Rebecca Howard, MD
Resident Physician
Icahn School of Medicine at Mount Sinai
New York, New York, United States
Adam T. Schulman, MD
Resident Physician
Mount Sinai Hospital
NYC, New York, United States
Tommy Brennan Tsang, MS
Medical Student
Burrell College of Osteopathic Medicine
Albuquerque, New Mexico, United States
Vincent Huang, MD
Attending Physician
Mount Sinai Hospital
New York, New York, United States
C5 palsy post cervical decompression, instrumentation and fusion
A 40-year-old male presented with 1 month of progressive bilateral lower extremity pain and upper extremity weakness. MRI demonstrated a C4/C5 herniated disc with myelomalacia requiring discectomy and fusion, with subsequent C4-5 ACDF revision for persistent weakness thought secondary to ossification of the posterior longitudinal ligament. Afterwards the patient had ongoing neuropathic pain in the left shoulder and bilateral hand numbness, requiring C2-6 PCDF. Three weeks after being readmitted to spinal cord injury rehabilitation, he continued to have pain in his left shoulder and developed significant weakness in shoulder abduction and elbow flexion. Both CT and MRI of the C-spine did not show any acute findings. An MRI of the brachial plexus was performed that showed diffuse thickening and abnormality at the left postganglionic C5 nerve roots, supporting a diagnosis of a post-surgical C5 neuropathy.
C5 palsy is a complication of cervical spinal surgeries, with incidence reported to be 4-8%. This complication can occur up to 2 months after the surgery, when many patients are undergoing acute rehabilitation. Patients can present with motor weakness in the C5 distribution with sensory deficits and shoulder pain, which our patient had. CT and MRI of the C-spine are often inconclusive given the underlying etiology of C5 palsy is not well understood and patients often have pre-existing spinal abnormalities. In these cases, an MRI of the brachial plexus may provide additional evidence of damage to C5 nerve roots to support the diagnosis.
Postoperative C5 palsy may be difficult to diagnose in the acute rehabilitation setting given the delayed presentation and range of pathologies that lead to shoulder pain and weakness. MRI brachial plexus can be useful to identify cases in which there has been injury to the nerve root and support a diagnosis of C5 palsy.
