(Dreaded) C5 Nerve Palsy

Don Moore, MDCenter for Spine Health

Cleveland ClinicMay 12, 2018

When All Else Fails, We Cannot Always Rely on…

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Etiology of C5 Palsy

Extrinsic factors – Nerve root traction or stenosis (tethering theory)

– Procedure dependent

– Lag correction by posterior correction and fusion with instrumentation

» Iatrogenic foraminal stenosis or tension on the root

» Kyphosis correction

Intrinsic factors– Spinal cord reperfusion injury

– Thermal damage theory

– Direct nerve injury

Multifactorial

Tethering of the nerve root

C5 is the midpoint of the decompression and the shifting is greater than other levels

C5 rootlets are shorter

Deltoid is innervated by a single root

Kazuo Y, Noboru, H., Motoki, I., Masatoshi, A., Keiro, O. Neurologic Complications of Surgery for Cervical Compression Myelopathy. Spine

1991;16(11):1277-1282

Nori S, Aoyama R, Ninomiya K, et al. Cervical laminectomy of limited width prevents postoperative C5 palsy: a multivariate analysis of 263

muscle-preserving posterior decompression cases. European spine journal. 2017;26(9):2393-2403.

Group A; 48 WLami, 38 DLP + WLami, 12 WLami> 3. Group B; 165 NLami (2-3 mm wider than SW)– (group A: 9 patients with C5P, group B: 2 patients),

No change in JOA scores and the RR between A and B

Risk factors: DLPm, ↑(DW - SW)m, ↓ DF @ C4-5m, ↑ agem , ↑ PSS @ C4-5 and ↑ #CL

↑ DW: ↑C5 traction due to PSS, heat injury

NLami reduced the C5 palsy from 9.2 to 1.2%

Nassr A, Aleem IS, Eck JC, et al. Does Resection of the Posterior Longitudinal Ligament Impact the Incidence of C5 Palsy After Cervical Corpectomy Procedures?: A Review of 459 Consecutive Cases. Spine

(Phila Pa 1976). 2017;42(7):E392-e397

225 ACCF (64.2%) and 142 ACCF+PCF (35.8%) patients.– Twenty-four patients with C5 nerve palsy

Alonso F, Voin V, Iwanaga J, et al. Potential Mechanism for Some Postoperative C5 Palsies: An Anatomical Study. Spine (Phila Pa

1976). 2018;43(3):161-166

10 specimen in supine position, dissected from C4 to T1.

greatest displacement by shoulder depression and occurred primarily at the intradural rootlet level.– C5 with the greatest displacement, decreasing to C7

Maximum depression led to cord movement to the ipsilateral side, touching the dura mater covering the lateral vertebral column with the C5 nerve root moving farthest

Procedure Dependent

Guzman JZ, Baird EO, Fields AC, et al. C5 nerve root palsy following decompression of the cervical spine: a systematic evaluation of the

literature. The bone & joint journal. 2014;96-b(7):950-955.

PubMed, Embase and Medline yielded 60 articles for inclusion

Anterior decompression: 0-26.4% (7.7%)– Two-level corpectomy with autograft fusion and plate fixation had

the highest incidence at 26.4%.*** (Liu Y, Qi M, Chen H, et al.)

– Anterior hybrid decompression incidence of 1.9-3.0 %.

Posterior decompression: 0-50% (7.8%)– Laminoplasty; up to 17%. 4% with expansive, 0.6% with bilateral

foraminotomies

– wide-door laminoplasty 5.3%, narrow-door 0%.» ↓ posterior shift

– Laminectomy ranged from 2.4% to 40%. (7.7%)

Wang H, Zhang X, Lv B, et al. Analysis of correlative risk factors for C5 palsy after anterior cervical decompression and fusion. International journal of clinical and experimental medicine. 2015;8(3):3983-3991.

Shou F, Li Z, Wang H, Yan C, Liu Q, Xiao C. Prevalence of C5 nerve root palsy after cervical decompressive surgery: a meta-

analysis. European spine journal. 2015;24(12):2724-2734.

Pubmed data up to 2014: 79 studies, with 704 C5 palsy cases in 13,621 patients– Pooled prevalence of C5 palsy was 5.3 %

– Approach: Posterior (5.8 %) > anterior (5.2 %)

– Dx: OPLL (5.8 %), CSM (4.5 %)

– Male (5.2 %), female (2.2 %)

– ACDF (3.3 %)**

– Laminoplasty only (5.1 %),

– Laminoplasty plus other posterior procedures (6.5 %)

– ACCF (7.5 %)

– Highest prevalence (11.0 %) in laminectomy and fusion (LIF)

Unilateral, diagnosed within 3 days

Basaran R, Kaner T. C5 nerve root palsy following decompression of cervical spine with anterior versus posterior types of procedures in patients with cervical myelopathy. European spine journal. 2016;25(7):2050-2059

CSM, 0 to 20.7 % (6.27 + 4.39). OPLL, 0 and 25 % (5.41 + 7.37) and CHNP, 0 and 6.6 % (3.52 + 3.27), (p=0.088)

4.98 + 3.80 % for anterior, 6.35 + 5.39 % for posterior (p=0.486)

Multilevel ACDF is the safest, followed by laminectomy

Laminectomy < lami + PSF (p=0.029) and laminoplasty (p= 0.37)

No difference between anterior vs posterior (p>0.05)

Recommendations– EMG

– Selective foraminotomies

Planchard RF, Maloney PR, Mallory GW, et al. Postoperative Delayed Cervical Palsies: Understanding the

Etiology. Global spine journal. 2016;6(6):571-583.

Out of 1,669 patients with decom +/- fusion, 56 (3.4%) developed a DCP. Although 71% of the palsies involved C5, 55% of palsies were multimyotomal and 18% were bilateral

Wang T, Wang H, Liu S, Ding WY. Incidence of C5 nerve root palsy after cervical surgery: A meta-analysis for last decade. Medicine.

2017;96(45):e8560.

PubMed/MEDLINE, Embase, the Cochrane library, CNKI, and WANFANG databases, from January 2007 to January 2017– 61 studies 721 out of 11,481 patients with C5 palsy (6.3%)

ACDF, ACCF, ACCDF, LP and LF: 5.5%, 7.5%, 6%, 4.4%, and 12.2%

Approach: Anterior (5%) lower than posterior (6.2%)

OPLL (8.1%) > CSM (4.8%)– ACDF and LP with OPLL (5.5%, 8.1%, respectively) > with CSM

(4.7%, 3.1%); LF with OPLL vs CSM (13.1% vs 13%)

Male to female: 5.9% vs. 4.1%

Mostly unilateral in 74.5%

Gu Y, Cao P, Gao R, et al. Incidence and risk factors of C5 palsy following posterior cervical decompression: a systematic review.

PloS one. 2014;9(8):e101933.

PubMed, Embase, Web of Science and Cochrane CENTRAL

25/589 studies, 5.8% incidence (95% CI)

Open-door, double-door, and laminectomy (4.5%, 3.1%, 11.3%)

OPLL, narrowed foramen, laminectomy, excessive cord drift, male gender

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. The spine journal. 2016;16(12):1486-1499.

45 eligible studies. Early vs late– ACDF, ACCF, LPN and PSF

– OPLL and non-OPLL

Early; PSF 9.0%>ACCF 3.7% and LPN 2.5%>ACDF 0.6%

Late: PSF 4.3%, ACCF 2.8%, and LPN 2.9% >>ACDF 1.0%

OPLL: higher in both early and late vs. non-OPLL

Early ULP in PSF due to a “lag” correction effect, which is triggered by posterior correction and fusion– A large amount posterior kyphosis correction

and fusion

Yang T, Wu L, Wang H, Fang J, Yao N, Xu Y. Inflammation Level after Decompression Surgery for a Rat Model of Chronic Severe Spinal Cord

Compression and Effects on Ischemia-Reperfusion Injury. Neurologia medico-chirurgica. 2015;55(7):578-586.

Expandible cellulose insertion at midthoracic spine in a rat model

Sham, sham + decompression, compression and compression + decompression

Compression group: TNF- and IL-1β: positive staining and increased in expression

Compression and decompression group: Higher TNF- and IL-1β than compression group

Thermal

Hosono N, Miwa T, Mukai Y, Takenaka S, Makino T, Fuji T. Potential risk of thermal damage to cervical nerve roots by a high-speed drill. The Journal

of bone and joint surgery British volume. 2009;91(11):1541-1544.

Fresh porcine lumbar spine model– 174°C max with a diamond burr and 77°C max with a steel burr.

Takenaka S, Hosono N, Mukai Y, Tateishi K, Fuji T. Significant reduction in the incidence of C5 palsy after cervical laminoplasty using chilled

irrigation water. The bone & joint journal. 2016;98-b(1):117-124.

400 patientsR with RT (25.6°C) vs 400 patientsp with LT (12.1°C)

LT vs. RT: 4.0%, (16) vs 9.5%* (38), ↓ early-onset palsy 1.0% vs 5.5%*

MVAnalysis: RT irrigation saline use, concomitant foraminotomy in at risk patients (2 /10 LT, 5/10 RT), and opened side (38 vs 14)

Sakaura H, Hosono N, Mukai Y, Fujii R, Iwasaki M, Yoshikawa H. Segmental motor paralysis after cervical laminoplasty: a prospective

study. Spine (Phila Pa 1976). 2006;31(23):2684-2688.

79 patients, pre- and post-op MRI compared to control

Prospective: Ten patients (12.7%) with unilateral motor paralysis between 0 and 15 days (mean, 3.6 days). – proximal (C5, C5–C6) in 5 patients, distal (C7, C7–C8) in 2, and

diffuse (C5–C8) in 3

– A linear HIA was noted in the corresponding paralyzed segment more frequently than a focal HIA or no HIA

Retrospective: Four patients (5.1%) with unilateral upper extremity between 0 and 5 days (average, 2.0 days)– proximal (C5, C5–C6) in 3 patients and diffuse (C5–C7) in 1

Nerve root theory as in “C5” palsy vs segmental cord injury

Multifactorial, need for functional imaging

Detection

132 retrospective and 68 prospective patients with cervical laminectomy for myelopathy– Addition of TceMEP and spEMG from deltoid and biceps

C5 palsy: 6 patients in retrospective group (no change in SSEP, dEP and TceMEP vs 2 in prospective group (Δ in deltoid and biceps TceMEP and spEMG – Treated with additional C4-5 foraminotomy

– Symptoms resolved in 24 hours and another improved in 7 days

Consider deltoid and biceps TceMEP and spEMG when there is a potential for iatrogenic C5 root injury

Fan D, Schwartz DM, Vaccaro AR, Hilibrand AS, Albert TJ. Intraoperative neurophysiologic detection of iatrogenic C5 nerve root injury during

laminectomy for cervical compression myelopathy. Spine (Phila Pa 1976). 2002;27(22):2499-2502.

Tanaka N, Nakanishi K, Fujiwara Y, Kamei N, Ochi M. 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):3013-3017.

Sixty-two consecutive patients (47 men and 15 women; mean age 64 years [range 32–89]), transcranial electric motor-evoked potentials– Complete recordings in 57 patients and incomplete in 5 patients

– No critical decrease in the amplitude observed in any of the 62 patients.

Postoperative transient C5 palsy occurred in 3 patients.

Postoperative C5 palsy is not associated with intraoperative injury of the nerve root or the spinal cord,

Spitz S, Felbaum D, Aghdam N, Sandhu F. Delayed postoperative C5 root palsy and the use of neurophysiologic monitoring. European

spine journal. 2015;24(12):2866-2871.

ACDF 456, ACCF 78, PLF 106, LP 4

SSEP, spontaneous EMG, and/or MEP

5 (2 with ACCF and 3 with PLF) cases (1.4 %) after 2 days

MEP, SSEP, and EMG may not be sensitive enough to assess the risk of developing C5 palsy

Macki M, Alam R, Kerezoudis P, Gokaslan Z, Bydon A, Bydon M. Manual muscle test at C5 palsy onset predicts the likelihood of and

time to C5 palsy resolution. Journal of clinical neuroscience

Of the 511 patients who met the selection criteria, 8.6% (n = 44) experienced C5 palsy.

C5 Palsy Management

Patient variables– Sex, Age, Dx (OPLL, Multilevel)

Surgeon variables– Thorough and repetitive preop exams (don’t forget the visual)

– Avoid excessive retraction during positioning and kyphosis correction

– Decrease thermal injury

– Optimum approach, # of levels and width of decompression

– Prophylactic foraminotomy

– Avoid PLL resection for ACCF

– IONM

– Patient education, expectations and reassurance» (eg. Retrograde ejaculation in ALIF, a known complications)