Post-operative nerve injuries after cervical spine surgery

Abstract

Although relatively rare, post-operative nerve injuries may occur after cervical spine procedures. The most common post-operative neural disorder is C5 nerve palsy. The risk factors for C5 nerve palsy are male gender, OPLL, and posterior cervical approaches. It generally presents with deltoid and/or biceps weakness, and may present immediately or several days after surgery. Treatment is generally conservative due to transient duration of symptoms, but evaluation of residual compression at C4–5 is essential. PTS (Parsonage-Turner syndrome) is an idiopathic plexopathy generally presenting with severe neuropathic pain in the shoulder, neck, and arms, followed by neurological deficits involving the upper brachial plexus. The deficits typically present in a delayed fashion after the onset of pain. Once residual nerve compression is ruled out, initial treatment is based on pain control and physical therapy. Post-operative C8-T1 nerve palsies occur with weakness of the five intrinsic muscles of the hand innervated by the medial nerve, with sensory symptoms in the territory innervated by the ulnar nerve (ulnar two digits of the hand), and also the medial forearm. The risk factors for C8-T1 nerve injuries after surgery are C7 pedicle subtraction osteotomies and posterior fixation of the cervico-thoracic junction, especially in patients with preoperative C7-T1 stenosis. A wide foraminal decompression at C7-T1 region is necessary to minimize risk of this complication. Finally, Horner’s syndrome can occur post-operatively, especially after anterolateral approaches to the middle and lower levels of the cervical spine. It is characterized by ipsilateral papillary miosis, facial anhydrosis, and ptosis secondary to injury of the cervical sympathetic nerves. Avoid using the cautery on the lateral border of the longus colli muscle, where the sympathetic chain lies and place the retractors properly underneath the muscle to decrease the chance of sympathetic injuries. It can also occur from iatrogenic compression or injury to the T1 nerve root, as the sympathetic chain gets some of its fibers from that level. Understanding the most common potential nerve injuries after cervical spine procedures is helpful in prevention, early diagnosis, and appropriate management.