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Guo C, Song X, Kong Q, Wang Y, Wu Y, Li W. [Research progress of etiologies for C 5 palsy after cervical decompression]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2022; 36:376-379. [PMID: 35293181 DOI: 10.7507/1002-1892.202111072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Objective To review the definition and possible etiologies for C 5 palsy. Methods The literature on C 5 palsy at home and abroad in recent years was extensively reviewed, and the possible etiologies were analyzed based on clinical practice experience. Results There are two main theories (nerve root tether and spinal cord injury) accounting for the occurrence of C 5 palsy, but both have certain limitations. The former can not explain the occurrence of C 5 palsy after anterior cervical spine surgery, and the latter can not explain that the clinical symptoms of C 5 palsy is often the motor dysfunction of the upper limb muscles. Based on the previous reports, combining our clinical experience and research, we propose that the occurrence of C 5 palsy is mainly due to the instrumental injury of anterior horn of cervical spinal cord during anterior cervical decompression. In addition, the C 5 palsy following surgery via posterior approach may be related to the nerve root tether caused by the spinal cord drift after decompression. Conclusion In view of the main cause of C 5 palsy after cervical decompression, it is recommended to reduce the compression of the spinal cord by surgical instruments to reduce the risk of this complication.
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Affiliation(s)
- Chuan Guo
- West China School of Medicine, Sichuan University, Chengdu Sichuan, 610041, P. R. China.,Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P. R. China
| | - Xinyue Song
- West China School of Medicine, Sichuan University, Chengdu Sichuan, 610041, P. R. China
| | - Qingquan Kong
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P. R. China
| | - Yu Wang
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P. R. China
| | - Ye Wu
- West China School of Medicine, Sichuan University, Chengdu Sichuan, 610041, P. R. China.,Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P. R. China
| | - Weilong Li
- West China School of Medicine, Sichuan University, Chengdu Sichuan, 610041, P. R. China.,Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P. R. China
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Odate S, Shikata J, Yamamura S, Okahata A, Kawaguchi S, Tanaka C. Insufficient Recovery From C5 Palsy Following Anterior Cervical Decompression and Fusion. Spine (Phila Pa 1976) 2022; 47:423-429. [PMID: 34545046 DOI: 10.1097/brs.0000000000004225] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE To determine the risk factors for insufficient recovery from C5 palsy (C5P) following anterior cervical decompression and fusion (ADF). SUMMARY OF BACKGROUND DATA Postoperative C5P is a frequent but unsolved complication following cervical decompression surgery. Although most patients gradually recover, some recover only partially. When we encounter new-onset C5P following ADF, the question that often arises is whether the palsy will sufficiently resolve. METHODS We retrospectively reviewed consecutive patients who underwent ADF at our institution. We defined C5P as postoperative deterioration of deltoid muscle strength by two or more grades determined by manual muscle testing (MMT). We evaluated the following demographic data: patient factors, surgical factors, and radiological findings. C5P patients were divided into two groups: sufficient recovery (MMT grade≧4) and insufficient recovery (MMT grade < 4). Each parameter was compared between the two groups. RESULTS Of 839 patients initially included in the study, 57 experienced new-onset C5P (6.8%). At the final follow-up (mean, 55 ± 17 months), 41 patients experienced sufficient recovery, whereas 16 (28%) still exhibited insufficient recovery. Compared with the sufficient recovery group, patients with insufficient recovery exhibited a higher decompression combination score, a larger anterior shift in preoperative cervical sagittal balance, less lordosis of the pre- and postoperative C4/C5 segment, more frequent stenosis at the C3/C4 segment, lower deltoid strength at C5P onset, more frequent co-occurrence of biceps weakness, greater postoperative expansion of the dura mater, and more frequent presence of postoperative T2 high-intensity areas. Multivariate analysis revealed that co-occurrence of biceps muscle weakness, less lordosis at the preoperative C4/C5 segment, and postoperative expansion of the dura mater were independent predictors of insufficient recovery. CONCLUSION The combination of unfavorable conditions, such as potential spinal cord disorder, cervical malalignment, and excessive expansion of the dura mater after corpectomy, predicts insufficient recovery from C5P.Level of Evidence: 4.
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Affiliation(s)
- Seiichi Odate
- Department of Orthopaedic Surgery, Gakkentoshi Hospital, Kyoto, Japan
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Pennington Z, Lubelski D, Westbroek EM, Ahmed AK, Ehresman J, Goodwin ML, Lo SF, Witham TF, Bydon A, Theodore N, Sciubba DM. Time to recovery predicted by the severity of postoperative C5 palsy. J Neurosurg Spine 2020; 32:191-199. [PMID: 31653818 DOI: 10.3171/2019.8.spine19602] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 08/06/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Postoperative C5 palsy affects 7%-12% of patients who undergo posterior cervical decompression for degenerative cervical spine pathologies. Minimal evidence exists regarding the natural history of expected recovery and variables that affect palsy recovery. The authors investigated pre- and postoperative variables that predict recovery and recovery time among patients with postoperative C5 palsy. METHODS The authors included patients who underwent posterior cervical decompression at a tertiary referral center between 2004 and 2018 and who experienced postoperative C5 palsy. All patients had preoperative MR images and full records, including operative note, postoperative course, and clinical presentation. Kaplan-Meier survival analysis was used to evaluate both times to complete recovery and to new neurological baseline-defined by deltoid strength on manual motor testing of the affected side-as a function of clinical symptoms, surgical maneuvers, and the severity of postoperative deficits. RESULTS Seventy-seven patients were included, with an average age of 64 years. The mean follow-up period was 17.7 months. The mean postoperative C5 strength was grade 2.7/5, and the mean time to first motor examination with documented C5 palsy was 3.5 days. Sixteen patients (21%) had bilateral deficits, and 9 (12%) had new-onset biceps weakness; 36% of patients had undergone C4-5 foraminotomy of the affected root, and 17% had presented with radicular pain in the dermatome of the affected root. On univariable analysis, patients' reporting of numbness or tingling (p = 0.02) and a baseline deficit (p < 0.001) were the only predictors of time to recovery. Patients with grade 4+/5 weakness had significantly shorter times to recovery than patients with grade 4/5 weakness (p = 0.001) or ≤ grade 3/5 weakness (p < 0.001). There was no difference between those with grade 4/5 weakness and those with ≤ grade 3/5 weakness. Patients with postoperative strength < grade 3/5 had a < 50% chance of achieving complete recovery. CONCLUSIONS The timing and odds of recovery following C5 palsy were best predicted by the magnitude of the postoperative deficit. The use of C4-5 foraminotomy did not predict the time to or likelihood of recovery.
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Affiliation(s)
- Zach Pennington
- 1Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland; and
| | - Daniel Lubelski
- 1Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland; and
| | - Erick M Westbroek
- 1Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland; and
| | - A Karim Ahmed
- 1Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland; and
| | - Jeff Ehresman
- 1Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland; and
| | - Matthew L Goodwin
- 1Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland; and
- 2Department of Orthopaedics, Washington University, St. Louis, Missouri
| | - Sheng-Fu Lo
- 1Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland; and
| | - Timothy F Witham
- 1Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland; and
| | - Ali Bydon
- 1Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland; and
| | - Nicholas Theodore
- 1Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland; and
| | - Daniel M Sciubba
- 1Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland; and
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Incidence of C5 Palsy: Meta-Analysis and Potential Etiology. World Neurosurg 2019; 122:e828-e837. [DOI: 10.1016/j.wneu.2018.10.159] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 10/21/2018] [Accepted: 10/23/2018] [Indexed: 11/15/2022]
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Spinal cord MRI signal changes at 1 year after cervical decompression surgery is useful for predicting midterm clinical outcome: an observational study using propensity scores. Spine J 2018; 18:755-761. [PMID: 28939166 DOI: 10.1016/j.spinee.2017.09.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 08/16/2017] [Accepted: 09/11/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT There is little information on the relationship between magnetic resonance imaging (MRI) T2-weighted high signal change (T2HSC) in the spinal cord and surgical outcome for cervical myelopathy. We therefore examined whether T2HSC regression at 1 year postoperatively reflected a 5-year prognosis after adjustment using propensity scores for potential confounding variables, which have been a disadvantage of earlier observational studies. PURPOSE The objective of this study was to clarify the usefulness of MRI signal changes for the prediction of midterm surgical outcome in patients with cervical myelopathy. STUDY DESIGN/SETTING This is a retrospective cohort study. PATIENT SAMPLE We recruited 137 patients with cervical myelopathy who had undergone surgery between 2007 and 2012 at a median age of 69 years (range: 39-87 years). OUTCOME MEASURES The outcome measures were the recovery rates of the Japanese Orthopaedic Association (JOA) scores and the visual analog scale (VAS) scores for complaints at several body regions. MATERIALS AND METHODS The subjects were divided according to the spinal MRI results at 1 year post surgery into the MRI regression group (Reg+ group, 37 cases) with fading of T2HSC, or the non-regression group (Reg- group, 100 cases) with either no change or an enlargement of T2HSC. The recovery rates of JOA scores from 1 to 5 years postoperatively along with the 5-year postoperative VAS scores were compared between the groups using t test. Outcome scores were adjusted for age, sex, diagnosis, symptom duration, and preoperative JOA score by the inverse probability weighting method using propensity scores. RESULTS The mean recovery rates in the Reg- group were 35.1%, 34.6%, 27.6%, 28.0%, and 30.1% from 1 to 5 years post surgery, respectively, whereas those in the Reg+ group were 52.0%, 52.0%, 51.1%, 49.0%, and 50.1%, respectively. The recovery rates in the Reg+ group were significantly higher at all observation points. At 5 years postoperatively, the VAS score for pain or numbnessin the arms or hands of the patients in the Reg+ group (24.7 mm) was significantly milder than that of the patients in the Reg- group (42.2 mm). CONCLUSIONS Spinal T2HSC improvement at 1 year postoperatively may predict a favorable recovery until up to 5 years after surgery.
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Liu G, Reyes MR, Riew KD. Why Does C5 Palsy Occur After Prophylactic Bilateral C4-5 Foraminotomy in Open-Door Cervical Laminoplasty? A Risk Factor Analysis. Global Spine J 2017; 7:696-702. [PMID: 28989850 PMCID: PMC5624369 DOI: 10.1177/2192568217699191] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
STUDY DESIGN Retrospective study. OBJECTIVES To evaluate the efficacy of bilateral C4-5 foraminotomy in preventing occurrence of postoperative C5 palsy and to identify possible risk factors for its development. METHODS A total of 70 consecutive patients who underwent open-door laminoplasty with bilateral C4-5 foraminotomy were included. Clinical, radiographic, and operative data was reviewed. Development of postoperative C5 palsy was analyzed. RESULTS A total of 54 males and 16 females were reviewed. Mean age was 56 years (range, 30-86 years). The primary pathology was spondylosis in 76% of cases and ossified posterior longitudinal ligament in 21%. Radiographic evidence of C4-5 foraminal stenosis was seen in 81% of the patients. The mean duration of preoperative symptoms was 7 ± 19 months. Four (5.7%) out of 70 patients developed C5 palsy after open-door laminoplasty with bilateral C4-5 foraminotomy. Multivariate analysis showed that a long duration of preoperative symptoms (>12 months) and the presence of preoperative C4-5 T2-MRI cord signal change were statistically significant risk factors for the development of C5 palsy even after bilateral C4-5 foraminotomy in open-door laminoplasty (P < .0001 and P = .036, respectively). CONCLUSIONS Prophylactic bilateral C4-5 foraminotomies do not completely eliminate the occurrence of C5 palsy. Prolonged duration of symptoms and presence of preoperative T2-MRI cord signal change increase the risk for developing postoperative C5 palsy despite foraminotomy.
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Affiliation(s)
- Gabriel Liu
- National University Hospital, Singapore,Gabriel Liu, MBBChBAO, MSc, FRCSI, FRCSEd(Ortho), FAMS, Orthopaedic Department, Level 11 NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228.
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Takenaka S, Nagamoto Y, Aono H, Kaito T, Hosono N. Differences in the time of onset of postoperative upper limb palsy among surgical procedures: a meta-analysis. Spine J 2016; 16:1486-1499. [PMID: 27725308 DOI: 10.1016/j.spinee.2016.09.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 08/24/2016] [Accepted: 09/12/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The time of onset of postoperative upper limb palsy (ULP), also referred to as C5 palsy, varies among patients. Although some studies addressed the relationship between the time of onset of ULP and the potential etiologies, no meta-analysis has been conducted regarding the association between the time of onset of ULP and other factors such as surgical procedure type and treated diseases. PURPOSE This study aimed to elucidate differences in the time of onset of ULP among spinal surgical procedures and treated diseases to understand its etiology. STUDY DESIGN This is a meta-analysis. OUTCOME MEASURES The time of onset of ULP after cervical decompression surgery. METHODS We conducted a meta-analysis via searches of the PubMed, EMBASE, and Cochrane Library databases. Upper limb palsy within 2 days postoperatively or at 3 days or more postoperatively was defined as early- and late-onset, respectively. We calculated the pooled prevalence of early- and late-onset ULP with regard to surgical procedures and diseases using a random effects model. The proportion of early-onset ULP relative to all ULP was also determined. Surgical procedures were categorized into four procedures: (1) anterior cervical discectomy and fusion (ACDF); (2) anterior cervical corpectomy and fusion (ACCF); (3) laminoplasty or laminectomy (LPN); and (4) posterior spinal fusion with decompression (PSF). Treated diseases were classified as ossification of the posterior longitudinal ligament (OPLL) and non-OPLL. RESULTS The pooled prevalence of early-onset ULP was significantly stratified across three groups of surgical procedures (PSF [9.0%]>ACCF [3.7%] and LPN [2.5%]>ACDF [0.6%]). In the pooled analysis of late-onset ULP prevalence, three procedures (PSF [4.3%], ACCF [2.8%], and LPN [2.9%]) were similar, but ACDF (1.0%) was associated with a significantly lower prevalence than LPN. The prevalence of both early- and late-onset ULP was significantly higher with OPLL than without OPLL. However, the proportion of early-onset ULP relative to all ULP was similar between non-OPLL and OPLL (50.8% vs. 49.5%). CONCLUSIONS The high prevalence of early-onset ULP in PSF is attributable to a lag correction effect, which is triggered by posterior correction and fusion through comparison with LPN. The combination of our meta-analysis results and previous knowledge facilitates our understanding of the etiology of ULP.
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Affiliation(s)
- Shota Takenaka
- Orthopaedic Surgery, National Hospital Organization, Osaka Medical Center, 2-1-14, Hoenzaka, Chuo-ku, Osaka 540-0006, Japan.
| | - Yukitaka Nagamoto
- Orthopaedic Surgery, National Hospital Organization, Osaka Medical Center, 2-1-14, Hoenzaka, Chuo-ku, Osaka 540-0006, Japan
| | - Hiroyuki Aono
- Orthopaedic Surgery, National Hospital Organization, Osaka Medical Center, 2-1-14, Hoenzaka, Chuo-ku, Osaka 540-0006, Japan
| | - Takashi Kaito
- Orthopaedic Surgery, Japan Community Healthcare Organization Osaka Hospital, 4-2-78 Fukushima, Osaka 553-0003, Japan
| | - Noboru Hosono
- Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan
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