C5/C6 Palsy Case
By Admin | July 03, 2024
Surgery is risky business and complications such as neurological injury, cerebral spinal fluid leak, infection, hardware failure, need for further surgery, vascular injury, bleeding, heart attack, deep venous thrombosis, pulmonary embolism, urinary tract infection, renal injury, stroke, chronic pain, and death might make someone question when it would be worthwhile!
For some people suffering through instability and gait abnormalities, numbness, weakness, arm pain, tingling, and neck pain on top of myelopathy and frequent falls, it might be one of their few options, as it was for our 72-year-old patient.
Diagnosed with spinal stenosis (narrowing of the spinal canal) and spondylosis (wear and tear of the spinal joints), the patient’s condition was quickly getting worse. The goal of surgery was to prevent worsening neurological decline and was done by a C3-C6 Anterior Cervical Discectomy and Fusion (ACDF) with posterior instrumentation fusion and laminectomies.
ACDF surgery is performed to relieve pressure on the spinal cord or nerve roots in the cervical spine. This pressure can be caused by a herniated disc, bone spurs, or other factors. During the surgery, the surgeon removes the damaged disc and inserts a bone graft or spacer to create space between the vertebrae. This helps alleviate pressure on the nerves and spinal cord, reducing pain, numbness, and weakness. While ACDF is a relatively common surgery with numerous benefits, there are inherent risks involved, including nerve injury.
To safeguard the patient's neurological health, the surgeon opted for various neuromonitoring modalities, including Somatosensory Evoked Potentials (SSEPs), Transcranial Electric Motor Evoked Potentials (TCeMEPs), Electromyography (EMG), and Electroencephalogram (EEG). These selected modalities were used to track the function of nerves throughout the surgery so the team could provide the best possible outcome available for the patient.
After decompressing the C4-C5 vertebrae, which involved removing some bone and disc material to create space, the MEP responses remained stable. This indicated good nerve function. However, the situation changed dramatically when the surgeon placed a cage (spacer) at the C4-C5 level. The MEP readings for the left bicep muscle showed a significant decrease in activity, exceeding a 90% drop in amplitude. This was a clear warning sign of potential nerve damage.
The surgeon was immediately alerted to this critical change, allowing them to take corrective action. Unfortunately, despite these efforts, the left bicep MEP responses remained significantly decreased. Notably, all other MEP readings remained stable, suggesting the intervention protected other nerves.
While the postoperative course confirmed the nerve damage detected by neuromonitoring and the patient was unable to lift their left arm, the use of monitoring modalities was able to help prevent further injuries during the surgery, protected other nerves, and likely prevented permanent damage as the patient recovered function days later.
This case serves as a stark reminder of the importance of neuromonitoring in safeguarding the delicate nerves during spinal surgery. By providing real-time feedback on nerve function, neuromonitoring empowers surgeons to ensure patient safety and minimize the risk of debilitating nerve injuries.
C5 palsy is a neurological complication affecting 5-10% of patients after cervical decompression surgery and while it was not able to be avoided in this surgery, quick action and acute awareness of all nerve functioning was able to protect the patient’s right arm despite similar MEP responses detected in the left arm.
The significance of neuromonitoring in spine surgeries cannot be overstated. Beyond its role in intraoperative safety, it provides best case scenario outcomes for patients. For more information on the transformative benefits of neuromonitoring, please contact us at 888-344-2947.
