Eur Spine J
DOI 10.1007/s00586-016-4567-4
REVIEW ARTICLE
C5 nerve root palsy following decompression of cervical spine
with anterior versus posterior types of procedures in patients
with cervical myelopathy
Recep Basaran1 • Tuncay Kaner1
Received: 9 November 2015 / Revised: 9 March 2016 / Accepted: 10 April 2016
Ó Springer-Verlag Berlin Heidelberg 2016
Abstract
Purpose C5 palsy is a well-known complication of cer-
vical spine decompression surgery. The complication
develops in both posterior and anterior approaches. We
aimed to review reports regarding postoperative C5 palsy in
hopes for better prevention and treatment of this morbidity.
Method We systematically reviewed and evaluated the
abstracts and full texts of the identified papers in the lit-
erature. We reviewed and analyzed papers published
between January 1970 and February 2015 regarding C5
palsy as a complication of cervical surgical procedures. We
made statistical comparisons as much as possible.
Results We did not find any statistical significance
between the pathologies (p = 0.088) and between the
surgical routes (p = 0.486). There was statistical signifi-
cance between the types of procedures (p \ 0.05). Poste-
rior laminectomy had low incidence of C5 palsy when
compared to laminectomy and fusion (p = 0.029) and
laminoplasty (p = 0.37). There was no statistically sig-
nificant difference between anterior cervical decompres-
sion and fusion and other procedures (p [ 0.05).
Conclusion Some studies conclude that anterior procedure
is more safe. Of all anterior procedures, the multilevel ACDF
had the lowest incidence of C5 palsy. The hybrid technique
can be chosen for more than two-vertebra corpectomy. In
term of posterior procedures, laminectomy is safer. To pre-
vent C5 palsy, electromyography can be used as a sensitive
predictor and selective foraminotomy can be performed.
& Recep Basaran
drrecepbasaran@gmail.com
1 We searched PubMed, Medline and Google Scholar sys-
Department of Neurosurgery, School of Medicine, Goztepe
Education and Research Hospital, Istanbul Medeniyet
University, 34730 Istanbul, Turkey
Keywords C5 palsy
Incidence
Cervical spine

Surgery
Complication
Introduction
Degenerative cervical spondylosis and cervical compres-
sion myelopathy are common causes of morbidity in
middle-aged and elderly individuals. One of the reasons of
the cervical myelopathy is ossification of the posterior
longitudinal ligament (OPLL). Clinical presentations
include progressive spastic quadriparesis, sensory loss at or
below the neck, and urinary incontinence. Although non-
operative treatment is acceptable in mild non-progressive
myelopathy, surgical decompression or stabilization is
indicated for severe or progressive myelopathy with
radiographic evidence of spinal cord compression [1].
Decompression of the spinal cord can be achieved through
either an anterior or posterior approach. The choice of the
surgical approach depends on the etiology of the
myelopathy, cervical alignment, and familiarity of the
surgeon with a given technique.
C5 palsy is a well-known complication of cervical spine
decompression surgery. The complication develops in both
posterior and anterior approaches. The mechanism of post-
operative C5 palsy is a controversial issue. Therefore, it is
valuable to review reports regarding postoperative C5 palsy in
hopes of clarifying, preventing and treating this morbidity.
Materials and methods
tematically, using the term ‘‘C5 palsy’’, ‘‘cervical spine’’
and ‘‘surgery’’ for studies published between January 1970
123

and February 2015. We sought to identify clinical trials
(e.g., randomized controlled trials, cohort studies, com-
parative studies, multicenter study) including anterior and/
or posterior procedures in patients with spinal cord com-
pression resulting in cervical myelopathy (CM). Two
reviewers (R.B. and T.K.) independently evaluated the
titles and abstracts of the identified papers. The data needed
for this systematic review are provided with published
articles.
We included patients of multilevel cervical corpectomy,
corpectomy with posterior fusion, posterior laminectomy,
posterior laminectomy and fusion, posterior laminoplasty
and posterior laminoplasty and fusion as types of
procedures.
Our exclusion criteria were lack of follow-up data,
presence of degenerative disc disease or degenerative joint
disease without CM, spinal tumor, concomitant infection,
and ankylosing spondylitis. Case series, case reports, data
not reported separately for each comparison group, or
studies that consisted of number less than 15 for either
comparison group were excluded.
We determined the incidence of C5 palsy and we
compared this incidence rate between types of procedures,
surgical routes and preoperative pathologies. The evidence
strength was rated using the GRADE (Grades of Recom-
mendation Assessment, Development, and Evaluation)
criteria.
Data extraction
We recorded data on a standard data extraction form. In
this form we recorded publication details (authors and
year), the type of study, the sample size and the type of the
surgery. Included types of surgical procedures are: anterior
corpectomy plus fusion, posterior laminectomy, posterior
laminectomy plus fusion, posterior laminoplasty, posterior
laminoplasty plus fusion, and the incidence of C5 palsy.
Statistical analysis
All analyzed studies have been examined and have been
divided into subgroups according to the type of surgical
procedure (anterior corpectomy plus fusion, posterior
laminectomy, posterior laminectomy plus fusion, posterior
laminoplasty, posterior laminoplasty plus fusion) and
surgical routes of procedures. We calculated the incidence
of C5 palsy with its 95 % confidence intervals (CI) for
each individual study. We used NCSS (Number Cruncher
Statistical System) 2007&PASS (Power Analysis and
Sample Size) and 2008 Statistical Software (Utah, USA)
for statistical analysis. We used Mann–Whitney U test to
evaluate descriptive statistical methods (mean, standard
deviation, median, frequency, rate, minimum, maximum),
123
Eur Spine J
and also to compare extraordinary parameters of two
groups. We used Kruskal–Wallis test to evaluate three or
more groups. We used Fisher-Freeman-Halton test to
compare qualitative data. We displayed significance as
p \ 0.01 and p \ 0.05.
Results
Eligible studies
After excluding the duplications, we found 714 potential
studies. We examined the titles and abstracts of these
articles and recruited 151 studies according to our includ-
ing criteria. After reading the full text of each study, we
selected 60 studies for this systematic review involving
10711 patients aged between 20 and 90 years at the time of
cervical spine surgery. Table 1 shows detailed information
about these studies. In all of the 60 studies the incidence of
C5 palsy for each procedure is reported.
Incidence of C5 palsy
The pathologies of the patients in the studies that we
examined were spondylotic myelopathy (75.7 %), ossified
posterior longitudinal ligament (OPLL) (18.9 %) and cer-
vical herniated nucleus pulposus (CHNP) (5.4 %). The
incidence of C5 palsy differed between pathologies. In
spondylotic myelopathy, the incidence of C5 palsy ranged
from 0 to 20.7 % (6.27 ± 4.39). In OPLL, the incidence
was calculated between 0 and 25 % (mean 5.41 ± 7.37)
and it was calculated between 0 and 6.6 % (mean
3.52 ± 3.27) in CHNP. We did not detect any statistical
significance between different pathologies (p = 0.088).
Fifty-six patients with spondylotic myelopathy have been
operated mostly by posterior surgical route of procedures
(71.4 %), fourteen patients with OPLL have been operated
mostly by surgical route of posterior procedures (71.4 %)
and three of four patients of CHNP have been operated by
surgical route of posterior procedure (75 %).
Our review includes 53 (71.6 %) studies reporting pos-
terior surgical routes and 21 (28.4 %) studies reporting
anterior surgical routes. The reported incidence of C5 palsy
following posterior approach ranges from 0 to 25 %. The
mean incidence is 6.35 ± 5.39 %. On the other hand, the
incidence of C5 palsy following anterior approach ranges
from 0 to 12 %. The mean incidence is 4.98 ± 3.80 %. We
did not detect any statistically significant heterogeneity
between anterior and posterior surgical routes of proce-
dures (p = 0.486).
According to types of procedures, eighteen studies
reported the incidence of C5 palsy ranging from 0 to 12 %
in patients who underwent anterior cervical decompression
 Table 1 Summary of studies about incidence of C5 palsy after different surgical routes and types of procedures
No. Author/year Study type Design Surgical Pathology in study No. of Type of procedure Rate of C5
route patient palsy (%)
Eur Spine J

1 Kanchiku et al. 2014 Clinical trial Retrospective Posterior Spondylotic myelopathy 43 Posterior cervical laminoplasty 6.9
2 Bydon et al. 2014 Comparative study Retrospective Anterior Spondylotic myelopathy 1001 Anterior cervical decompression and fusion 1.6
posterior Posterior cervical decompression and fusion 8.6
3 Chang et al. 2013 Comparative study Retrospective Anterior Spondylotic myelopathy 364 Anterior cervical decompression and fusion 0.7
posterior Posterior cervical laminoplasty 8.8
4 Liu et al. 2013 Clinical trial Retrospective Posterior OPLL 146 Posterior cervical laminectomy 0
5 Yang et al. 2013 Comparative study Retrospective Posterior Spondylotic myelopathy 141 Posterior cervical laminoplasty 4
Posterior cervical laminectomy 16.6
6 Chen et al. 2013 Cohort study Retrospective Posterior OPLL 30 Posterior cervical laminoplasty 2.4
7 Katsumi et al. 2013 Clinical trial Retrospective Posterior Spondylotic myelopathy 141 Posterior cervical laminoplasty 6.4
8 Choi et al. 2013 Clinical trial Retrospective Posterior CHNP 133 Posterior cervical foraminotomy 1.5
9 Park et al. 2012 Comparative study Retrospective Posterior Spondylotic myelopathy 100 Posterior cervical laminoplasty 7
10 Chen et al. 2012 Comparative study Retrospective Anterior OPLL 164 Anterior cervical decompression and fusion 0
posterior Posterior cervical laminoplasty 2.44
Posterior cervical laminectomy ? fusion 25
11 Liu et al. 2012 Comparative study Retrospective Anterior Spondylotic myelopathy 286 Anterior cervical discectomy 3.88
Anterior cervical decompression and fusion 9.83
12 Nakashima et al. 2012 Clinical trial Retrospective Posterior Spondylotic myelopathy, OPLL 84 Posterior laminectomy and fusion 11.9
13 Boontongjai et al. 2012 Cohort study Retrospective Posterior Spondylotic myelopathy, OPLL 38 Posterior cervical laminoplasty 0
14 Chen et al. 2012 Comparative study Retrospective Posterior Spondylotic myelopathy 54 Posterior cervical laminoplasty 7.4
15 Nakamae et al. 2012 Clinical trial Retrospective Posterior Spondylotic myelopathy 184 Posterior cervical laminoplasty 3.3
16 Nassr et al. 2012 Comparative study Retrospective Anterior Spondylotic myelopathy 630 Anterior cervical decompression and fusion 5.1
posterior Posterior cervical laminectomy and fusion 9.5
Posterior cervical laminoplasty 4.8
17 Zhao et al. 2012 Clinical trial Retrospective Posterior OPLL 82 Posterior cervical laminectomy 2.4
18 Katsumi 2012 Comparative study Prospective Posterior Spondylotic myelopathy 282 Posterior cervical laminoplasty 3.9
19 Lin et al. 2012 Comparative study Retrospective Anterior Spondylotic myelopathy 120 Anterior cervical discectomy 3.5
Anterior cervical decompression and fusion 4.8
20 Kim et al. 2012 Clinic trial Retrospective Anterior Spondylotic myelopathy 134 Anterior cervical discectomy 4.3
21 Odate et al. 2012 Comparative study Retrospective Anterior Spondylotic myelopathy, OPLL 81 Anterior cervical decompression and fusion 11.1
22 Eskander et al. 2012 Clinical trial Retrospective Anterior Spondylotic myelopathy 176 Anterior cervical decompression and fusion 6.8
23 Zhang et al. 2012 Comparative study Retrospective Posterior Spondylotic myelopathy 198 Posterior cervical laminoplasty 6.3
24 Kotil et al. 2011 Clinical trial Retrospective Anterior Spondylotic myelopathy 21 Anterior cervical decompression and fusion 12
25 Xia et al. 2011 Clinical trial Retrospective Posterior Spondylotic myelopathy 32 Posterior cervical laminectomy 0
Posterior cervical laminoplasty 5

123
 Table 1 continued
No. Author/year Study type Design Surgical Pathology in study No. of Type of procedure Rate of C5
route patient palsy (%)

123
26 Guo et al. 2011 Clinical trial Retrospective Anterior Spondylotic myelopathy 53 Anterior cervical decompression and fusion 1.9
27 Kim et al. 2011 Clinical trial Retrospective Posterior Spondylotic myelopathy 17 Posterior cervical laminectomy 0
28 Xia et al. 2011 Comparative study Prospective Posterior Spondylotic myelopathy 102 Posterior cervical laminoplasty 2.9
29 Katonis et al. 2011 Clinical trial Retrospective Posterior Spondylotic myelopathy 225 Posterior cervical laminectomy and fusion 2.2
30 Chen et al. 2011 Comparative study Retrospective Anterior OPLL 75 Anterior cervical decompression and fusion 0
posterior Posterior cervical laminoplasty 2
Posterior cervical laminectomy and fusion 4
31 Campbell et al. 2010 Clinical trial Retrospective Anterior Spondylotic myelopathy 119 Anterior cervical decompression and fusion 0
posterior Posterior cervical laminectomy and fusion 1.7
32 Dalbayrak et al. 2010 Clinical trial Retrospective Anterior OPLL 29 Anterior cervical decompression and fusion 3.4
33 Kaneyama et al. 2010 comparative study Prospective Posterior Spondylotic myelopathy 146 Posterior cervical laminoplasty 5.4
34 Liu et al. 2010 Clinical trial Retrospective Posterior Spondylotic myelopathy 101 Posterior cervical laminectomy and fusion 20.7
35 Hashimato et al. 2010 Clinical trial Retrospective Anterior Spondylotic myelopathy 199 Anterior cervical decompression and fusion 8.5
36 Imagama et al. 2010 Clinical trial Retrospective Posterior Spondylotic myelopathy 1858 Posterior cervical laminoplasty 2.3
multicentric
37 Minamide et al. 2010 Clinical trial Retrospective Posterior Spondylotic myelopathy 51 Posterior cervical laminoplasty 3.9
38 Shibuya et al. 2010 Comparative study Retrospective Anterior Spondylotic myelopathy 83 Anterior cervical decompression and fusion 8.8
posterior Posterior cervical laminoplasty 10.2
39 Kaner et al. 2009 Clinical trial Retrospective Posterior Spondylotic myelopathy 19 Posterior cervical laminoplasty 10.5
40 Shiozaki et al. 2009 Clinical trial Retrospective Posterior Spondylotic myelopathy 19 Posterior cervical laminoplasty 10.5
41 Takemitsu et al. 2008 Clinical trial Retrospective Posterior Spondylotic myelopathy 73 Posterior cervical laminoplasty 14
42 Chen et al. 2007 Clinical trial Retrospective Posterior OPLL 49 Posterior cervical laminectomy and fusion 18.3
43 Bose et al. 2007 Clinical trial Retrospective Anterior OPLL 238 Anterior cervical decompression and fusion 5
44 Hasegawa et al. 2007 Comparative study Retrospective Anterior Spondylotic myelopathy 857 Anterior cervical decompression and fusion 5.2
posterior Posterior cervical laminoplasty 6.1
Posterior cervical laminectomy 6.6
45 Tanaka et al. 2006 Clinical trial Retrospective Posterior Spondylotic myelopathy 62 Posterior cervical laminoplasty 4.8
46 Kaneko et al. 2006 Clinical trial Retrospective Posterior Spondylotic myelopathy 66 Posterior cervical laminoplasty 7.6
47 Sakaura et al. 2005 Comparative study Retrospective Anterior CHNP 36 Anterior cervical decompression and fusion 0
posterior Posterior cervical laminoplasty 6
48 Komagata et al. 2004 Clinical trial Retrospective Posterior Spondylotic myelopathy 305 Posterior cervical laminoplasty 4.3
49 Seichi et al. 2004 Clinical trial Retrospective Posterior Spondylotic myelopathy 114 Posterior cervical laminoplasty 3.5
50 Sasai et al. 2003 Comparative study Prospective Posterior Spondylotic myelopathy 111 Posterior cervical laminoplasty 2.7
51 Minoda et al. 2003 Clinical trial Retrospective Posterior Spondylotic myelopathy 45 Posterior cervical laminoplasty 8.9
52 Huang et al. 2003 Clinical trial Retrospective Posterior Spondylotic myelopathy 32 Posterior cervical laminectomy and fusion 6
Eur Spine J
Eur Spine J

Rate of C5
and the mean incidence of fusion has been reported as
palsy (%)
5.17 ± 4.09 %. Three studies reported the incidence of C5

1.3
2.8
6.6

5.5
12.9
palsy ranging from 3.5 to 4.3 % in patients who underwent

0
0
4

5
17
anterior cervical discectomy with a mean incidence of

Anterior cervical decompression and fusion

Anterior cervical decompression and fusion

3.87 ± 0.40 %. Thirty-four studies reported the incidence
of C5 palsy ranging from 0 to 16 % in patients who
underwent posterior cervical laminoplasty with a mean
incidence of 5.88 ± 3.54 %. Ten studies reported the
Posterior cervical laminectomy

Posterior cervical laminectomy

Posterior cervical laminoplasty
Posterior cervical laminoplasty

Posterior cervical laminoplasty

Posterior cervical laminoplasty

Posterior cervical laminoplasty

Posterior cervical laminoplasty

incidence of C5 palsy ranging from 1.7 to 25 % in patients
who underwent posterior cervical laminectomy and the
mean incidence of fusion ranging from 10.59 ± 8.18 %.
Type of procedure

Eight studies reported the incidence of C5 palsy ranging

from 0 to 16 % in patients who underwent posterior cer-
vical laminectomy with a mean incidence of
3.62 ± 5.69 %. One study reported the incidence of C5
palsy as 1.5 % in patients who underwent posterior cervical
foraminotomy. We detected statistically significant
patient
No. of

heterogenity between the types of procedures (p \ 0.05).

15
30
38

47

18
200

287
365

Posterior cervical laminectomy had statistically low inci-

dence of C5 palsy when compared to posterior laminec-
tomy and fusion (p = 0.029) and posterior cervical
laminoplasty (p = 037). We did not detect any statistical
Spondylotic myelopathy
Spondylotic myelopathy

Spondylotic myelopathy

Spondylotic myelopathy

Spondylotic myelopathy
Spondylotic myelopathy
Spondylotic myelopathy

significance between anterior cervical decompression and

fusion and other procedures (p [ 0.05).
Pathology in study

Discussion
CHNP

C5 palsy is manifested by paresis of the deltoid and/or

biceps brachia muscle, sensory deficits, and/or
posterior

posterior

intractable pain in the shoulders. The palsy is typically

Posterior
Posterior
Posterior

Posterior
Posterior
Posterior
Anterior

Anterior
Surgical

unilateral, but may be bilateral in 5–7 % of patients [2]. It’s

route

rate varies between 0 and 25 % depending on the types of

procedures [2–61] (Table 1). We detected the overall
Retrospective
Retrospective
Retrospective
Retrospective

Retrospective

Retrospective
Retrospective
Retrospective

incidence of C5 palsy for entire group of patients as

5.95 %.
Design

The anterior or posterior surgical routes

of procedure?
Comparative study

Comparative study
Cohort study
Cohort study
Clinical trial

Clinical trial
Clinical trial
Clinical trial

In the study of the largest case series (1001 patients) of

Study type

comparison between anterior and posterior surgical routes

of procedures, Bydon M et al. reported that the incidence
of C5 palsy is statistically higher in the posterior cohort
then the anterior cohort (8.6 vs. 1.6 %) (p \ 0.001). The
incidence of C5 palsy after a posterior C5 foraminotomy
Fujimoto et al. 2002

Uematsu et al. 1998

Edwards et al. 2002

Edwards et al. 2000

Chiba et al. 2002

(14.49 %) has been found significantly higher than after

Wada et al. 2001
Fan et al. 2002

Dai et al. 1998

an anterior C5 foraminotomy (2.41 %) (p \ 0.01) [5].

Table 1 continued
Author/year

Two large studies of literature showed that anterior

operations have an increasing number of corpectomy
levels and have a higher incidence of C5 palsy [5, 44].
Chang et al. performed another study that compares
No.

53
54
55
56

57

58
59
60

anterior and posterior surgical routes of procedures. In

123

their study, the incidence of C5 palsy has been reported
as 0.7 and 8.8 % for anterior and posterior, respectively.
They determined statistically significant difference
between groups [7]. In 2012, Chen et al. reported the
incidence of C5 palsy following posterior surgical routes
as 24.3 and 0 % following anterior surgical routes [12]. In
the same study, the highest incidence of C5 palsy of all
published studies has been reported (25 % for posterior
laminectomy and fusion) [12]. These studies revealed that
anterior surgical routes for patients have lower risk of
developing postoperative C5 palsy [5, 7, 12].
In the second largest case series with 857 patients of the
literature comparing anterior and posterior surgical routes
of procedures, Hasegava et al. reported that C5 impediment
has been noted in only 19 of 857 patients (2.2 %). Statis-
tical analyses did not reveal any difference in the incidence
of palsy among types of procedures, anterior versus pos-
terior surgical routes of procedures. In contrary, there was a
significant effect of diagnosis, with a higher incidence of
palsy occurring in ossification of the posterior longitudinal
ligament (p \ 0.0001) [23]. In the same study, the etiology
of the palsy was found as a transient spinal cord injury [23].
Another study including 630 patients (third of the largest
series in the literature) by Nassr et al., reported that the
incidence of C5 nerve palsy was highest for the laminec-
tomy and fusion group with a rate of 9.5 %, and it was
followed by the anterior corpectomy with posterior fusion
group with a rate of 8.4 %, the anterior corpectomy alone
group with a rate of 5.1 %, and finally the laminoplasty
group with a rate of 4.8 %. The overall incidence for
posterior surgical routes of procedures was 7.2 %. There
was no statistical significance (p = 0.28) [44].
In addition, with respect to the posterior approach,
laminectomy and instrumented fusion improved the surgi-
cal results of patients with cervical kyphosis [12]. Post-
operative cervical lordosis after anterior corpectomy or
laminectomy and instrumented fusion was significantly
larger when compared to laminoplasty alone. Anterior
corpectomy and fusion was significantly more effective for
treatment of OPLL when compared with posterior
laminoplasty in the cervical spine [11]. Surgical outcomes
were similar whether multilevel cervical spondylotic
myelopathy was treated with corpectomy or with lamino-
plasty [47, 55].
As a result of all studies presented above, some studies
revealed that there was no difference in the incidence of
palsy among surgical procedures, anterior versus posterior.
However, most of the studies indicated that the incidence
of C5 palsy is higher in posterior procedures. For this
reason, anterior procedure can be considered safer for
postoperative C5 palsy. As a result of increasing number of
corpectomy levels in anterior operations, C5 palsy had a
higher incidence.
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Eur Spine J
Which anterior procedure?
Liu et al. found in their study that analyses complications
of different reconstructive techniques following anterior
decompression, that most of the patients who had C5 palsy
belonged to multilevel corpectomy group (11.9 %) and that
the procedure of multilevel corpectomy may lead to sig-
nificant drift of spinal cord away from ventral side. But no
statistical significance has been detected between proce-
dures [39]. This study that includes 286 patients has the
highest number of case series of C5 palsy for anterior
procedures. They reported that the patients in the multi-
level ACDF group had the highest fusion rate and lowest
incidence of C5 palsy [39]. Another study realized by Lin
et al. that compares anterior cervical discectomy and cor-
pectomy in patients with multilevel cervical spondylotic
myelopathy reported the incidence of C5 palsy as 3.5 % in
anterior cervical discectomy and fusion (ACDF) and as
4.8 % in anterior cervical corpectomy and fusion (ACCF).
ACCF had higher incidence of C5 palsy. No statistical
significance has been detected between groups. In addition,
Lin et al. suggest that ACDF has better outcomes than
ACCF in terms of blood loss, lordotic curvature improve-
ment and instrumentation and graft related-complication
rates, with the exception of operation times. Iatrogenic C5
palsy has had transient symptoms and resolved within
2 months [36].
In the study of Bose, Hashimato, Eskander, Odate, Guo
and Kotil that consists of 768 patients, mean incidence of
C5 palsy has been detected as 7.4 % [4, 19, 22, 24, 35, 45].
Bose B reported that the risk of new-onset C5 palsy fol-
lowing anterior cervical spinal surgery is greatest for
patients who underwent aggressive treatment of severe
spinal cord compression at three or more levels spanning
C4–5 and C5–6. Transcranial electrical stimulation-in-
duced MEPs and spontaneous EMG activity recorded from
C5 myotome has been sensitive to evolving iatrogenic C5
spinal nerve root deficit caused by anterior cervical spinal
surgery [4]. Jimenez et al. reported a decrease in the inci-
dence of C5 nerve root palsy from 7.3 to 0.9 % as a result
of modification of their intraoperative neuromonitoring
protocol for cervical spinal surgery to include EMG
recordings from the deltoid muscle [62]. Hashimato indi-
cated that the more levels are involved in anterior cervical
decompression, the more likely C5 palsy will occur [24]. In
his study of the association between preoperative spinal
cord rotation and postoperative C5 nerve palsy, Eskander
suggested that spinal cord rotation is a strong and signifi-
cant predictor of postoperative C5 palsy (p \ 0.001). They
classified patients into three groups, Type 1 representing
mild rotation (0° to 5°), Type 2 representing moderate
rotation (6° to 10°), and Type 3 representing severe rota-
tion (C11°). The rate of C5 palsy has been found as zero of
Eur Spine J
159 patients in the Type-1 group, eight of 13 patients in the
Type-2 group, and four of four patients in the Type-3
group. This information has been suggested for surgeons
and patients considering anterior surgery in the C4–C6
levels [19].
Odate and Guo suggested that anterior hybrid decom-
pression and segmental fixation as a safe and effective
procedure for the treatment of adjacent three-level cervical
spondylosis [22, 45]. In this surgical procedure, patients
have been treated with a plated two-vertebra corpectomy
and an adjacent single-level discectomy with stand-alone
cage fixation. Odate suggested that the hybrid technique
has the following advantages over three-vertebra corpec-
tomy for four-segment cervical fixation: it requires a
shorter graft bone and plate; it results in the greater initial
stability of the fixed segment; it simplifies postoperative
external immobilization; and it reduces the risk of recon-
struction failure and postoperative C5 palsy markedly.
At the end of all studies presented above, we conclude
that multilevel ACDF had the lowest incidence of C5
palsy. When a surgeon has to apply corpectomy, he/she
should remember that the more levels are involved in
anterior cervical decompression, the more likely the
occurrence of C5 palsy will be. The hybrid technique can
be chosen for over two-vertebra corpectomy.
Which posterior procedure?
Posterior surgical procedures are applied to most of cer-
vical spondylotic myelopathy patients during laminec-
tomy with or without fusion and during different types of
laminoplasty. The safest procedure approach for preven-
tion of C5 palsy is controversial. Yang et al. compared
open-door laminoplasty and laminectomy in 2013, and
they reported that C5 palsy occurred in three and 11
patients in the laminoplasty and the laminectomy and
fusion groups, respectively (p \ 0.05). C5 palsy rate in
the laminoplasty group has been found significantly
higher than the laminectomy and fusion group and
patients with C5 palsy showed a significantly greater
change in dural sac area and a greater spinal cord shift
compared with those without C5 palsy in both groups. For
this reason, they suggested modified laminoplasty as a
more viable option for patients with cervical stenotic
myelopathy [58]. In the study of Xia G, no significant
difference between laminectomy and laminoplasty has
been reported. Their results revealed that both laminec-
tomy and laminoplasty can produce a similar degree of
posterior movement of the spinal cord and that cervical
lordosis is not associated with the posterior movement of
the cord. The preoperative JOA scores are important
determinants for postoperative outcome, but not posterior
movement of the cord and age [56].
In a multicentric study, the largest case series including
1858 patients who underwent cervical laminoplasty has
been reported by Imagama et al. in 2010 [2]. The authors
included in their study 43 patients (2.3 %) who developed
C5 palsy with manual muscle testing (MMT) grade of 0–2
in the deltoid, with or without involvement of the biceps.
When the clinical features and radiological findings of
patients with (group 1; 43 patients) and without (group 2;
100 patients) C5 palsy were compared, CT scanning of
group 1 revealed a significant narrowing of the interver-
tebral foramen of C5 (p \ 0.005) and a larger superior
articular process (p \ 0.05). On MRI, the posterior shift of
the spinal cord at C4–5 has been significantly greater in
group 1, than in group 2 (p \ 0.01). Early foraminotomy in
susceptible individuals and the avoidance of tethering of
the cord by excessive laminoplasty may prevent a post-
operative palsy of the C5 nerve root [2]. Similar to study of
Imagama, Komagata and Katsumi suggest that there are no
specific risk factors among the preoperative clinical find-
ings related to C5 palsy. Bilateral partial foraminotomy is
effective for preventing C5 palsy [30, 34]. In investigation
of segmental motor paralysis after cervical laminoplasty,
Nakamea et al. indicated that after cervical laminoplasty,
postoperative segmental motor paralysis occurs even if
there are no abnormal findings during intraoperative spinal
cord monitoring with transcranial electric motor-evoked
potentials [42].
Contrarily, Chen et al. had a different result of C5 palsy
for different posterior procedures. In the study of 36
patients with posterior procedure, they reported the inci-
dence of C5 palsy in patients undergoing laminectomy and
instrumented fusion as significantly higher than that in
patients undergoing laminoplasty (p \ 0.001) [12]. Simi-
larly, Nassr et al. reported in one of the largest case series
in the literature that the incidence of C5 nerve palsy was
highest for the laminectomy and fusion group with 11 of
116 (9.5 %), followed by the laminoplasty group with 5 of
105 (4.8 %), and these differences did not reach statistical
significance (p = 0.28) [44]. In the study of cervical
laminectomy and fusion, Katonis et al. indicated that the
incidence of C5 palsy was 2.2 % [29]. They reported that
lateral mass fixation can be used safely with minimal
complications and that it causes low rate of morbidity
following cervical myelopathy treatment [29]. Fan et al.
reported in a similar study that iatrogenic C5 nerve root
injury was 1.3 % during laminectomy [20]. This finding is
informative for clinicians to consider intraoperative deltoid
and biceps transcranial electrical motor-evoked potential
and spontaneous electromyography monitoring whenever
there was potential for iatrogenic C5 nerve root injury to
reduce postoperative C5 root palsy [20]. In their study that
evaluates causes of C5 palsy, Liu et al. found that tethering
the nerve root causes C5 palsy. They suggest that excessive
123

intraoperative traction and the use of internal fixation may
be one of the most important reasons for this. They also
indicated that the cervical curvature index change rate
reflected both a change in cervical height and a change in
the overall cervical curvature. According to their study, it is
more sensitive in reflecting the degree of cervical traction
and the change of the cervical alignment [38]. The poste-
rior movement of spinal cord has been hypothesized to
result from the bowstring effect with an increased tension
in the spinal cord following the posterior decompression
surgery that widens the spinal canal [63]. Nakashima et al.
suggests that the cause of C5 palsy is the posterior shift of
the spinal cord, and additional iatrogenic foraminal stenosis
due to cervical alignment correction after posterior
instrumentation with fusion [43]. For prevention of C5
palsy they suggest prophylactic foraminotomy at C4–5
levels when there is preoperative foraminal stenosis on CT.
Furthermore, it might be also useful for treating postop-
erative C-5 palsy. According to the authors, appropriate
kyphosis reduction should be considered carefully to pre-
vent excessive posterior shift of the spinal cord [43].
As a result of all studies presented above, the incidence of
C5 palsy in patients undergoing laminectomy and instru-
mented fusion is significantly higher than that in patients
undergoing laminoplasty. In an effort to reduce postoperative
C5 nerve root palsy, the clinician should consider intraoper-
ative deltoid and biceps transcranial electrical motor-evoked
potential and spontaneous electromyography monitoring
whenever there is potential for iatrogenic C5 nerve root injury.
For prevention of C5 palsy, prophylactic foraminotomy at
C4–5 might be useful when preoperative foraminal stenosis is
present on CT. To prevent excessive posterior shift of the
spinal cord, appropriate kyphosis reduction should be con-
sidered carefully. However, according to our study comparing
all studies including anterior and posterior procedures, pos-
terior cervical laminectomy without fusion is safer than pos-
terior cervical laminectomy with fusion and posterior cervical
laminoplasty.
Pathogenesis: In the report by Sakaura et al., a typical
postoperative C5 palsy is considered to be a result of nerve
root injury or segmental spinal cord disorder [64]. As
several conditions may contribute to C5 palsy, the current
authors recommend distinguishing five pathologic mecha-
nisms as follows: (1) inadvertent injury to the nerve root
during surgery [65]; (2) nerve root traction caused by
consecutive shifting of the cord following decompression
surgery [63]; (3) spinal cord ischemia due to decreased
blood supply from radicular arteries [66]; (4) segmental
spinal cord disorder [67]; and (5) reperfusion injury of the
spinal cord [13].
Risk factors and Prevention: Lubelski et al. reported that
for every 1-mm increase in anteroposterior diameter (APD)
and foraminal diameter (FD), the odds of developing palsy
123
Eur Spine J
decrease 69 % (p \ 0.0001) and 98 % (p \ 0.0003),
respectively. Contrarily, for every 1° increase in cord-
lamina angle (CLA), the odds of developing palsy increase
by 43 % (p \ 0.0001) [68]. In addition, extremely wide and
asymmetric decompression accompanying pre-existing C4–
C5 foraminal stenosis may cause postoperative C5 palsy.
Thus, surgeons should consider restricting the decompres-
sion width to less than 15 mm and avoiding asymmetric
decompression to reduce the incidence of C5 palsy [69]. In
addition, electromyography was a sensitive predictor of
postoperative C5 palsy [20]. Finally, this complication may
be avoided by performing selective foraminotomy in addi-
tion to posterior central canal decompression. It should be
kept in mind that pre-existing subclinical C5 root com-
pression is a cause of C5 palsy after posterior cervical
decompression for myelopathy [30, 34, 48].
Treatment and Prognosis: Nakashima reported that
seven of ten patients who developed postoperative C-5
palsy recovered fully from the neurological complications
[43]. Nevertheless, sometimes the C5 palsy does not heal
with time and conservative treatment [56]. Conservative
treatment of this condition includes neurotrophic drugs,
hyperbaric oxygen therapy and functional exercises [10].
The time of complete recovery may range from 1 week to
5 months [10, 20, 29].
Conclusion
Some studies detected no differences among anterior or
posterior approaches but some of them indicate that ante-
rior procedure is more safe. Within anterior procedures, the
multilevel ACDF had the lowest incidence of C5 palsy.
The hybrid technique can be chosen for over two-vertebra
corpectomy. In term of posterior procedures, the incidence
of C5 palsy in laminectomy and fusion group has been
found significantly higher than laminoplasty group. In
addition, electromyography is a sensitive predictor of
postoperative C5 palsy. This complication may be avoided
by performing selective foraminotomy. The time of com-
plete recovery may range from 1 week to 5 months.
Compliance with ethical standards
Conflict of interest The authors report no conflict of interest con-
cerning the materials and methods used in this study or the findings
specified in this paper.
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