Optimal timing of referral for nerve transfer surgery for postoperative C5 palsy

Saadeh, Yamaan S; Chopra, Zoey; Olsen, Eric; Smith, Brandon W.; Kashlan, Osama N.; Yang, Lynda J.‐S.; Park, Paul

doi:10.3171/2022.3.spine2222

Cited by 3 publications

(10 citation statements)

References 44 publications

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“…There was little recourse for patients with severe C5P that failed to improve. 38,54 However, in the past several years, nerve transfer surgical procedures 16 NA Paresis of deltoid and/or biceps brachii muscle, sensory deficits, &/or intractable pain in shoulders.…”

Section: Discussionmentioning

confidence: 99%

“…Across all of these studies, a grade of 2 or less on MMT was unanimously characterized as severe C5P. 3,14,22,36,38 However, there was variability between studies in the threshold MMT grade for determining mild and moderate C5P. 3,22,38 These differences are illustrated in Table 2.…”

Section: Classification Of C5p Severitymentioning

confidence: 99%

“…3,14,22,36,38 However, there was variability between studies in the threshold MMT grade for determining mild and moderate C5P. 3,22,38 These differences are illustrated in Table 2.…”

Section: Classification Of C5p Severitymentioning

confidence: 99%

“…Generally, recovery was based on extent of improvement in deltoid muscle strength, as shown in Table 3. 10,13,19,21,29,34,37,38 Complete recovery was commonly defined as achieving a grade of 5 on MMT, whereas less than 100% improvement on MMT was considered partial recovery. 10,13,37 However, 2 studies considered MMT grade 4 or higher to be adequate recovery, while 1 other study classified Medical Research Council (MRC) grade 3 or higher as useful recovery.…”

Section: C5p Recoverymentioning

confidence: 99%

“…10,13,37 However, 2 studies considered MMT grade 4 or higher to be adequate recovery, while 1 other study classified Medical Research Council (MRC) grade 3 or higher as useful recovery. 21,34,38…”

Section: C5p Recoverymentioning

confidence: 99%

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Defining postoperative C5 palsy and recovery: a systematic review

Deshpande¹,

Stino

Smith

et al. 2023

Journal of Neurosurgery: Spine

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OBJECTIVE Postoperative C5 palsy (C5P) is a well-recognized and often-delayed complication of cervical spine surgery. Most patients recover within 6 months of onset, but the prognosis of severe cases is poor. The clinical significance and natural history of mild versus severe C5P appear to differ substantially, but palsy severity and recovery have been poorly characterized in the literature. METHODS Owing to the varying prognoses and expanding treatment options such as nerve transfer surgery to reconstruct the C5 myotome, this systematic review attempted to describe how C5P severity is classified and how C5P and its recovery are defined, with the aim of proposing a postoperative C5P scale to support clinical decision-making. PubMed was searched for articles in English published since 2000 that offer a clear definition of postoperative C5P or its recovery. Only articles reporting exclusively on C5 palsy for patients undergoing surgery for degenerative disease were included. A single reviewer screened titles and abstracts and reviewed the full text of relevant articles, with consultation as needed from a second reviewer. Data collected included postoperative C5P definitions, classification of C5P severity, and definition and/or classification of C5P recovery. Qualitative analysis was performed. RESULTS Full-text reviews were conducted of 98 of 272 articles identified and screened, and 43 met the inclusion criteria. Postoperative C5P was most commonly defined as a reduction in deltoid muscle strength by ≥ 1 grade using manual muscle testing (MMT), with potential biceps involvement also noted by some studies. The few studies that stratified C5P on the basis of severity unanimously characterized severe C5P as MMT grade ≤ 2. Nine studies reported on C5P recovery. Deltoid muscle strength improvement of MMT grade 5 commonly defined complete recovery, with no MMT improvement considered partial recovery. CONCLUSIONS This review identified clear discrepancies in the definitions of C5P and its recovery, leading to heterogeneity in its evaluation and management. With the emergence of therapeutic procedures for severe C5P, standardization of the definitions of C5P and its recovery is critical. The authors propose MMT grades of 4, 3, and ≤ 2 to classify C5P as mild, moderate, and severe, respectively, and grades of 5, 4, and 3 to classify recovery as complete, sufficient, and useful, respectively.

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Section: Discussionmentioning

confidence: 99%

Section: Classification Of C5p Severitymentioning

confidence: 99%

“…3,14,22,36,38 However, there was variability between studies in the threshold MMT grade for determining mild and moderate C5P. 3,22,38 These differences are illustrated in Table 2.…”

Section: Classification Of C5p Severitymentioning

confidence: 99%

Section: C5p Recoverymentioning

confidence: 99%

Section: C5p Recoverymentioning

confidence: 99%

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Defining postoperative C5 palsy and recovery: a systematic review

Deshpande¹,

Stino

Smith

et al. 2023

Journal of Neurosurgery: Spine

Self Cite

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Upper Extremity Nerve Transfers for Treatment of Nerve Injury After Cervical Spine Surgery

Doucet,

Clark,

Giuffre

2024

Ann Plast Surg

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Purpose Nerve transfers to restore or augment function after spinal cord injury is an expanding field. There is a paucity of information, however, on the use of nerve transfers for patients having undergone spine surgery. The incidence of neurologic deficit after spine surgery is rare but extremely debilitating. The purpose of this study was to describe the functional benefit after upper extremity nerve transfers in the setting of nerve injury after cervical spine surgery. Methods A single-center retrospective review of all patients who underwent nerve transfers after cervical spine surgery was completed. Patient demographics, injury features, spine surgery procedure, nerve conduction and electromyography study results, time to referral to nerve surgeon, time to surgery, surgical technique and number of nerve transfers performed, complications, postoperative muscle testing, and subjective outcomes were reviewed. Results Fourteen nerve transfers were performed in 6 patients after cervical spine surgery. Nerve transfer procedures consisted of a transfer between a median nerve branch of flexor digitorum superficialis into a biceps nerve branch, an ulnar nerve branch of flexor carpi ulnaris into a brachialis nerve branch, a radial nerve branch of triceps muscle into the axillary nerve, and the anterior interosseous nerve into the ulnar motor nerve. Average patient age was 55 years; all patients were male and underwent surgery on their left upper extremity. Average referral time was 7 months, average time to nerve transfer was 9 months, and average follow-up was 21 months. Average preoperative muscle grading was 0.9 of 5, and average postoperative muscle grading was 4.1 of 5 (P < 0.00001). Conclusions Upper extremity peripheral nerve transfers can significantly help patients regain muscle function from deficits secondary to cervical spine procedures. The morbidity of the nerve transfers is minimal with measurable improvements in muscle function.

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Treatment of C5 Palsy: An International Survey of Peripheral Nerve Surgeons

Lubelski

Hersh

Feghali

et al. 2023

Global Spine Journal

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Study Design International survey. Objectives C5 palsy (C5P) is a neurological complication affecting 5-10% of patients after cervical decompression surgery. Most cases improve with conservative treatment; however, nearly 20% of patients may be left with residual deficits. Guidelines are lacking on C5P management and timing of surgical intervention. Therefore, we sought to survey peripheral nerve surgeons on their management of C5P. Methods An online survey was distributed centered around a patient with C5P after posterior cervical decompression and fusion. Questions included surgeon demographics, diagnostic modalities, and timing and choice of operation. Responses were summarized and the chi-squared and Kruskal-Wallis H tests were used to examine differences across specialties. Results A total of 154 surgeons responded to the survey, of which 59 (38%) indicated that they manage C5P cases. Average time prior to operating was 4.5 ± 2.2 months for complete injuries and 6.6 ± 3.2 months for partial injuries, with neurosurgeons significantly more likely to wait longer periods for complete ( P = .01) and partial injuries ( P = .03). Foraminotomies were selected by 19% of surgeons, while 92% selected nerve transfers. Transfer of the ulnar nerve to the musculocutaneous nerve was the most common choice (81%), followed by transfer of the radial nerve to the axillary nerve (58%). Conclusion Consensus exists among peripheral nerve surgeons on the use of nerve transfers for surgical treatment in cases with severe motor weakness failing to improve. Most surgeons advocate for early intervention in complete injuries. Disagreement concerns the type of nerve transfer employed, timing of surgery, and efficacy of foraminotomy.

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Optimal timing of referral for nerve transfer surgery for postoperative C5 palsy

Cited by 3 publications

References 44 publications

Defining postoperative C5 palsy and recovery: a systematic review

Defining postoperative C5 palsy and recovery: a systematic review

Upper Extremity Nerve Transfers for Treatment of Nerve Injury After Cervical Spine Surgery

Treatment of C5 Palsy: An International Survey of Peripheral Nerve Surgeons

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