J. Collins, MD2 1Division of Neurosurgery and 2Department of Orthopedic Surgery, Maimonides Medical Center, Brooklyn; and 3Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, New York 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 ossifi- cation 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 inci- dence was significantly lower following anterior surgery (6 of 441 [1.4%]) compared with that following cervical lami- nectomy 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 defi- cit, and weakness is frequently appreciated in the biceps and triceps muscles in addition to the deltoid muscle. Preop- erative 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. https://thejns.org/doi/abs/10.3171/2020.5.SPINE20514 KEYWORDS C5 nerve palsy; cervical fusion; complications; myelomalacia; myelopathy; T2 cord change; deltoid weakness ARESIS of the C5 nerve is a well-recognized com- appearing in a delayed fashion in the days or weeks fol- plication of decompressive cervical spine surgery lowing surgery. Numerous studies have investigated its in- involving the C4–5 level and is known to occur fol- cidence and possible causes, but most do not provide detail Plowing both anterior and posterior approaches.1–4 The syn- about the specific pattern of neurological deficits seen and drome is characterized by predominantly motor deficits the time course and character of neurological recovery. In 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. SUBMITTED April 6, 2020. ACCEPTED May 11, 2020. INCLUDE WHEN CITING Published online July 31, 2020; DOI: 10.3171/2020.5.SPINE20514. 742 J Neurosurg Spine Volume 33 • December 2020 ©AANS 2020, except where prohibited by US copyright law Unauthenticated | Downloaded 10/06/21 10:10 AM UTC Houten et al. this investigation, we assessed the preoperative character- we used 4-mg intravenous infusions of dexamethasone ev- istics of C5 palsy that developed in patients after surgery, ery 6 hours for 3 days. All patients were ordered to under- looking at the incidence and factors in patient history or go physical therapy that included range of motion exercises imaging findings associated with the complication. Par- intended to retard the development of a frozen shoulder. In ticular focus, however, was directed at carefully reviewing the initial years of the study period, all patients underwent the specific details of the neurological examination and MRI following the appearance of the deficit; in subsequent narrative descriptions of the symptoms of these patients, years, however, we did not image patients with a C5 palsy both in the hospital progress notes and office records. unless they had associated deterioration of underlying my- elopathic symptoms. Methods Statistical Analysis After institutional review board approval, we conducted a retrospective review of records of consecutive patients Statistical analysis was done using commercially avail- who underwent decompressive cervical spine surgery for able software (GraphPad Prism 4, GraphPad Software) spondylosis, disc herniation, or ossification of the poste- using the Student t-test, Mann-Whitney U-test, Fisher’s rior longitudinal ligament, which included the C4–5 level, exact test, or the chi-square test, with p < 0.05 considered treated by a single surgeon over a 15-year period, and we statistically significant. identified cases complicated by C5 nerve palsy. Patients with acute spinal cord injury from trauma and those with Results active spinal infection/discitis were excluded. Data col- A total of 642 patients met the inclusion criteria, 18 of lected included patient age, sex, diabetes and smoking sta- whom developed C5 palsy (2.8%). Data describing clinical tus, body mass index (BMI), surgical levels, and approach; characteristics of the patients suffering from C5 palsy and in each patient, a pre- and postoperative modified Japanese comparisons of those with and without C5 palsy can be Orthopaedic Association (mJOA) score was calculated. viewed in Tables 1 and 2. The C5 palsy complication rate was significantly lower in patients who underwent ante- Surgery rior surgery, occurring in 6 of 441 cases (1.4%) following Cervical laminectomy and fusion (CLF) was the surgi- the anterior approach and in all anterior cervical discec- cal procedure used for all posterior surgeries, employing a tomy and fusion (ACDF) cases, compared with 12 of 201 previously published decompression technique5 in which (6.0%) cases following cervical laminectomy and fusion (p a rough 6-mm extra-coarse ball diamond burr (Midas < 0.001). There were 10 men and 8 women, whose mean Rex, Medtronic Power Tools) is used to thin the lamina age was 66.7 years (range 54–76 years); their mean preop- at the junction of the medial facet, layer by layer, until the erative mJOA score of 11.4 improved to 15.6 at the latest inner cortex was just traversed. The ligamentous attach- follow-up visit. Compared with those not developing a C5 ments were then cut with Metzenbaum scissors, while the palsy, the patients with palsy did not differ significantly “floating” laminas were elevated with toothed forceps. All with respect to sex, age, number of levels treated, or pre- patients had internal fixation with cervical lateral mass and postoperative mJOA score. In the patients who devel- screw/rod fixation. Pedicle screws were used for C7 fixa- oped palsy, there were no non–C5-palsy-related neuro- tion in some patients and in all those in whom fixation logical complications or wound infections, but one patient extended to the upper thoracic spine. In cases of anterior developed a deep vein thrombosis and one patient suffered cervical discectomy, we used a machined allograft block anginal chest pain that required an urgent stenting proce- graft or polyetheretherketone (PEEK) cages filled with de- dure. Fifteen of these 18 patients (83%) had signal change mineralized bone graft; in cases involving corpectomy, we on preoperative T2-weighted imaging/myelomalacia, com- used PEEK cages filled with local bone. Plate fixation was pared with 436 of 624 (70%) patients without palsy; how- performed in all anterior-approach cases. Intraoperative ever, looking specifically at signal change/myelomalacia at neuromonitoring was used in all surgeries and included the C4–5 level, it was present in 12 of 18 (67%) with C5 somatosensory (SSEP) and motor evoked potential (MEP) palsy, a significantly higher rate than that seen in the 149 of monitoring and free-running electromyography. We did 624 (24%) without palsy (p < 0.00003). Paresis was unilat- not routinely use perioperative intravenous steroids. eral in 16 (89%) and bilateral in 2 (11%) of the patients with palsy. All patients with C5 palsy presented with weakness Postoperative Assessment of the deltoid muscle (mean 1.33 on the 0–5 manual mus- Narrative descriptions of the character and course of the cle testing scale), but other muscles were affected as well, patient’s neurological examination were reviewed from the with 15 patients (83%) also demonstrating new weakness hospital progress notes and all office follow-up visits. Any in the biceps (a mean score of 3.08), 8 (44%) demonstrat- surgical complications were noted.
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