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Lubelski D, Hersh AM, Feghali J, Sciubba DM, Witham T, Bydon A, Theodore N, Belzberg AJ. Treatment of C5 Palsy: An International Survey of Peripheral Nerve Surgeons. Global Spine J 2023:21925682231171853. [PMID: 37122174 DOI: 10.1177/21925682231171853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
STUDY DESIGN International survey. OBJECTIVES C5 palsy (C5P) is a neurological complication affecting 5-10% of patients after cervical decompression surgery. Most cases improve with conservative treatment; however, nearly 20% of patients may be left with residual deficits. Guidelines are lacking on C5P management and timing of surgical intervention. Therefore, we sought to survey peripheral nerve surgeons on their management of C5P. METHODS An online survey was distributed centered around a patient with C5P after posterior cervical decompression and fusion. Questions included surgeon demographics, diagnostic modalities, and timing and choice of operation. Responses were summarized and the chi-squared and Kruskal-Wallis H tests were used to examine differences across specialties. RESULTS A total of 154 surgeons responded to the survey, of which 59 (38%) indicated that they manage C5P cases. Average time prior to operating was 4.5 ± 2.2 months for complete injuries and 6.6 ± 3.2 months for partial injuries, with neurosurgeons significantly more likely to wait longer periods for complete (P = .01) and partial injuries (P = .03). Foraminotomies were selected by 19% of surgeons, while 92% selected nerve transfers. Transfer of the ulnar nerve to the musculocutaneous nerve was the most common choice (81%), followed by transfer of the radial nerve to the axillary nerve (58%). CONCLUSION Consensus exists among peripheral nerve surgeons on the use of nerve transfers for surgical treatment in cases with severe motor weakness failing to improve. Most surgeons advocate for early intervention in complete injuries. Disagreement concerns the type of nerve transfer employed, timing of surgery, and efficacy of foraminotomy.
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Affiliation(s)
- Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andrew M Hersh
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - James Feghali
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY, USA
| | - Timothy Witham
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ali Bydon
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Allan J Belzberg
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Dombrowski ME, Morales-Restrepo A, Fourman MS, Vaudreuil N, Lee JY. Prophylactic perioperative dexamethasone decreases the incidence of postoperative C5 palsies after a posterior cervical laminectomy and fusion. Spine J 2019; 19:253-260. [PMID: 29800704 DOI: 10.1016/j.spinee.2018.05.031] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 04/20/2018] [Accepted: 05/16/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Postoperative C5 palsy is a well-known complication of cervical decompression procedures. Studies have shown that posterior laminectomy and fusions confer the greatest risk of C5 palsy. Despite this, pharmacologic preventive measures remain unknown. We hypothesize that prophylactic perioperative dexamethasone (DEX) will decrease the rate of postoperative C5 palsy in patients undergoing a multilevel posterior cervical laminectomy and fusion. PURPOSE The purpose of this study was to assess the safety and efficacy of prophylactic perioperative DEX in decreasing the rate of postoperative C5 palsy. DESIGN This is a retrospective, single-institution clinical study. PATIENT SAMPLE The patient population included all patients undergoing multilevel posterior cervical laminectomy and instrumented fusion procedures for myeloradiculopathy or myelopathy, who also received a course of perioperative dexamethasone. Surgeries occurred between 2012 and 2017 at a single tertiary care center by a single surgeon with at least 1 year of follow-up. Patients who underwent decompression procedures other than multilevel posterior cervical laminectomy and instrumented fusions; had trauma, fracture; underwent decompression not including C5-level, insulin-dependent diabetes mellitus; and had documented adverse reactions to steroids were excluded. OUTCOME MEASURES Preoperative demographics and postoperative complications, including development of postoperative C5 palsy, were considered as outcome measures. MATERIALS AND METHODS A total of 189 consecutive patients who underwent multilevel posterior cervical laminectomy and instrumented fusion and received prophylactic perioperative DEX were reviewed. The rate of C5 palsy was investigated and compared with our historical control rate of C5 palsy before the institutional implementation of perioperative DEX. Demographics were reviewed, and risk factor stratification was analyzed. The safety of using DEX was investigated by examining postoperative complications. The clinical course of patients who developed C5 palsy was then reported. RESULTS Postoperative C5 palsy occurred in 5 of the 138 patients (3.6%) meeting the inclusion criteria. Patients receiving perioperative DEX had a significantly decreased rate of postoperative C5 palsy compared with those who did not (3.6% vs. 9.5%, p=.01). Age was the only risk factor that was significantly correlated with development of C5 palsy (72.71±7.76 vs. 61.07±10.59, p=.02). Infection, seroma, and wound complication rates were 2.8%, 2.17%, and 1.44%, respectively, in patients receiving prophylactic DEX. All five patients receiving DEX who developed C5 palsy recovered with no residual deficits at an average of 16.8 weeks postoperatively. CONCLUSIONS Perioperative prophylactic DEX therapy is a safe and effective way to decrease the incidence of C5 palsies in patients who undergo multilevel posterior laminectomy and fusion for myeloradiculopathy or myelopathy.
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Affiliation(s)
- Malcolm E Dombrowski
- Department of Orthopaedic Surgery, Ferguson Laboratory for Orthopaedic Research, University of Pittsburgh, E1643 Biomedical Science Tower, 200 Lothrop St, Pittsburgh, PA 15213, USA
| | - Alejandro Morales-Restrepo
- Department of Orthopaedic Surgery, Ferguson Laboratory for Orthopaedic Research, University of Pittsburgh, E1643 Biomedical Science Tower, 200 Lothrop St, Pittsburgh, PA 15213, USA
| | - Mitchell S Fourman
- Department of Orthopaedic Surgery, Ferguson Laboratory for Orthopaedic Research, University of Pittsburgh, E1643 Biomedical Science Tower, 200 Lothrop St, Pittsburgh, PA 15213, USA
| | - Nicholas Vaudreuil
- Department of Orthopaedic Surgery, Ferguson Laboratory for Orthopaedic Research, University of Pittsburgh, E1643 Biomedical Science Tower, 200 Lothrop St, Pittsburgh, PA 15213, USA
| | - Joon Y Lee
- Department of Orthopaedic Surgery, Ferguson Laboratory for Orthopaedic Research, University of Pittsburgh, E1643 Biomedical Science Tower, 200 Lothrop St, Pittsburgh, PA 15213, USA.
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Thompson SE, Smith ZA, Hsu WK, Nassr A, Mroz TE, Fish DE, Wang JC, Fehlings MG, Tannoury CA, Tannoury T, Tortolani PJ, Traynelis VC, Gokaslan Z, Hilibrand AS, Isaacs RE, Mummaneni PV, Chou D, Qureshi SA, Cho SK, Baird EO, Sasso RC, Arnold PM, Buser Z, Bydon M, Clarke MJ, De Giacomo AF, Derakhshan A, Jobse B, Lord EL, Lubelski D, Massicotte EM, Steinmetz MP, Smith GA, Pace J, Corriveau M, Lee S, Cha PI, Chatterjee D, Gee EL, Mayer EN, McBride OJ, Roe AK, Yanez MY, Stroh DA, Than KD, Riew KD. C5 Palsy After Cervical Spine Surgery: A Multicenter Retrospective Review of 59 Cases. Global Spine J 2017; 7:64S-70S. [PMID: 28451494 PMCID: PMC5400195 DOI: 10.1177/2192568216688189] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN A multicenter, retrospective review of C5 palsy after cervical spine surgery. OBJECTIVE Postoperative C5 palsy is a known complication of cervical decompressive spinal surgery. The goal of this study was to review the incidence, patient characteristics, and outcome of C5 palsy in patients undergoing cervical spine surgery. METHODS We conducted a multicenter, retrospective review of 13 946 patients across 21 centers who received cervical spine surgery (levels C2 to C7) between January 1, 2005, and December 31, 2011, inclusive. P values were calculated using 2-sample t test for continuous variables and χ2 tests or Fisher exact tests for categorical variables. RESULTS Of the 13 946 cases reviewed, 59 patients experienced a postoperative C5 palsy. The incidence rate across the 21 sites ranged from 0% to 2.5%. At most recent follow-up, 32 patients reported complete resolution of symptoms (54.2%), 15 had symptoms resolve with residual effects (25.4%), 10 patients did not recover (17.0%), and 2 were lost to follow-up (3.4%). CONCLUSION C5 palsy occurred in all surgical approaches and across a variety of diagnoses. The majority of patients had full recovery or recovery with residual effects. This study represents the largest series of North American patients reviewed to date.
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Affiliation(s)
- Sara E. Thompson
- Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Zachary A. Smith
- Northwestern University, Feinberg School of Medicine, Chicago, IL, USA,Zachary A. Smith, Northwestern Medicine, 676 N St, Clair Street, Ste 2210, Chicago IL 60611, USA.
| | - Wellington K. Hsu
- Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | | | | | - David E. Fish
- The UCLA Spine Center, Santa Monica, CA, USA,University of California, Los Angeles, CA, USA
| | | | | | | | | | - P. Justin Tortolani
- Medstar Union Memorial Hospital, Baltimore, MD, USA,Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | | | - Ziya Gokaslan
- Brown University, Providence, RI, USA,The Miriam Hospital, Providence, RI, USA,Rhode Island Hospital, Providence, RI, USA,Norman Prince Neurosciences Institute, Providence, RI, USA
| | - Alan S. Hilibrand
- Jefferson Medical College, The Rothman Institute, Philadelphia, PA, USA
| | | | | | - Dean Chou
- University of California, San Francisco, CA, USA
| | - Sheeraz A. Qureshi
- Mount Sinai Hospital, New York, NY, USA,Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samuel K. Cho
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | - Zorica Buser
- University of Southern California, Los Angeles, CA, USA
| | | | | | | | | | | | | | | | - Eric M. Massicotte
- Toronto Western Hospital, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada
| | | | | | - Jonathan Pace
- University Hospitals Case Medical Center, Cleveland, OH, USA
| | - Mark Corriveau
- University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Sungho Lee
- University Hospitals Case Medical Center, Cleveland, OH, USA
| | | | | | | | | | | | | | | | | | - Khoi D. Than
- Oregon Health & Science University, Portland, OR, USA
| | - K. Daniel Riew
- Columbia University, New York, NY, USA,New York-Presbyterian/The Allen Hospital, New York, NY, USA
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Bydon M, Macki M, Kaloostian P, Sciubba DM, Wolinsky JP, Gokaslan ZL, Belzberg AJ, Bydon A, Witham TF. Incidence and prognostic factors of c5 palsy: a clinical study of 1001 cases and review of the literature. Neurosurgery 2015; 74:595-604; discussion 604-5. [PMID: 24561867 DOI: 10.1227/neu.0000000000000322] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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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Affiliation(s)
- Mohamad Bydon
- ‡Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; §Johns Hopkins Spinal Biomechanics and Surgical Outcomes Laboratory, Baltimore, Maryland
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