Elsevier

World Neurosurgery

Volume 146, February 2021, Pages e14-e21
World Neurosurgery

Original Article
Direct Involvement of Concomitant Foraminotomy for Radiculomyelopathy in Postoperative Upper Limb Palsy in Cervical Laminoplasty

https://doi.org/10.1016/j.wneu.2020.09.105Get rights and content

Objective

Although concomitant foraminotomy has been reported to increase the risk of postoperative upper limb palsy (ULP) in cervical laminoplasty, the specific effects of concomitant foraminotomy on ULP remain uncertain. This study aimed to clarify the effect of concomitant foraminotomy on ULP in cervical laminoplasty.

Methods

We identified 19 patients who developed ULP after laminoplasty with concomitant foraminotomy for radiculomyelopathy with nerve root impingement (laminoplasty with concomitant foraminotomy group [F-group]) from 4080 patients who underwent primary cervical laminoplasty at 27 affiliated institutions between 2012 and 2018. An age- and sex-matched control group comprised patients who developed ULP after laminoplasty without concomitant foraminotomy (n = 76, 4:1 ratio with F-group). Collected data included the time of onset and distribution of ULP (side and level). The site of foraminotomy was recorded in the F-group.

Results

The F-group showed a significantly higher incidence of ULP than the candidates for the control group (15.1% vs. 3.1%, P < 0.001). The site of foraminotomy was consistent with the distribution of ULP in 79% (15 of 19 patients) of the F-group. The F-group showed a significantly higher proportion of preoperative upper-limb muscle weakness (74% vs. 37%, P = 0.005) and early-onset ULP occurring by postoperative day 1 (63% vs. 33%, P = 0.02) compared with the control group.

Conclusions

Our results indicate that the foraminotomy procedure in the stenotic foramen is directly involved in ULP. Combined with a previous report suggesting that early-onset ULP is associated with thermal nerve damage, our results indicate that thermal nerve damage partly explains the increased incidence of ULP in the F-group.

Introduction

Laminoplasty and foraminotomy are established procedures for treating cervical compressive myelopathy and radiculopathy, respectively.1,2 However, postoperative upper limb palsy (ULP), the incidence of which was reported to be 5.3% in a meta-analysis,3 is a well-recognized complication of cervical spine surgery, also termed C5 palsy.4 Although the prognosis is generally good, ULP can be a serious problem that decreases a patient's quality of life and increases health care costs.5

Previous studies reported that foraminotomy was a risk factor for ULP after cervical spine surgery.6, 7, 8 Moreover, another study indicated that concomitant foraminotomy that was performed in patients with nerve root impingement in laminoplasty was one of the predictors for ULP.9 These findings suggest that concomitant decompression of the stenotic foramen may paradoxically cause ULP after laminoplasty. However, because of its low incidence,6,7,9 no studies have revealed the detailed characteristics of ULP after laminoplasty with concomitant foraminotomy. In particular, it is crucial to confirm the consistency between the site of foraminotomy and the distribution of ULP.

In evaluating complications with a low incidence, many studies have used national databases to obtain a large sample size. However, some authors concluded that these databases tend to underestimate the incidence of surgery-related complications.10,11 In contrast, surgeon-maintained databases were reported to have accurate data with regard to surgery-related complications.10,11 In this study, we aimed to elucidate what effects concomitant foraminotomy has on ULP after laminoplasty other than the increased incidence. We used a matched case-control study design with a sufficient sample size based on a surgeon-maintained multicenter database.

Section snippets

Materials and Methods

All protocols for this study were approved by the central institutional review board and ethics committee of our university. These protocols were reviewed and agreed on by the local institutional review boards in all institutions participating in this study.

Patient Demographics

The incidence of ULP was significantly higher in the F-group (19/126, 15.1%) than in the candidates for the C-group (124 of 3954 patients; 3.1%) (P < 0.001, Fisher exact test) (Figure 1). The 2 groups were comparable in terms of age at surgery, sex ratio, ossification of the posterior longitudinal ligament, procedure distribution, number of opened laminae, operative time per lamina, estimated blood loss per lamina, postoperative JOA score, recovery rate of JOA score, and follow-up period.

Discussion

In this study, we investigated the characteristics of ULP in patients undergoing cervical laminoplasty with concomitant foraminotomy using a matched case-control study based on a multicenter surgeon-maintained database. Concomitant foraminotomy remarkably increased ULP, and the site of foraminotomy was consistent with the distribution of ULP in 79% of the F-group. The proportions of early-onset ULP and preoperative upper-limb muscle weakness were higher in the F-group than in the C-group.

In

Conclusions

In ULP after cervical laminoplasty with concomitant foraminotomy, the distribution of ULP was highly consistent with the site of foraminotomy. The F-group included more patients with early-onset ULP and with preoperative muscle weakness compared with the C-group. Together with previous studies, our results suggest that thermal damage to the nerve roots by a high-speed drill is partly responsible for ULP. Our findings will be useful for patients and clinicians in terms of sharing information

CRediT authorship contribution statement

Hiroyuki Ishiguro: Validation, Investigation, Writing - original draft, Visualization. Shota Takenaka: Conceptualization, Methodology, Software, Validation, Formal analysis, Data curation, Writing - review & editing, Project administration. Masafumi Kashii: Resources, Data curation. Yuichiro Ukon: Investigation. Yukitaka Nagamoto: Investigation. Masayuki Furuya: Investigation. Takahiro Makino: Writing - review & editing. Yusuke Sakai: Writing - review & editing. Takashi Kaito: Writing - review

Acknowledgments

We thank Sadaaki Kanayama, M.D. (Ikeda Municipal Hospital), Shuichi Hamamoto, M.D. (Japanese Red Cross Society Himeji Hospital), Yusuke Kuroda, M.D. (Sakai City Hospital Organization, Sakai City Medical Center), Tokimitsu Morimoto, M.D. (Suita Municipal Hospital), Atsunori Ohnishi, M.D., and Akira Yamagishi, M.D. (Kansai Rosai Hospital), Yuya Kanie, M.D. (Hoshigaoka Medical Center), Kunihiko Hashimoto, M.D. (Osaka Police Hospital), Hiroki Hagizawa, M.D., and Rintaro Okada, M.D. (Minoh City

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      In our study, only one cadaver had shorter BAL of C6, C7, and C8 than that of C5. A research indicates that postoperative palsy occurs more at the proximal level (C5–C6) than at the distal level (C7–C8) [29]. These findings may be compatible with our results.

    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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