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The Incidence of C5 Palsy after Multilevel Cervical Decompression Procedures: A Review

of 750 Consecutive Cases.

Ahmad Nassr, MD

Jason C. Eck, DO, MS

Ravi K. Ponnappan, MD

Rami R. Zanoun, BS

William F. Donaldson, III, MD

James D. Kang, MD

2009 AAOS Annual MeetingFebruary 25th-28th

Las Vegas, NV

Introduction• C5 Palsy rates vary in the literature ranging from 0-30%.1-3

• Symptoms may include:– paresis of the deltoid and/or biceps brachii muscle

– sensory deficits and/or

– intractable pain in the shoulders.

• The etiology remains uncertain– iatrogenic nerve injury during surgery4

– tethering of the nerve from shifting of the spinal cord5

– spinal cord ischemia6

– reperfusion injury of the spinal cord.7

• The rate of C5 nerve palsy with different surgical procedures is unclear.

Purpose

The purpose of this study was to review the incidence of postoperative C5 nerve palsy in a large consecutive series of multilevel cervical spine decompression procedures to determine if any patient factors or surgical approach affected the incidence.

Methods• Retrospective review of 750 consecutive patients after multilevel

cervical decompression.

• Patients divided into 4 categories:– Anterior Corpectomy

– Anterior Decomp/Posterior Fusion

– Laminectomy and Fusion

– Laminaplasty

• Patients were excluded if:– there was lack of adequate follow-up data

– spinal cord injury preventing preoperative or postoperative motor testing

– or if the decompressive surgery did not include the C5 level.

Results

• 120 patients excluded

• 630 Patients Included – 292 Females, 338 Males– Ages 19-87 (mean 58 yo)– 255 Corpectomy Pts– 154 Anterior/Poster Fusion Pts– 116 Laminectomy and Fusion Pts– 105 Laminaplasty Pts

• C5 Palsy rate = 6.7% (42/630pts)

Summary of Demographics and Results

Procedure Patients

Incidence Age M/F Onset Residual Deficit

Time to Maximal Improvement

Laminoplasty 105 5 (4.8%) 60.0 (26-86)

70/35 Postop-2months 0 (0%) 21.8wks (1-60)

Corpectomy 255 13 (5.1%) 54.2 (29-84)

131/124 Postop-3weeks 2 (15.4%)

18.1wks (7-40)

Anterior/Posterior Fusion

154 13 (8.4%) 57.9 (36-86)

68/86 Postop-2months 3 (23.1%)

28.5wks (4-104)

Laminectomy and Fusion

116 11 (9.5%) 63.3 (19-87)

69/47 Postop-3weeks 3 (27.3%)

18.3wks (4-36)

Combined 630 42 (6.7%)

P=0.28

57.7 (18-87)

P=0.64

338/292 Postop-2months 8 (19%) 20.9wks (1-104)

• 3/42 Bilateral palsies (7%)• 2/42 Multi-segment Paresis (5%)

Entire Group Compared

Gender Smoking Revision

Surgery

Diabetes Preop Weakness

C5 Palsy Rate

Male 8.6%

Female 4.5%

No 8.2%

Yes 4.8%

No 7.5%

Yes 4.9%

No 7.3%

Yes 6.8%

No 8.0%

Yes 5.6%

P Value P=0.05 P=0.21 P=0.43 P=1.00 P=0.32

Anterior/Posterior Fusion

Risk Factor Probability

Male Gender P=0.56 (Fisher’s Exact)

Smoking P=0.14 (Fisher’s Exact)

Previous Cervical Surgery P=0.22 (Fisher’s Exact)

Hx of Upper Extremity Surgery P=0.13 (Fisher’s Exact)

Diabetes P=0.69 (Fisher’s Exact)

Preoperative Weakness P=1.00 (Fisher’s Exact)

# of Corpectomy Levels P=0.47 (Mantel Haenszel Chi-Square)

Age P=0.44 (2 Sample T-test)

• 13/155 (8.4%) pts with C5 Palsy• 8/13 after 3 or 4 level corpectomies• Resolution in 1 month to 2 years• 3 Pts with residual weakness at final f/u

Corpectomy Group

Risk Factor Probability

Male Gender P=0.57 (Fisher’s Exact)

Smoking P=0.52 (Fisher’s Exact)

Previous Cervical Surgery P=0.70 (Fisher’s Exact)

Hx of Upper Extremity Surgery P=1.00 (Fisher’s Exact)

Diabetes P=0.65 (Fisher’s Exact)

Preoperative Weakness P=1.00 (Fisher’s Exact)

# of Corpectomy LevelsP=0.002 (Mantel Haenszel Chi-Square)

More levels = Higher Risk

AgeP=0.01 (2 Sample T-test)

Palsy Mean 62yo vs. No Palsy 54yo

• 13/255 (5.1%) Pts with C5 Palsy• 12/13 after 3 level corpectomies• Resolution in 7weeks to 10 months• 2 Pts with residual weakness at final f/u

Laminectomy/Fusion Group

Risk Factor Probability

Male Gender P=0.20 (Fisher’s Exact)

Smoking P=1.00 (Fisher’s Exact)

Previous Cervical Surgery P=0.16 (Fisher’s Exact)

Hx of Upper Extremity Surgery P=1.00 (Fisher’s Exact)

Diabetes P=0.69 (Fisher’s Exact)

Preoperative Weakness P=0.50 (Fisher’s Exact)

# of Laminectomy Levels P=0.44 (Mantel Haenszel Chi-Square)

Age P=0.14 (2 Sample T-test)

• 11/116 (9.5%) of Pts with C5 Palsy• Resolution in 1 month - 9 months PO• 3 Pts with residual weakness at final f/u

Laminaplasty Group

• 5/105 (4.8%) Pts with C5 Palsy• Resolution in 1 week to 15 months• No pts with residual weakness at final f/u

Risk Factor Probability

Male Gender P=0.17 (Fisher’s Exact)

Smoking P=0.65 (Fisher’s Exact)

Previous Cervical Surgery P=1.00 (Fisher’s Exact)

Hx of Upper Extremity Surgery P=0.28 (Fisher’s Exact)

Diabetes P=1.00 (Fisher’s Exact)

Preoperative Weakness P=0.65 (Fisher’s Exact)

AgeP=0.04 (2 Sample T-test)

Palsy Mean 47yo vs. No Palsy 60yo

Summary• Largest group of North

American patients evaluated to determine the incidence of C5 Palsy

• 6.7% Rate of C5 Palsy is consistent with previous published reports

• Rate varies with surgical procedure chosen but did not reach statistical significance

•Can occur after surgery to 2 months post-op•Varying time to resolution with mean of 21 wks (1-104 wks)•71% improve within 6months•19% of patients with residual deficit at final f/u•Increased rate of palsy with:

–Male Gender–# of Corpectomy levels