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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 4  |  Issue : 3  |  Page : 129-131

Bilateral C5 palsy after posterior cervical spine decompression surgery: A case report and literature review


Department of Pain Medicine, Anaesthesiology, Pain Management Centre, Singapore General Hospital, Singapore

Date of Submission11-Apr-2020
Date of Decision08-Jun-2020
Date of Acceptance02-May-2020
Date of Web Publication18-Jul-2020

Correspondence Address:
Dr. Yuen-Mei Chow
Department of Pain Medicine, Anaesthesiology, Pain Management Centre, 16 College Road, Block 6 Level 2, Singapore General Hospital, 169854
Singapore
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/BJOA.BJOA_49_20

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  Abstract 


C5 palsy is a well-known complication following cervical spine surgery. We describe a case of a 68-year-old male who underwent C3 to C6 posterior instrumentation and fusion with laminectomy and C7 hemilaminectomy for severe multilevel cervical stenosis. This is complicated by severe bilateral C5 palsy and neuropathic symptoms postoperatively, which improved with conservative management and acupuncture. This is the first described case of acupuncture being used in the treatment of C5 palsy. Further studies are needed to determine the efficacy of acupuncture in the management of neuropathic symptoms in patients with C5 palsy.

Keywords: Acupuncture, cervical myelopathy, nerve palsy, neuropathic pain, postoperative pain


How to cite this article:
Chow YM. Bilateral C5 palsy after posterior cervical spine decompression surgery: A case report and literature review. Bali J Anaesthesiol 2020;4:129-31

How to cite this URL:
Chow YM. Bilateral C5 palsy after posterior cervical spine decompression surgery: A case report and literature review. Bali J Anaesthesiol [serial online] 2020 [cited 2020 Aug 6];4:129-31. Available from: http://www.bjoaonline.com/text.asp?2020/4/3/129/290095




  Introduction Top


C5 palsy is a well-known complication following cervical spine surgery. The incidence of C5 palsy varies according to the underlying pathology and the surgical approach that was used. It has been reported to be as high as 20% following posterior cervical decompression surgery in patients with cervical myelopathy.[1],[2] Patients with C5 palsy may present with motor weakness in the upper limbs with or without sensory symptoms such as numbness, dysesthesia, or radicular pain.[2],[3] Although most patients with C5 palsy recover with conservative management, some patients do not improve and have permanent neurological deficits.[2] We would like to present a case of postoperative bilateral C5 palsy with persistent neurological deficits and the management of its associated neuropathic symptoms.


  Case Report Top


A 68-year-old Chinese male presented to the hospital with frequent falls due to progressive gait instability and left upper limb weakness. He did not have pain or any other sensory deficits. On physical examination, he had a Grade 4 power in his left C5 myotome according to the Medical Research Council grading system. He was unable to complete the grip and release test and had Hoffmann's sign bilaterally. Furthermore, he had an unsteady tandem gait. The deep tendon reflexes were intact, and his sensation was normal.

Magnetic resonance imaging (MRI) cervical spine showed severe multilevel cervical stenosis with disc prolapses and degenerative osteochondral bars compressing the spinal cord at multiple levels from C3/4 to C6/7 [Figure 1]. There was a focus of increased cord signal at the C5/6 level.
Figure 1: Preoperative magnetic resonance imaging cervical spine

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The patient subsequently underwent C3 to C6 posterior instrumentation and fusion with laminectomy from C3 to C6 and C7 hemilaminectomy. Prophylactic cervical foraminotomies were not performed as per the surgeon's routine practice. There were no intraoperative complications. Neuromonitoring of somatosensory-evoked potentials, motor-evoked potentials, and electromyography (EMGs) remained stable throughout the operation.

There was no change in the patient's neurology immediately postsurgery. However, on the 2nd postoperative day, the patient started to develop weakness in his right upper limb and was found to have Grade 2 power in the deltoid and biceps. The power in his left upper limb remained the same, and sensation was intact in the bilateral upper limbs at this point. By the 9th postoperative day, the patient had developed weakness in his left upper limb, and on examination, the power in his left deltoid and biceps was Grade 2. He also had sensory loss across all dermatomes in the bilateral upper limbs. A computed tomography scan of the cervical spine was performed, which showed adequate decompression of the central canal, and the appropriate positioning of the implants [Figure 2].
Figure 2: Postoperative computed tomography scan showing appropriate implant placement. (a) Screws on the right lateral masses. (b) Screws on the left lateral masses

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The patient subsequently underwent 2 months of rehabilitation, but the power in the bilateral deltoids and biceps remained in Grade 2. Although there was an improvement in his sensation, residual sensory deficits remained. Given his persisting symptoms, a postoperative MRI scan of his cervical spine was performed [Figure 3]. It showed severe but stable exit foraminal stenosis from C4/5 to C7/T1 levels. There was adequate decompression of the spinal cord, but the foci of increased cord signal remained. Nerve conduction studies and EMG were performed, and it was consistent with the diagnosis of C5 palsy.
Figure 3: Postoperative magnetic resonance imaging demonstrating adequate decompression

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Because of the severe motor and sensory deficits, the patient was referred for the consideration of nerve transfer. However, he was deemed to be a poor candidate due to his age and comorbidities. Subsequently, he was referred to the chronic pain clinic for further management of his bilateral upper limb numbness 8 months after his surgery. The patient was prescribed gabapentin 300 mg nightly with tramadol 25 mg as necessary. He also underwent traditional acupuncture with dry needling, and after 3 months of combined therapy, the patient reported significant improvement in his numbness. He was encouraged to continue rehabilitation to improve his muscle strength and range of motion.


  Discussion Top


C5 palsy is a potentially devastating complication following cervical spine surgery. Although the prognosis for C5 palsy is generally favorable, a significant proportion of patients experience residual deficits.[1],[2],[4],[5] Thompson et al. reviewed 59 cases of patients with C5 palsy and reported complete recovery in 54.2% of patients, whereas 17% of patients showed no recovery.[2] Imagama et al.[5] reported that 33% of patients who had C5 palsy have long-term motor paralysis, and 18% of patients have chronic pain despite conservative treatment.

Currently, there is no proven method to prevent postoperative C5 palsy. Although there is some evidence that prophylactic foraminotomies may reduce the incidence of C5 palsy, it does not prevent it completely.[6] Furthermore, there may even be an increased risk of C5 palsy with prophylactic foraminotomies.[4]

The initial treatment for C5 palsy is generally conservative, as the majority of patients recover with such treatment. In patients with persistent neurological deficits, additional surgical interventions have been recommended by some authors. Khaled Saoud and El-Shazly[1] reviewed ten patients who underwent additional Anterior cervical discectomy and fusion (ACDF) for persistent postoperative C5 palsy, and all patients showed improvement in their motor power after the surgery. Foraminotomies have also been shown to be effective in the treatment of C5 palsy, and some authors recommend early foraminotomies to be performed for patients with severe neurological deficits.[1],[7],[8]

The role of pharmacological treatment for C5 palsy is less clear. Corticosteroids are frequently utilized as initial treatment for C5 palsy, but there is a lack of evidence regarding its efficacy.[5],[9] Despite the lack of evidence, a short course of low-dose corticosteroids is cheap with minimal side effects and can be considered for patients with C5 palsy. Gabapentin is a medication that is used to treat neuropathic pain and is effective in providing pain relief for patients with postherpetic neuralgia and diabetic neuropathy. However, there is limited evidence for using it to treat other types of neuropathic pain, and there are no studies regarding its use for C5 palsy.[10] Nonetheless, it may be worthwhile for a trial of gabapentin in patients with chronic pain due to C5 palsy.

Acupuncture has a long history, and it has been used in a multitude of acute and chronic medical disorders. The World Health Organization describes the efficacious effect of acupuncture in conditions such as sciatica, neck, and low back pain.[11] However, there is no literature describing its use or efficacy in postoperative C5 palsy. This is the first case where acupuncture has been described as a complementary treatment for C5 palsy.

Other therapies, such as mannitol and hyperbaric oxygen therapy, have been proposed by some authors, but they are not widely used and may have significant side effects and require specialized equipment.[12]


  Conclusion Top


We describe an unfortunate case of bilateral C5 palsy post-posterior cervical decompression and fusion that subsequently improved with conservative management. Although C5 palsy is a well-known complication after cervical spine surgery, it has a significant adverse impact on the quality of life. Multiple surgical treatments had been described and used successfully, but conservative treatment is usually attempted initially. This is the first described case of acupuncture being used in the treatment of C5 palsy with a good response. Further studies will be necessary to determine the efficacy of acupuncture in the management of neuropathic symptoms in patients with C5 palsy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Khaled Saoud AE, El-Shazly A. Surgical management of C5 palsy resulting from posterior spinal decompression for the treatment of cervical spondylotic myelopathy. J Spine 2013;2:1-4.  Back to cited text no. 1
    
2.
Thompson SE, Smith ZA, Hsu WK, Nassr A, Mroz TE, Fish DE, et al. C5 palsy after cervical spine surgery: A multicenter retrospective review of 59 cases. Global Spine J 2017;7:64S-70S.  Back to cited text no. 2
    
3.
Hirabayashi S, Kitagawa T, Yamamoto I, Yamada K, Kawano H. Postoperative C5 palsy: Conjectured causes and effective countermeasures. Spine Surg Relat Res 2019;3:12-6.  Back to cited text no. 3
    
4.
Bydon M, Macki M, Kaloostian P, Sciubba DM, Wolinsky JP, Gokaslan ZL, et al. Incidence and prognostic factors of c5 palsy: A clinical study of 1001 cases and review of the literature. Neurosurgery 2014;74:595-604.  Back to cited text no. 4
    
5.
Imagama S, Matsuyama Y, Yukawa Y, Kawakami N, Kamiya M, Kanemura T, et al. C5 palsy after cervical laminoplasty: A multicentre study. J Bone Joint Surg Br 2010;92:393-400.  Back to cited text no. 5
    
6.
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. 6
    
7.
Nakashima H, Imagama S, Yukawa Y, Kanemura T, Kamiya M, Yanase M, et al. Multivariate analysis of C-5 palsy incidence after cervical posterior fusion with instrumentation. J Neurosurg Spine 2012;17:103-10.  Back to cited text no. 7
    
8.
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. Yasuda T, ed. Case Rep Orthop 2016;2016:1250810.  Back to cited text no. 8
    
9.
Chen G, Wang Y, Wang Z, Zhu R, Yang H, Luo Z. Analysis of C5 palsy in cervical myelopathy with massive anterior compression following laminoplasty. J Orthop Surg Res 2018;13:26.  Back to cited text no. 9
    
10.
Wiffen PJ, Derry S, Bell RF, Rice AS, Tölle TR, Phillips T, et al. Gabapentin for chronic neuropathic pain in adults. Cochrane Database Syst Rev 2017;6:CD007938.  Back to cited text no. 10
    
11.
World Health Organization. Acupuncture: Review and Analysis of Reports on Controlled Clinical Trials. Geneva: World Health Organization; 2003.  Back to cited text no. 11
    
12.
Wu HT, Wang Y, Liu JT, Pang QJ. Factors affecting C5 nerve root palsy after decompressive anterior cervical surgery. Int J Clin Exp Med 2018;11:13651-6.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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