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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 1  |  Issue : 1  |  Page : 22-24

Successful conservative treatment of a bilateral C5 palsy following posterior cervical decompression and fusion surgery for ossification of posterior longitudinal ligament


1 Department of Neurosurgery, Justus-Liebig-University, Giessen, Germany
2 Diagnostic Centre for Radiology and Neurology, Giessen, Germany

Date of Web Publication29-May-2017

Correspondence Address:
Karsten Schöller
Department of Neurosurgery, Justus-Liebig-University, Klinikstrasse 33, 35392 Giessen
Germany
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/EJSS.EJSS_5_17

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  Abstract 

We report a case of a progressive bilateral C5 palsy (C5P) following multilevel posterior cervical decompression and fusion surgery that was successfully treated with conservative management. A 58-year-old female patient with ossification of the posterior longitudinal ligament and resulting spinal canal stenosis underwent surgery in August 2015. Weakness in her both deltoid and biceps muscles was immediately detected after surgery and gradually deteriorated to severe paresis in the following 2 days. Postoperative magnetic resonance imaging showed sufficient decompression of the spinal cord with posterior shifting. However, residual neuroforaminal bilateral stenosis at levels C4/5 and C5/6 was found on postoperative computed tomography. After discussion of the therapeutic options, we decided to start conservative management including physical therapy and to follow the patient closely including clinical and neurophysiological examinations for the next 12 months. After 3 months, improvement of bilateral paresis was already evident. Muscle strength in the right biceps and the right deltoid muscles recovered completely within a year, but Grade 4 muscle weakness remained in the left deltoid and biceps muscles. Repetitive electromyography also showed continuous improvement of the interference patterns of the deltoid and biceps muscles. Although a standard management protocol for the treatment of postoperative C5P has not yet been established, a conservative therapy may be warranted even for severe and bilateral C5P.

Keywords: C5 palsy, cervical spinal stenosis, conservative treatment, neurophysiological examination, ossification of the posterior longitudinal ligament, outcome


How to cite this article:
Kim SW, Gronen F, Uhl E, Schöller K. Successful conservative treatment of a bilateral C5 palsy following posterior cervical decompression and fusion surgery for ossification of posterior longitudinal ligament. J Spinal Stud Surg 2017;1:22-4

How to cite this URL:
Kim SW, Gronen F, Uhl E, Schöller K. Successful conservative treatment of a bilateral C5 palsy following posterior cervical decompression and fusion surgery for ossification of posterior longitudinal ligament. J Spinal Stud Surg [serial online] 2017 [cited 2020 Sep 28];1:22-4. Available from: http://www.jsss-journal.com/text.asp?2017/1/1/22/207211


  Introduction Top


Ossification of the posterior longitudinal ligament (OPLL) is a relatively rare cause of cervical spinal canal stenosis and myelopathy in Central Europe. In cases of severe or progressive myelopathy symptoms, surgical decompression of the spinal cord might be indicated, usually through a posterior approach.[1] C5 palsy (C5P) is a well-known complication of anterior and posterior cervical decompression, particularly in multilevel surgeries that involve the level C4/5.[2] Most of the palsies occur unilaterally. Bilateral cases, however, are very rare, and only few reports have previously described their outcome.[3],[4] Furthermore, risk factors, preventive measures, and optimal management of C5P are not well established yet. We report about a patient with a severe progressive bilateral C5P after posterior decompression and fusion surgery for OPLL who was closely followed by 3 monthly clinical and neurophysiological examinations. The patient has almost recovered complete strength at 12 months under conservative therapy in adherence to a rigorous physical therapy protocol.


  Case Report Top


A 58-year-old female patient with medical history of hypothyroidism and a body mass index of 31 complained about unsteady gait and numbness of the hands. On physical examination, hypesthesia was detected on both of her hands. No muscle weakness was found on both upper and lower extremities including bilateral deltoid and biceps muscles, but deep tendon reflexes were accentuated, and gait ataxia was clearly evident. Preoperative median and tibial nerve somatosensory evoked potentials showed normal latencies but reduced amplitudes on the right side. Mixed type-OPLL was seen at levels C4/5 through C 5/6 on the preoperative cervical computed tomography (CT) scan [Figure 1]a and [Figure 1]b. The preoperative T2-weighted magnetic resonance imaging (MRI) scan demonstrated multilevel spinal cord compression from C3/4 to C5/6 and myelopathic increased signal intensity at level C4/C5 [Figure 1]c. Laminectomy, lateral mass screw instrumentation [Figure 2]a, and fusion were conducted from C3–C6 without any remarkable intraoperative events.
Figure 1: Preoperative computed tomography (a and b) and magnetic resonance imaging (c) show a mixed-type ossification of the posterior longitudinal ligament C4/5 and C5/6 contributing to spinal stenosis C3–C6. A spinal cord increased intensity area was detected at level C5.

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Figure 2: Postoperative X-ray (a), magnetic resonance imaging (b) and computed tomography (c). Imaging shows regular placement of instrumentation, adequate decompression with posterior shift of the spinal cord, as well as residual neuroforaminal stenosis C4/5 und 5/6 (arrows).

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Immediately after surgery, weakness of the left deltoid and biceps muscles (Grade 2 each) was noted, and gradual deterioration to a Grade 1 paresis occurred within a few hours despite dexamethasone bolus infusion. Two days after surgery, delayed paresis developed in the patient's right deltoid and biceps muscles (Grade 3), also followed by gradual deterioration within 24 h to severe paresis (Grade 2).

The postoperative T2-weighted MRI showed sufficient decompression and posterior shifting of the spinal cord without new increased signal intensity areas [Figure 2]b. There was no screw malposition on the postoperative CT, but clear residual bilateral neuroforaminal stenosis was present at levels C4/5 and C5/6 [Figure 2]c.

After discussion of the management options (conservative treatment vs. foraminotomy) in our spine conference and with the patient, a conjoined decision was taken to initiate conservative management. In adherence to a rigorous protocol, the patient underwent physical therapy consisting of muscle strengthening exercises and range of motion exercises of the shoulders and elbow joints at a rehabilitation hospital during the early postoperative period and on an outpatient basis later. Already 3 months after initiation of the physical therapy, improvement of muscle strength was seen in deltoids and biceps muscles bilaterally (Grades 3 left and 4 right). Muscle strength in the right biceps and the right deltoid muscles recovered completely, and gait ataxia was improved after 12 months, but Grade 4 muscle weakness remained in the left deltoid and biceps muscles [Table 1].
Table 1: A timeline-based table for the changes of manual muscle test grades in bilateral deltoid and biceps

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The follow-up electromyogram performed within 2 months after surgery showed spontaneous activity with abnormal interference pattern in bilateral deltoid and biceps muscles. Three months after surgery, spontaneous activity and polyphasic muscle action potential (MAP) were already decreased. At 12 months, spontaneous activity and polyphasic MAP were rarely detectable, and the interference pattern was almost normalized.


  Discussion Top


Despite the common nature of C5Ps after cervical decompression procedures, the etiology has not been well clarified yet. Pathological concepts include intraoperative injury, nerve root tethering from posterior shifting of the spinal cord, or reperfusion injury of the spinal cord.[5]

Meanwhile, several risk factors for a postoperative C5P have been identified [6] including OPLL and C4/5 foraminal stenosis, which were present in our patient. The role of the type of surgery chosen leading to C5P is not entirely clear yet since the rates after anterior and posterior decompression surgeries seem to be more or less the same, as indicated by Basaran and Kaner.[7] Furthermore, width of corpectomy or laminectomy is still under discussion but are not highly reproducible as risk factors.[8] However, relevant posterior shifting of the spinal cord that might result not only from wide decompression, from OPLL per se but also from overcorrection of kyphosis, seems to have a negative influence.[9] The lesser degree of sagittal profile correction from laminoplasty might be one reason why Lee et al.[10] found a lower rate of C5P compared to laminectomy/fusion. We avoided overcorrection of the sagittal profile and wide laminectomy in our patient, but posterior shifting of the cord was still evident, most probably due to the anterior OPLL mass. Katsumi et al.[11] suggested that a prophylactic foraminotomy might reduce the rate of C5P, but this also stands against the recommendation to reduce the laminectomy width to prevent a C5P.[12]

The optimal treatment for patients with a C5P is also still a matter of ongoing debate. Most of the authors, however, recommend a conservative management, which includes physical therapy and arm sling aids in cases of joint contracture, because of the generally good prognosis. Interestingly, Nassr et al.[13] showed that approximately 70% of patients completely recovered at 6 months after surgery without further treatment. Remarkably, the onset of the palsy did not statistically correlate with duration of recovery for C5P, but a higher manual muscle test grade at palsy onset predicted a higher chance of resolution and a shorter recovery time.[14] To the best of our knowledge, Kudo et al.[3] up to now published the only report on a similar case as ours, a bilateral C5P in a patient with OPLL after posterior decompression and fusion surgery. C5P was immediately detected after surgery and gradually deteriorated to complete palsy. Postoperative MRI showed sufficient decompression of the spinal cord and posterior shifting, similar to our case. In contrast to our considerations, however, the authors chose to conduct an additional bilateral foraminotomy due to the suspicion that a bilateral residual foraminal stenosis might have contributed to the paralysis. After surgery and physical therapy, complete motor recovery was achieved within a year. Kudo, therefore, recommended additional bilateral foraminotomy at an early stage for cases of severe C5P. In our case, however, we recognized the persistent foraminal stenosis at C4–C6 but chose a conservative therapy with a satisfactory result. Therefore, the role of an additional secondary foraminotomy can be questioned.


  Conclusion Top


Several factors potentially influence the development of a C5P after cervical decompression but, up to know, no surgical strategy offers clear advantages over the other. Posterior shifting of the spinal cord should be avoided, but this is not always possible. Nevertheless, the prognosis of a C5P is good, and in our opinion, physical therapy using a rigorous treatment protocol is also adequate in patients with severe and bilateral palsies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Kadanka Z, Mares M, Bednaník J, Smrcka V, Krbec M, Stejskal L, et al. Approaches to spondylotic cervical myelopathy: Conservative versus surgical results in a 3-year follow-up study. Spine (Phila Pa 1976) 2002;27:2205-10.  Back to cited text no. 1
    
2.
Kaneyama S, Sumi M, Kanatani T, Kasahara K, Kanemura A, Takabatake M, et al. Prospective study and multivariate analysis of the incidence of C5 palsy after cervical laminoplasty. Spine (Phila Pa 1976) 2010;35:E1553-8.  Back to cited text no. 2
    
3.
Kudo Y, Toyone T, Shirahata T, Ozawa T, Matsuoka A, Jin Y, et al. A case of successful foraminotomy for severe bilateral C5 palsy following posterior decompression and fusion surgery for cervical ossification of posterior longitudinal ligament. Case Rep Orthop 2016;2016:1250810.  Back to cited text no. 3
[PUBMED]    
4.
David KS, Rao RD. Bilateral C5 motor paralysis following anterior cervical surgery – A case report. Clin Neurol Neurosurg 2006;108:675-81.  Back to cited text no. 4
[PUBMED]    
5.
Hasegawa K, Homma T, Chiba Y. Upper extremity palsy following cervical decompression surgery results from a transient spinal cord lesion. Spine (Phila Pa 1976) 2007;32:E197-202.  Back to cited text no. 5
    
6.
Gu Y, Cao P, Gao R, Tian Y, Liang L, Wang C, et al. Incidence and risk factors of C5 palsy following posterior cervical decompression: A systematic review. PLoS One 2014;9:e101933.  Back to cited text no. 6
    
7.
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. Eur Spine J 2016;25:2050-9.  Back to cited text no. 7
    
8.
Klement MR, Kleeman LT, Blizzard DJ, Gallizzi MA, Eure M, Brown CR. C5 palsy after cervical laminectomy and fusion: Does width of laminectomy matter? Spine J 2016;16:462-7.  Back to cited text no. 8
    
9.
Kurakawa T, Miyamoto H, Kaneyama S, Sumi M, Uno K. C5 nerve palsy after posterior reconstruction surgery: Predictive risk factors of the incidence and critical range of correction for kyphosis. Eur Spine J 2016;25:2060-7.  Back to cited text no. 9
    
10.
Lee SH, Suk KS, Kang KC, Cho SW, Juh HS, Lee JH, et al. Outcomes and related factors of C5 palsy following cervical laminectomy with instrumented fusion compared with laminoplasty. Spine (Phila Pa 1976) 2016;41:E574-9.  Back to cited text no. 10
    
11.
Katsumi K, Yamazaki A, Watanabe K, Ohashi M, Shoji H. Can prophylactic bilateral C4/C5 foraminotomy prevent postoperative C5 palsy after open-door laminoplasty? A prospective study. Spine (Phila Pa 1976) 2012;37:748-54.  Back to cited text no. 11
    
12.
Radcliff KE, Limthongkul W, Kepler CK, Sidhu GD, Anderson DG, Rihn JA, et al. Cervical laminectomy width and spinal cord drift are risk factors for postoperative C5 palsy. J Spinal Disord Tech 2014;27:86-92.  Back to cited text no. 12
    
13.
Nassr A, Eck JC, Ponnappan RK, Zanoun RR, Donaldson WF 3rd, Kang JD. The incidence of C5 palsy after multilevel cervical decompression procedures: A review of 750 consecutive cases. Spine (Phila Pa 1976) 2012;37:174-8.  Back to cited text no. 13
    
14.
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. J Clin Neurosci 2016;24:112-6.  Back to cited text no. 14
    


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