Cause analysis and clinical intervention of C<sub>5</sub> palsy after cervical surgery_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

XU Chenpei ^1,2,3,4,5,6 , ZHOU Mingjie ^1,2,3,4,5,6 , CHEN Chuxiang ^1,2,3,4,5,6 , WANG Hongli ^7,8 ,  JIANG Su ^1,2,3,4,5,6

1. Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, 200040, P. R. China;
2. National Health Commission Key Laboratory of Hand Reconstruction, Shanghai, 200032, P. R. China;
3. Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, 200032, P. R. China;
4. National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, 200040, P. R. China;
5. Institute of Hand Surgery, Shanghai, People’s Republic of China, Shanghai, 200040, P. R. China;
6. Institute of Hand Surgery, Fudan University, Shanghai, 200040, P. R. China;
7. Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, 200040, P. R. China;
8. Spinal Surgery Center, Fudan University, Shanghai, 200040, P. R. China;

Corresponding?author：

JIANG Su, Email: oscarjiangsu@126.com

Keywords：

C₅ palsy; nerve root injury; cervical surgery; complication

DOI：

10.7507/1002-1892.202402006

Video：

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Objective To review the research progress of C₅ palsy (C₅P) after cervical surgery, providing new clinical intervention ideas for the C₅P patients. Methods The relevant literature domestically and abroad was extensively consulted and the latest developments in the incidence, risk factors, manifestations and diagnosis, prevention, and intervention measures of C₅P were systematically expounded. Results C₅P is characterized by weakness in the C₅ nerve innervation area after cervical decompression surgery, manifested as limited shoulder abduction and elbow flexion, with an incidence rate more than 5%, often caused by segmental spinal cord injury or mechanical injury to the nerve roots. For patients with risk factors, careful operation and preventive measures can reduce the incidence of C₅P. Most of the patients can recover with conservative treatment such as drug therapy and physical therapy, while those without significant improvement after 6 months of treatment may require surgical intervention such as foraminal decompression and nerve displacement. Conclusion Currently, there has been some advancement in the etiology and intervention of C₅P. Nevertheless, further research is imperative to assess the timing of intervention and surgical protocol.

Citation： XU Chenpei, ZHOU Mingjie, CHEN Chuxiang, WANG Hongli, JIANG Su. Cause analysis and clinical intervention of C₅ palsy after cervical surgery. Chinese Journal of Reparative and Reconstructive Surgery, 2024, 38(5): 608-612. doi: 10.7507/1002-1892.202402006 Copy

1.	Scoville WB. Cervical spondylosis treated by bilateral facetectomy and laminectomy. J Neurosurg, 1961, 18(4): 423-428.
2.	Stoops WL, King RB. Neural complications of cervical spondylosis: their response to laminectomy and foramenotomy. J Neurosurg, 1962, 19(11): 986-999.
3.	Houten JK, Buksbaum JR, Collins MJ. Patterns of neurological deficits and recovery of postoperative C₅ nerve palsy. J Neurosurg Spine, 2020, 33(6): 742-750.
4.	Wagner SC, Sebastian AS, Butler JS, et al. C₅ motor palsy after single-and multi-level anterior cervical diskectomy and fusion: a retrospective review. J Am Acad Orthop Surg, 2019, 27(8): e390-e394.
5.	Barak U, Sheinis D, Sidon E, et al. C₅ palsy following cervical spine decompression. Isr Med Assoc J, 2021, 23(8): 521-525.Barak U, Sheinis D, Sidon E, et al. C₅ palsy following cervical spine decompression. Isr Med Assoc J, 2021, 23(8): 521-525.
6.	Wang T, Wang H, Liu S, et al. Incidence of C₅ nerve root palsy after cervical surgery: A meta-analysis for last decade. Medicine (Baltimore), 2017, 96(45): e8560. doi: 10.1097/MD.0000000000008560.
7.	Pan FM, Wang SJ, Ma B, et al. C₅ nerve root palsy after posterior cervical spine surgery. J Orthop Surg (Hong Kong), 2017, 25(1): 2309499016684502. doi: 10.1177/2309499016684502.
8.	Seth NH, Joshi MV, Phansopkar P. C₅ nerve root palsy: An uncommon postoperative complication and its management. Cureus, 2022, 14(9): e28988. doi: 10.7759/cureus.28988.
9.	Levi DJ, Brusko GD, Levi AD, et al. Does hinge sidedness influence laterality of C₅ palsy after expansile open-door cervical laminoplasty? Neurosurg Focus, 2023, 55(3): E6. doi: 10.3171/2023.6.FOCUS23297.
10.	陳新焰, 陳峰, 胡建華, 等. 頸椎術后C₅神經根麻痹發病機制研究進展. 中華骨與關節外科雜志, 2023, 16(12): 1139-1144.
11.	Mizutani M, Fujishiro T, Obo T, et al. Impact of morphological restoration of the spinal cord from the preoperative to early postoperative periods on C₅ palsy development. J Neurosurg Spine, 2021, 35(5): 624-632.
12.	Rajabian A, Quraishi NA. C₅ palsy after cervical spine decompression: topographic correlation with C₆ chassaignac tubercle?: A fresh-cadaveric study of the cervical spine and rediscussion of etiological hypotheses. Spine (Phila Pa 1976), 2020, 45(15): E903-E908.
13.	Zhao J, Zhao Q, Liu Z, et al. The anatomical mechanism of C₅ palsy after expansive open-door laminoplasty. Spine J, 2020, 20(11): 1776-1784.
14.	Usami Y, Yokota A, Kondo Y, et al. Morphology of cervical periradicular fibrous sheath and nerve roots in relation to postoperative C₅ palsy. Spine J, 2022, 22(4): 690-696.
15.	Santos JLM, Kalhorn SP. Anatomy of the posterolateral spinal epidural ligaments. Surg Neurol Int, 2021, 12: 33. doi: 10.25259/SNI_894_2020.
16.	Hirabayashi S, Kitagawa T, Yamamoto I, et al. Postoperative C₅ palsy: Conjectured causes and effective countermeasures. Spine Surg Relat Res, 2018, 3(1): 12-16.
17.	Oshina M, Segawa T, Oshima Y, et al. C₅ palsy after C_5/6/7 posterior foraminal decompression: A case report. Medicine (Baltimore), 2020, 99(3): e18817. doi: 10.1097/MD.0000000000018817.
18.	Woodroffe RW, Helland LC, Bryant A, et al. Intraoperative shoulder traction as cause of C₅ palsy: magnetic resonance imaging study. World Neurosurg, 2020, 136: e393-e397.
19.	Traynelis VC, Fontes RBV, Kasliwal MK, et al. Risk factors for C₅ palsy: a systematic review and multivariate analysis. J Neurosurg Spine, 2023, 40(2): 216-228.
20.	Zheng C, Nie C, Zhu Y, et al. Preoperative electrophysiologic assessment of C₅-innervated muscles in predicting C₅ palsy after posterior cervical decompression. Eur Spine J, 2021, 30(6): 1681-1688.
21.	Liu B, Chu Y, Ma J, et al. Analysis of risk factors for C₅ nerve root paralysis after posterior cervical decompression. BMC Musculoskelet Disord, 2021, 22(1): 614. doi: 10.1186/s12891-021-04434-y.
22.	Emamhadi M, Dogahe MH, Emamhadi A. Iatrogenic cervical nerve root injury after spine surgery: how nerve surgeons can assist spine surgeons. Int J Spine Surg, 2022, 16(6): 1041-1045.
23.	Imagama S, Matsuyama Y, Yukawa Y, et al. C₅ palsy after cervical laminoplasty: a multicentre study. J Bone Joint Surg (Br), 2010, 92(3): 393-400.
24.	Katsumi K, Hirano T, Watanabe K, et al. A novel concept of posterior decompression and instrumented fusion with selective lordotic correction for cervical ossification of the posterior longitudinal ligament. J Clin Neurosci, 2019, 68: 312-316.
25.	Wilent WB, Rhee JM, Harrop JS, et al. Therapeutic impact of traction release after C₅ nerve root motor evoked potential (MEP) alerts in cervical spine surgery. Clin Spine Surg, 2020, 33(10): E442-E447.
26.	Jack AS, Osburn BR, Tymchak ZA, et al. Foraminal ligaments tether upper cervical nerve roots: a potential cause of postoperative C₅ palsy. J Brachial Plex Peripher Nerve Inj, 2020, 15(1): e9-e15.
27.	Ishiguro H, Takenaka S, Kashii M, et al. Direct involvement of concomitant foraminotomy for radiculomyelopathy in postoperative upper limb palsy in cervical laminoplasty. World Neurosurg, 2021, 146: e14-e21.
28.	袁心偉, 萬侖, 胡豇, 等. 頸椎后路單開門術中預防性行C_4、5椎間孔擴大對術后發生C₅神經根麻痹綜合征的影響. 中國修復重建外科雜志, 2021, 35(10): 1318-1322.
29.	Deshpande N, Stino AM, Smith BW, et al. Defining postoperative C₅ palsy and recovery: a systematic review. J Neurosurg Spine, 2022, 38(4): 457-464.
30.	王媚, 王立恒, 趙耀, 等. 齊刺法治療頸椎術后C₅神經根麻痹30例. 中國中醫藥科技, 2014, 21(6): 690-691.
31.	Wan Q, Li S, Liu W, et al. Posterior percutaneous endoscopic cervical discectomy for single-level soft, huge central disc herniation. Pain Physician, 2024, 27(1): E99-E107.
32.	呂南千, 費青, 張麒云, 等. 甲鈷胺對C₅神經根麻痹治療的前瞻性對照研究. 中國骨科臨床與基礎研究雜志, 2012, 4(3): 173-177.
33.	Kubota S, Kadone H, Shimizu Y, et al. Feasibility and efficacy of the newly developed robotic hybrid assistive limb shoulder exercises in patients with C₅ palsy during the acute postoperative phase. Medicina (Kaunas), 2023, 59(8): 1496. doi: 10.3390/medicina59081496.
34.	顧春雅, 曾至立, 王建杰, 等. 重復經顱磁刺激治療頸椎前路術后C₅神經根麻痹1例報告. 海軍軍醫大學學報, 2022, 43(9): 1107-1109.
35.	王興平. 富血小板血漿在后路頸椎減壓后C₅神經麻痹治療中的價值. 中國組織工程研究, 2016, 20(46): 6930-6936.
36.	高學明, 王中華, 薛文, 等. 頸椎減壓術后C₅神經根麻痹的中西醫診療進展. 世界科學技術-中醫藥現代化, 2019, 21(12): 2714-2719.
37.	葛黁黁. 補陽還五湯加味治療頸椎后縱韌帶骨化癥術后C₅神經根麻痹的臨床研究. 蘭州: 甘肅中醫藥大學, 2019.
38.	李盛華, 梁雄勇, 李亞軍. 中醫藥治療神經根型頸椎病的現狀. 西部中醫藥, 2011, 24(1): 74-77.
39.	徐王兵, 李勇, 鐘發明, 等. 腧穴熱敏化艾灸治療脊髓型頸椎病減壓術后C₅神經根麻痹臨床研究. 中國中醫藥現代遠程教育, 2021, 19(23): 112-113.
40.	李亞偉. 針刺聯合紅光治療頸椎術后C₅神經根麻痹(氣虛血瘀型)臨床療效觀察. 鄭州: 河南中醫藥大學, 2022.
41.	刁永帥, 柳源, 馮奇, 等. 中醫整脊法治療神經根型頸椎病的研究進展. 中國中醫急癥, 2018, 27(9): 1667-1669, 1677.
42.	Lubelski D, Pennington Z, Kopparapu S, et al. Nerve transfers after cervical spine surgery: multi-institutional case series and review of the literature. World Neurosurg, 2021, 156: e222-e228.
43.	Nassr A, Eck JC, Ponnappan RK, et al. The incidence of C₅ palsy after multilevel cervical decompression procedures: a review of 750 consecutive cases. Spine (Phila Pa 1976), 2012, 37(3): 174-178.
44.	謝雁春, 軒安武, 李卓, 等. 頸椎減壓術后C₅神經根麻痹癥狀恢復時間的影響因素. 局解手術學雜志, 2017, 26(2): 114-118.
45.	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.
46.	Nath RK, Somasundaram C. Double fascicular nerve transfer restored nearly normal functional movements in a completely paralyzed upper extremity resulting from an ACDF surgery: A case report and review of recent literature. Am J Case Rep, 2023, 24: e938650. doi: 10.12659/AJCR.938650.
47.	Gu YD, Zhang GM, Chen DS, et al. Seventh cervical nerve root transfer from the contralateral healthy side for treatment of brachial plexus root avulsion. J Hand Surg (Br), 1992, 17(5): 518-521.
48.	Zheng MX, Hua XY, Feng JT, et al. Trial of contralateral seventh cervical nerve transfer for spastic arm paralysis. N Engl J Med, 2018, 378(1): 22-34.
49.	Jiang S, Ng CY, Xu WD. The derivation of C₇ nerve root as a potential donor nerve: a historical note. J Hand Surg (Eur Vol), 2018, 43(2): 213-214.
50.	徐文東, 顧玉東. 健側頸7移位術30年. 中華手外科雜志, 2016, 32(4): 247-249.

1. Scoville WB. Cervical spondylosis treated by bilateral facetectomy and laminectomy. J Neurosurg, 1961, 18(4): 423-428.
2. Stoops WL, King RB. Neural complications of cervical spondylosis: their response to laminectomy and foramenotomy. J Neurosurg, 1962, 19(11): 986-999.
3. Houten JK, Buksbaum JR, Collins MJ. Patterns of neurological deficits and recovery of postoperative C₅ nerve palsy. J Neurosurg Spine, 2020, 33(6): 742-750.
4. Wagner SC, Sebastian AS, Butler JS, et al. C₅ motor palsy after single-and multi-level anterior cervical diskectomy and fusion: a retrospective review. J Am Acad Orthop Surg, 2019, 27(8): e390-e394.
5. Barak U, Sheinis D, Sidon E, et al. C₅ palsy following cervical spine decompression. Isr Med Assoc J, 2021, 23(8): 521-525.Barak U, Sheinis D, Sidon E, et al. C₅ palsy following cervical spine decompression. Isr Med Assoc J, 2021, 23(8): 521-525.
6. Wang T, Wang H, Liu S, et al. Incidence of C₅ nerve root palsy after cervical surgery: A meta-analysis for last decade. Medicine (Baltimore), 2017, 96(45): e8560. doi: 10.1097/MD.0000000000008560.
7. Pan FM, Wang SJ, Ma B, et al. C₅ nerve root palsy after posterior cervical spine surgery. J Orthop Surg (Hong Kong), 2017, 25(1): 2309499016684502. doi: 10.1177/2309499016684502.
8. Seth NH, Joshi MV, Phansopkar P. C₅ nerve root palsy: An uncommon postoperative complication and its management. Cureus, 2022, 14(9): e28988. doi: 10.7759/cureus.28988.
9. Levi DJ, Brusko GD, Levi AD, et al. Does hinge sidedness influence laterality of C₅ palsy after expansile open-door cervical laminoplasty? Neurosurg Focus, 2023, 55(3): E6. doi: 10.3171/2023.6.FOCUS23297.
10. 陳新焰, 陳峰, 胡建華, 等. 頸椎術后C₅神經根麻痹發病機制研究進展. 中華骨與關節外科雜志, 2023, 16(12): 1139-1144.
11. Mizutani M, Fujishiro T, Obo T, et al. Impact of morphological restoration of the spinal cord from the preoperative to early postoperative periods on C₅ palsy development. J Neurosurg Spine, 2021, 35(5): 624-632.
12. Rajabian A, Quraishi NA. C₅ palsy after cervical spine decompression: topographic correlation with C₆ chassaignac tubercle?: A fresh-cadaveric study of the cervical spine and rediscussion of etiological hypotheses. Spine (Phila Pa 1976), 2020, 45(15): E903-E908.
13. Zhao J, Zhao Q, Liu Z, et al. The anatomical mechanism of C₅ palsy after expansive open-door laminoplasty. Spine J, 2020, 20(11): 1776-1784.
14. Usami Y, Yokota A, Kondo Y, et al. Morphology of cervical periradicular fibrous sheath and nerve roots in relation to postoperative C₅ palsy. Spine J, 2022, 22(4): 690-696.
15. Santos JLM, Kalhorn SP. Anatomy of the posterolateral spinal epidural ligaments. Surg Neurol Int, 2021, 12: 33. doi: 10.25259/SNI_894_2020.
16. Hirabayashi S, Kitagawa T, Yamamoto I, et al. Postoperative C₅ palsy: Conjectured causes and effective countermeasures. Spine Surg Relat Res, 2018, 3(1): 12-16.
17. Oshina M, Segawa T, Oshima Y, et al. C₅ palsy after C_5/6/7 posterior foraminal decompression: A case report. Medicine (Baltimore), 2020, 99(3): e18817. doi: 10.1097/MD.0000000000018817.
18. Woodroffe RW, Helland LC, Bryant A, et al. Intraoperative shoulder traction as cause of C₅ palsy: magnetic resonance imaging study. World Neurosurg, 2020, 136: e393-e397.
19. Traynelis VC, Fontes RBV, Kasliwal MK, et al. Risk factors for C₅ palsy: a systematic review and multivariate analysis. J Neurosurg Spine, 2023, 40(2): 216-228.
20. Zheng C, Nie C, Zhu Y, et al. Preoperative electrophysiologic assessment of C₅-innervated muscles in predicting C₅ palsy after posterior cervical decompression. Eur Spine J, 2021, 30(6): 1681-1688.
21. Liu B, Chu Y, Ma J, et al. Analysis of risk factors for C₅ nerve root paralysis after posterior cervical decompression. BMC Musculoskelet Disord, 2021, 22(1): 614. doi: 10.1186/s12891-021-04434-y.
22. Emamhadi M, Dogahe MH, Emamhadi A. Iatrogenic cervical nerve root injury after spine surgery: how nerve surgeons can assist spine surgeons. Int J Spine Surg, 2022, 16(6): 1041-1045.
23. Imagama S, Matsuyama Y, Yukawa Y, et al. C₅ palsy after cervical laminoplasty: a multicentre study. J Bone Joint Surg (Br), 2010, 92(3): 393-400.
24. Katsumi K, Hirano T, Watanabe K, et al. A novel concept of posterior decompression and instrumented fusion with selective lordotic correction for cervical ossification of the posterior longitudinal ligament. J Clin Neurosci, 2019, 68: 312-316.
25. Wilent WB, Rhee JM, Harrop JS, et al. Therapeutic impact of traction release after C₅ nerve root motor evoked potential (MEP) alerts in cervical spine surgery. Clin Spine Surg, 2020, 33(10): E442-E447.
26. Jack AS, Osburn BR, Tymchak ZA, et al. Foraminal ligaments tether upper cervical nerve roots: a potential cause of postoperative C₅ palsy. J Brachial Plex Peripher Nerve Inj, 2020, 15(1): e9-e15.
27. Ishiguro H, Takenaka S, Kashii M, et al. Direct involvement of concomitant foraminotomy for radiculomyelopathy in postoperative upper limb palsy in cervical laminoplasty. World Neurosurg, 2021, 146: e14-e21.
28. 袁心偉, 萬侖, 胡豇, 等. 頸椎后路單開門術中預防性行C_4、5椎間孔擴大對術后發生C₅神經根麻痹綜合征的影響. 中國修復重建外科雜志, 2021, 35(10): 1318-1322.
29. Deshpande N, Stino AM, Smith BW, et al. Defining postoperative C₅ palsy and recovery: a systematic review. J Neurosurg Spine, 2022, 38(4): 457-464.
30. 王媚, 王立恒, 趙耀, 等. 齊刺法治療頸椎術后C₅神經根麻痹30例. 中國中醫藥科技, 2014, 21(6): 690-691.
31. Wan Q, Li S, Liu W, et al. Posterior percutaneous endoscopic cervical discectomy for single-level soft, huge central disc herniation. Pain Physician, 2024, 27(1): E99-E107.
32. 呂南千, 費青, 張麒云, 等. 甲鈷胺對C₅神經根麻痹治療的前瞻性對照研究. 中國骨科臨床與基礎研究雜志, 2012, 4(3): 173-177.
33. Kubota S, Kadone H, Shimizu Y, et al. Feasibility and efficacy of the newly developed robotic hybrid assistive limb shoulder exercises in patients with C₅ palsy during the acute postoperative phase. Medicina (Kaunas), 2023, 59(8): 1496. doi: 10.3390/medicina59081496.
34. 顧春雅, 曾至立, 王建杰, 等. 重復經顱磁刺激治療頸椎前路術后C₅神經根麻痹1例報告. 海軍軍醫大學學報, 2022, 43(9): 1107-1109.
35. 王興平. 富血小板血漿在后路頸椎減壓后C₅神經麻痹治療中的價值. 中國組織工程研究, 2016, 20(46): 6930-6936.
36. 高學明, 王中華, 薛文, 等. 頸椎減壓術后C₅神經根麻痹的中西醫診療進展. 世界科學技術-中醫藥現代化, 2019, 21(12): 2714-2719.
37. 葛黁黁. 補陽還五湯加味治療頸椎后縱韌帶骨化癥術后C₅神經根麻痹的臨床研究. 蘭州: 甘肅中醫藥大學, 2019.
38. 李盛華, 梁雄勇, 李亞軍. 中醫藥治療神經根型頸椎病的現狀. 西部中醫藥, 2011, 24(1): 74-77.
39. 徐王兵, 李勇, 鐘發明, 等. 腧穴熱敏化艾灸治療脊髓型頸椎病減壓術后C₅神經根麻痹臨床研究. 中國中醫藥現代遠程教育, 2021, 19(23): 112-113.
40. 李亞偉. 針刺聯合紅光治療頸椎術后C₅神經根麻痹(氣虛血瘀型)臨床療效觀察. 鄭州: 河南中醫藥大學, 2022.
41. 刁永帥, 柳源, 馮奇, 等. 中醫整脊法治療神經根型頸椎病的研究進展. 中國中醫急癥, 2018, 27(9): 1667-1669, 1677.
42. Lubelski D, Pennington Z, Kopparapu S, et al. Nerve transfers after cervical spine surgery: multi-institutional case series and review of the literature. World Neurosurg, 2021, 156: e222-e228.
43. Nassr A, Eck JC, Ponnappan RK, et al. The incidence of C₅ palsy after multilevel cervical decompression procedures: a review of 750 consecutive cases. Spine (Phila Pa 1976), 2012, 37(3): 174-178.
44. 謝雁春, 軒安武, 李卓, 等. 頸椎減壓術后C₅神經根麻痹癥狀恢復時間的影響因素. 局解手術學雜志, 2017, 26(2): 114-118.
45. 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.
46. Nath RK, Somasundaram C. Double fascicular nerve transfer restored nearly normal functional movements in a completely paralyzed upper extremity resulting from an ACDF surgery: A case report and review of recent literature. Am J Case Rep, 2023, 24: e938650. doi: 10.12659/AJCR.938650.
47. Gu YD, Zhang GM, Chen DS, et al. Seventh cervical nerve root transfer from the contralateral healthy side for treatment of brachial plexus root avulsion. J Hand Surg (Br), 1992, 17(5): 518-521.
48. Zheng MX, Hua XY, Feng JT, et al. Trial of contralateral seventh cervical nerve transfer for spastic arm paralysis. N Engl J Med, 2018, 378(1): 22-34.
49. Jiang S, Ng CY, Xu WD. The derivation of C₇ nerve root as a potential donor nerve: a historical note. J Hand Surg (Eur Vol), 2018, 43(2): 213-214.
50. 徐文東, 顧玉東. 健側頸7移位術30年. 中華手外科雜志, 2016, 32(4): 247-249.

Chinese Journal of Reparative and Reconstructive Surgery

Cause analysis and clinical intervention of C₅ palsy after cervical surgery

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Chinese Journal of Reparative and Reconstructive Surgery

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Cause analysis and clinical intervention of C₅ palsy after cervical surgery