Posterior expansive foraminotomy before laminectomy combined with pedicle screw fixation can decrease the incidence of C5 palsy in complex surgery in patients with severe myeloradiculopathy

Introduction C5 palsy is a frequent sequela of cervical decompression surgeries for cervical myelo-radiculopathy. Although many researchers have suggested that foramen size is an independent risk factor for C5 palsy, there is no consensus regarding this issue.
Aims/Objectives So, we tried to investigate different techniques for foramen decompression with posterior cervical fusion and assess the incidence of C5 palsy with each technique.
Methods A combined approach with LMS and uncovertebrectomy was used in Group 1. Group 2: combined approach with pedicle screws and posterior foraminotomy, while posterior approach only with pedicle screws and foraminotomy was used in Group 3. The propensity score was utilized to select matched groups for our study to have significant results. Among all surgical patients, cases presented with myelo-radiculopathy symptoms with C4-5 foramen stenosis were selected. Motor manual testing was performed preoperatively and postoperatively to assess C5 palsy. Neck Disability Index (NDI) and Japanese Orthopedic Association (JOA) scores were determined before and after surgery. Lateral radiographs were obtained to assess cervical lordosis parameters preoperatively and postoperatively.
Results A total of 362 patients were enrolled in this study: 208 in group 1 (PAP with LMS), 72 in group 2 (PAP with pedicle screws), and 82 in group 3 (posterior only with pedicle screws) The mean age was 63.2, 65.5, and 66.6 years in groups 1–3, respectively. The median for fused levels was 4 for the three groups. There was no significant difference between groups regarding the number of fused levels. Weight, height, comorbidities, and diagnosis were not significantly different between groups. Preoperative JOA scores were similar between groups (p=0.256), whereas the preoperative NDI score was significantly higher in group 3 than in group 2 (p=0.040) Mean JOA score at 12-month follow-up was 15.5±1.89, 16.1±1.48, and 16.1±1.48 for groups 1–3, respectively; it was higher in group 3 compared with group 1 (p=0.008) and in group 2 compared with group 1 (p=0.024). NDI score at 12 months was 13, 12, and 13 in groups 1–3, respectively; it was significantly better in group 3 than in group 1 (p=0.040), but there were no other significant differences between groups. The incidence of C5 palsy was significantly lower in posterior foraminotomy groups with pedicle screws (groups 2 and 3) than in LMS with uncovertebrectomy (group 1) (p < 0.001).
Conclusions
Thus, Preventive expansive foraminotomy before decompressive laminectomy can significantly decrease the incidence of C5 palsy associated with posterior and combined posterior and anterior cervical fusion surgeries. Also, such expansive foraminotomy is appropriate with pedicle screw insertion.