C5 Palsy after Cervical Disc Arthroplasty: Case Reports and Literature Review

C5 Palsy after Cervical Disc Arthroplasty: Case Reports and Literature Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report C5 Palsy after Cervical Disc Arthroplasty: Case Reports and Literature Review Cesar Carballo, Gabriel Flores, Nicolas Baerga, Puya Alikhani, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4113763/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract CDA has become an alternative for the treatment of cervical spondylosis with radicular or myelopathic symptoms, however there is limited literature regarding its complications and outcomes. We present two cases of C5 nerve palsy (C5P) following cervical disc arthroplasty (CDA). C5 Palsy Arthroplasty ACDF Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction C5 palsy (C5P) is a known complication after cervical spine surgery in both anterior and posterior approaches. There has been significant literature published regarding C5P following cervical spine surgery with an overall incidence of 5.3% [1-3]. Classically, C5P is a delayed, usually temporary, focal paresis of the deltoid and possibly the bicep muscle after cervical spine surgery [4, 5]. The diagnosis of C5P is one of exclusion and other etiologies for C5 nerve weakness must be ruled out, including disc herniation, residual stenosis, or hematoma [5]. Although the literature reports C5P after posterior cervical laminectomy, foraminotomy, and anterior fusion, to date there have been no reports of C5P following by cervical arthroplasty. We present two independent cases of C5P from two independent surgeons after CDA and situate their cases within the broader literature. Case presentation Case 1: A 47-year-old female presented with progressive bilateral upper extremity radicular pain. The radicular pain was consistent with bilateral C5 and right C7 dermatome distribution. She had a past surgical history of C5-C6 anterior cervical fusion. On her physical exam she demonstrated hyperreflexia of the biceps, patella, and brachioradialis. Cervical spine MRI demonstrated severe spinal cord compression at the C6-C7 level along with moderate stenosis at C4-C5, consistent with adjacent level disease (Figure 1). The patient underwent disc replacement with bilateral foraminotomies at C4-C5 and C6-C7. The intervention was performed using standard technique with the use of intraoperative neuromonitoring with combination of motor and somatosensory evoked potentials and electromyography. A 6mm ProDisc implant was placed at both levels (Figure 2). Neuromonitoring remained stable throughout the procedure. The patient was discharge on post-operative day 1 with resolution of pre-operative symptoms; she was full strength bilaterally at time of discharge. On POD 3, the patient complained of sudden left sided arm and neck pain with progression of severity which progressed until POD 8 when she had a sudden onset of left arm weakness, prompting emergent medical attention. On physical examination, she had left deltoid weakness 2/5 with inability to raise her arm above 30 degrees at shoulder level; the remainder of her neurologic exam was normal. A CT myelogram was performed showing no cervical cord compression or foraminal stenosis with no hardware failure (Figure 3). The patient was diagnosed with C5P and was discharged home with oral dexamethasone 2mg two times daily, ibuprofen 400mg every 6 hours and, gabapentin 300 mg every 8 hours. She was encouraged to use a shoulder sling to prevent secondary traction injury and started on physical therapy to assist with shoulder mobilization. Patient had full return of strength in the deltoid 6 weeks after surgery and remains well greater than one year past surgery. Case 2: A 52-year-old female presented with intermittent neck pain radiating to the right shoulder and arm. On the physical exam, she was full strength but demonstrated marked spasticity, with bilateral patellar hyperreflexia as well as bilateral Hoffman's sign and 1-2 beats of ankle clonus, consistent with cervical myelopathy. A non-contrast cervical spine MRI (Figure 4) demonstrated severe stenosis at C3-C4 and moderate stenosis at C4-C5 level. Patient underwent CDA using the Mobi-C implant at both levels. Patient was discharged home on POD 1 without new neurologic deficit. Starting on POD 4, however, the patient developed progressively worsening severe bilateral neck and right shoulder pain which was managed in the outpatient setting using gabapentin. However, on POD 14, she was unable to abduct her right arm past ten degrees with 1/5 motor power; the remainder of her neurologic exam was intact. Postoperative x-rays showed stable hardware. She was managed on oral dexamethasone 2mg every 12 hours therapy and physical therapy. She demonstrated resolution of her pain and full restoration of deltoid power approximately four weeks after surgery. She remains well at one year following surgery without evidence of residual weakness. Discussion Although C5P is a well noted complication after cervical spine surgery, no reports to date describe C5P after arthroplasty. Traditional theories of C5P posit posterior translation of the spinal cord with resulting nerve root traction as the cause of delayed paresis [6, 7]. While compelling, these explanations fail to account for the small but substantial rate of C5P following anterior cervical surgery [8], prompting other etiological hypotheses, such as ischemia reperfusion injury and residual foraminal stenosis [9]. However, a single unifying theory remains elusive, and C5P is better understood as a clinical phenomenon rather than a single pathophysiological entity [10]. Therefore, we will focus on several pertinent detail of the case, rather than attempt to posit a single causative theory of C5P after arthroplasty. First, motion through the cervical spine represents a complex mixture of rotation and translation, described kinematically through the instantaneous axis of rotation (IAR). Although disc replacement devices attempt to reproduce this motion, they do so imperfectly. This discord between the native cervical spine’s IAR and that of the disc replacement device may potentially lead to dynamic foraminal encroachment [11]. This phenomenon may be relevant to both cases, where use of a full constrained device (Case 1) or anterior placement of the device’s IAR to the disc’s natural IAR (Case 2) could lead to abnormal disc kinematics with dynamic encroachment and compression of the C5 nerve root. Second, both patients demonstrated a classic presentation of C5 palsy with delayed onset weakness followed by relatively rapid return of arm function. Although multiple factors predict recovery after C5 palsy, spontaneous full recovery is the general natural history of the phenomenon, especially in patients without bicep involvement and partially preserved deltoid strength [12]. Our cases of C5 arthroplasty demonstrate a similar recovery trajectory to those following other forms of neck surgery. Although posterior foraminotomy represents a biomechanically sound way to salvage post-operative radiculopathy following cervical arthroplasty, our experience suggests against its routine usage in the management of C5 palsy after cervical arthroplasty [13]. Although standard protocols for C5 palsy do not exist, non-operative management consisting of physical therapy and steroids provided rapid resolution of symptoms in both patients. In summary, we present a novel presentation of a well characterized complication of cervical spine surgery. Although increasingly well-established, cervical arthroplasty represents a relatively novel surgical technique with different complication profiles compared to other forms of surgical decompression. Our experience illustrates that cervical arthroplasty is not exempt from the possibility of C5 palsy and that expectant management remains an appropriate management strategy with the potential for excellent outcomes. Conclusion We present two independent cases of C5 palsy after CDA performed by independent surgeons using independent device classes. Both cases resolved with expectant management, suggesting that C5 palsy after disc replacement may be managed in similar fashion to C5 palsy following other cervical procedures. Abbreviations ACDF= Anterior Cervical Discectomy and Fusion C5P= C5 Palsy Cervical disc arthroplasty = CDA NSAID= non-steroidal anti-inflammatory drug POD= Postoperative day Declarations No funding was received to assist with the preparation of this manuscript and the authors have no relevant financial or non-financial interests to disclose. Disclosure of Funding: No funding or financial support was received for this study. Conflict of Interest: The authors report no conflict of interest. Data Availability Statement The data that support the findings of this study are not openly available due to reasons of sensitivity and to preserve patient’s privacy. The reason for this is that this is a case report and patient identifiable information will always be protected. Authors Contributions The authors confirm contributions for the paper and all the members contributed to the realization of this study. Their contributions are as follows: study conception and design: C.C, E.H, data collection: C.C, E.H, G.F, N.B, analysis and interpretation of results: C.C, E.H, M.G, P.A, draft manuscript preparation: C.C, G.F, E.H, N.B, M.G, P.A, figure preparation C.C. All authors reviewed the results and approved the final version of the manuscript. Informed Consent All the study subjects were consented at an academic institution and were consented for their described surgical procedure and participation for this study. Participants agreed, understood, and signed the informed consent. References Bydon, M., G.D. Michalopoulos, and R.J. Spinner, Postoperative C5 Palsy: Apples, Oranges, and Rotten Tomatoes . World Neurosurg, 2021. 151: p. 145–146. Shou, F., et al., Prevalence of C5 nerve root palsy after cervical decompressive surgery: a meta-analysis . Eur Spine J, 2015. 24(12): p. 2724–34. Wang, T., et al., Incidence of C5 nerve root palsy after cervical surgery: A meta-analysis for last decade . Medicine (Baltimore), 2017. 96(45): p. e8560. Anderson, P.A., et al., Laminectomy and fusion for the treatment of cervical degenerative myelopathy . J Neurosurg Spine, 2009. 11(2): p. 150–6. Tanaka, N., et al., Postoperative segmental C5 palsy after cervical laminoplasty may occur without intraoperative nerve injury: a prospective study with transcranial electric motor-evoked potentials . Spine (Phila Pa 1976), 2006. 31(26): p. 3013–7. Tsuzuki, N., et al., Paralysis of the arm after posterior decompression of the cervical spinal cord. II. Analyses of clinical findings . Eur Spine J, 1993. 2(4): p. 197–202. Uematsu, Y., Y. Tokuhashi, and H. Matsuzaki, Radiculopathy after laminoplasty of the cervical spine . Spine (Phila Pa 1976), 1998. 23(19): p. 2057–62. Aiba, A., et al., Characteristics of Postoperative C5 Palsy Following Anterior Decompression and Fusion Surgery for Cervical Degenerative Disorders: Trends Associated with Advancements in Surgical Technique . World Neurosurg, 2023. 176: p. e232-e239. Jack, A., et al., Factors Associated With C5 Palsy Following Cervical Spine Surgery: A Systematic Review . Global Spine J, 2019. 9(8): p. 881–894. Bydon, M., et al., Incidence and prognostic factors of c5 palsy: a clinical study of 1001 cases and review of the literature . Neurosurgery, 2014. 74(6): p. 595–604; discussion 604-5. Patwardhan, A.G. and R.M. Havey, Biomechanics of Cervical Disc Arthroplasty-A Review of Concepts and Current Technology . Int J Spine Surg, 2020. 14(s2): p. S14-S28. Pennington, Z., et al., Time to recovery predicted by the severity of postoperative C5 palsy . J Neurosurg Spine, 2019. 32(2): p. 191–199. Staudt, M.D., et al., Biomechanical evaluation of the ProDisc-C stability following graded posterior cervical injury . J Neurosurg Spine, 2018. 29(5): p. 515–524. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4113763","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":304438661,"identity":"96845681-57db-4fb4-b8c3-71df65a41bfd","order_by":0,"name":"Cesar Carballo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7UlEQVRIie3OsYrCQBDG8QkLSbNH2hWLe4UBIRIE8yqGFDaCrXCBmyCYJg+gID6GYLfLQmwWbD1sDBY2V9xxcHDdaS+Ldhb7r+fHNwAu1zOHwAoJE4CAAMSdxCMJBoDLh4g3u4OEZdn8TPL+uBsokt8rnXBg6sAtRBjTaZk6izdVSmqx1mkFftazERQjaBXEEGVK+mWtBwnwqG0lr+fTX0HviLvmQpbXx8JfOxEQXVY04v66QtqrgPtWIswoiqneYjxvSM3rYVoxvxMvLSQst6cPyt+wG2bq+JX3Eh5Mm/2nhdyIPXbucrlcrhv9A328Tnq7d+STAAAAAElFTkSuQmCC","orcid":"","institution":"University of South Florida","correspondingAuthor":true,"prefix":"","firstName":"Cesar","middleName":"","lastName":"Carballo","suffix":""},{"id":304438662,"identity":"ce799007-2d2d-4639-b0e4-c421ed3fbd3e","order_by":1,"name":"Gabriel Flores","email":"","orcid":"","institution":"University of South Florida","correspondingAuthor":false,"prefix":"","firstName":"Gabriel","middleName":"","lastName":"Flores","suffix":""},{"id":304438663,"identity":"bca08df5-bede-482b-9eac-03e5777583f1","order_by":2,"name":"Nicolas Baerga","email":"","orcid":"","institution":"University of South Florida","correspondingAuthor":false,"prefix":"","firstName":"Nicolas","middleName":"","lastName":"Baerga","suffix":""},{"id":304438666,"identity":"f9886343-79ea-4146-b3bb-b5f35fd7939f","order_by":3,"name":"Puya Alikhani","email":"","orcid":"","institution":"University of South Florida","correspondingAuthor":false,"prefix":"","firstName":"Puya","middleName":"","lastName":"Alikhani","suffix":""},{"id":304438668,"identity":"eed6a3de-0245-491c-ace0-56c080ce7543","order_by":4,"name":"Erik Hayman","email":"","orcid":"","institution":"University of South Florida","correspondingAuthor":false,"prefix":"","firstName":"Erik","middleName":"","lastName":"Hayman","suffix":""},{"id":304438669,"identity":"192baf2b-d437-490b-8e52-81f301691348","order_by":5,"name":"Mark Greenberg","email":"","orcid":"","institution":"University of South Florida","correspondingAuthor":false,"prefix":"","firstName":"Mark","middleName":"","lastName":"Greenberg","suffix":""}],"badges":[],"createdAt":"2024-03-16 15:14:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4113763/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4113763/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":57429370,"identity":"b53300ce-3e89-4932-a3af-3edada233119","added_by":"auto","created_at":"2024-05-30 14:47:33","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":69107,"visible":true,"origin":"","legend":"\u003cp\u003e(Left) preoperative cervical MRI showing sagittal T2-weighted view showing diffuse stenosis at levels C3-C4, C4-C5 and C6-C7. (Right) Axial T2-weighted view showing stenosis at the C6-C7 level with cord compression.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4113763/v1/8047fc2ea463ada25662bac5.jpg"},{"id":57430739,"identity":"9d8631ec-8c5d-4ef5-b758-f82faba449d6","added_by":"auto","created_at":"2024-05-30 14:55:33","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":55930,"visible":true,"origin":"","legend":"\u003cp\u003e(Left) Preoperative sagittal cervical X-ray showing anterior cervical fusion of C5-C6 with anterior plate and evidence of loss of lordosis. (Right) Postoperative sagittal cervical x-ray showing presence of arthroplasty implants at the C4-C5 and C6-C7 levels with restoration of cervical lordosis.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4113763/v1/c6af3166db9420c63b3dcff6.jpg"},{"id":57429374,"identity":"594630a5-c91d-4d1f-8d0f-30e43b91049c","added_by":"auto","created_at":"2024-05-30 14:47:33","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":35756,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative cervical sagittal CT myelogram showing no cord compression and adequate hardware placement and cervical lordosis without migration of instrumentation at POD 15.\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4113763/v1/ca607f0e221cc09fb9e34857.jpg"},{"id":57429373,"identity":"b0ef99dd-983f-4b08-9255-2bd2b1723042","added_by":"auto","created_at":"2024-05-30 14:47:33","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":83019,"visible":true,"origin":"","legend":"\u003cp\u003e(Left) Preoperative cervical spine MRI showing sagittal T2 weighted view with stenosis at the C3-4 and C4-C5 levels. (Middle) preoperative cervical spine MRI showing axial T2-weighted view showing severe stenosis at the C3-C4 level. (Right) preoperative cervical spine MRI showing axial T2-weighted view showing moderate stenosis at the C4-C5 level.\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4113763/v1/617a8c9369e0578e04080e36.jpg"},{"id":57430740,"identity":"0ed2d1d4-f529-4a0b-ada0-9bc7cee2b466","added_by":"auto","created_at":"2024-05-30 14:55:33","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":51882,"visible":true,"origin":"","legend":"\u003cp\u003ePost operative cervical x rays lateral view (Left) and AP view (Right)\u003c/p\u003e","description":"","filename":"5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4113763/v1/fa421ba983741f8efc934a65.jpg"},{"id":59635907,"identity":"9d9514c4-daf1-405e-9866-c52e260a6716","added_by":"auto","created_at":"2024-07-04 06:39:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":513643,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4113763/v1/a8660a71-d673-4121-a7b5-bc58953edc77.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"C5 Palsy after Cervical Disc Arthroplasty: Case Reports and Literature Review","fulltext":[{"header":"Introduction ","content":"\u003cp\u003eC5 palsy (C5P) is a known complication after cervical spine surgery in both anterior and posterior approaches. There has been significant literature published regarding C5P following cervical spine surgery with an overall incidence of 5.3% [1-3]. \u0026nbsp;Classically, C5P is a delayed, usually temporary, focal paresis of the deltoid and possibly the bicep muscle after cervical spine surgery [4, 5]. The diagnosis of C5P is one of exclusion and other etiologies for C5 nerve weakness must be ruled out, including disc herniation, residual stenosis, or hematoma [5]. Although the literature reports C5P after posterior cervical laminectomy, foraminotomy, and anterior fusion, to date there have been no reports of C5P following by cervical arthroplasty. We present two independent cases of C5P from two independent surgeons after CDA and situate their cases within the broader literature.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003e\u003cem\u003eCase 1:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA 47-year-old female presented with progressive bilateral upper extremity radicular pain. The radicular pain was consistent with bilateral C5 and right C7 dermatome distribution. She had a past surgical history of C5-C6 anterior cervical fusion. On her physical exam she demonstrated hyperreflexia of the biceps, patella, and brachioradialis.\u003c/p\u003e\n\u003cp\u003eCervical spine MRI demonstrated severe spinal cord compression at the C6-C7 level along with moderate stenosis at C4-C5, consistent with adjacent level disease (Figure 1). The patient underwent disc replacement with bilateral foraminotomies at C4-C5 and C6-C7. The intervention was performed using standard technique with the use of intraoperative neuromonitoring with combination of motor and somatosensory evoked potentials and electromyography. A 6mm ProDisc implant was placed at both levels (Figure 2). Neuromonitoring remained stable throughout the procedure. \u0026nbsp;The patient was discharge on post-operative day 1 with resolution of pre-operative symptoms; she was full strength bilaterally at time of discharge.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOn POD 3, the patient complained of sudden left sided arm and neck pain with progression of severity which progressed until POD 8 when she had a sudden onset of left arm weakness, prompting emergent medical attention. On physical examination, she had left deltoid weakness 2/5 with inability to raise her arm above 30 degrees at shoulder level; the remainder of her neurologic exam was normal. A CT myelogram was performed showing no cervical cord compression or foraminal stenosis with no hardware failure (Figure 3). The patient was diagnosed with C5P and was discharged home with oral dexamethasone 2mg two times daily, ibuprofen 400mg every 6 hours and, gabapentin 300 mg every 8 hours. \u0026nbsp;She was encouraged to use a shoulder sling to prevent secondary traction injury and started on physical therapy to assist with shoulder mobilization. \u0026nbsp;Patient had full return of strength in the deltoid 6 weeks after surgery and remains well greater than one year past surgery. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCase 2:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA 52-year-old female presented with intermittent neck pain radiating to the right shoulder and arm. On the physical exam, she was full strength but demonstrated marked spasticity, with bilateral patellar hyperreflexia as well as bilateral Hoffman\u0026apos;s sign and 1-2 beats of ankle clonus, consistent with cervical myelopathy. \u0026nbsp;A non-contrast cervical spine MRI (Figure 4) demonstrated severe stenosis at C3-C4 and moderate stenosis at C4-C5 level. Patient underwent CDA using the Mobi-C implant at both levels. \u0026nbsp;Patient was discharged home on POD 1 without new neurologic deficit. \u0026nbsp;Starting on POD 4, however, the patient developed progressively worsening severe bilateral neck and right shoulder pain which was managed in the outpatient setting using gabapentin. \u0026nbsp;However, on POD 14, she was unable to abduct her right arm past ten degrees with 1/5 motor power; the remainder of her neurologic exam was intact. \u0026nbsp;Postoperative x-rays showed stable hardware. She was managed on oral dexamethasone 2mg every 12 hours therapy and physical therapy. \u0026nbsp;She demonstrated resolution of her pain and full restoration of deltoid power approximately four weeks after surgery. \u0026nbsp;She remains well at one year following surgery without evidence of residual weakness.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAlthough C5P is a well noted complication after cervical spine surgery, no reports to date describe C5P after arthroplasty. \u0026nbsp;Traditional theories of C5P posit posterior translation of the spinal cord with resulting nerve root traction as the cause of delayed paresis\u0026nbsp;[6, 7]. \u0026nbsp;While compelling, these explanations fail to account for the small but substantial rate of C5P following anterior cervical surgery\u0026nbsp;[8], prompting other etiological hypotheses, such as ischemia reperfusion injury and residual foraminal stenosis\u0026nbsp;[9]. \u0026nbsp; However, a single unifying theory remains elusive, and C5P is better understood as a clinical phenomenon rather than a single pathophysiological entity\u0026nbsp;[10]. \u0026nbsp; Therefore, we will focus on several pertinent detail of the case, rather than attempt to posit a single causative theory of C5P after arthroplasty.\u003c/p\u003e\n\u003cp\u003eFirst, motion through the cervical spine represents a complex mixture of rotation and translation, described kinematically through the instantaneous axis of rotation (IAR). \u0026nbsp;Although disc replacement devices attempt to reproduce this motion, they do so imperfectly. This discord between the native cervical spine\u0026rsquo;s IAR and that of the disc replacement device may potentially lead to dynamic foraminal encroachment\u0026nbsp;[11]. This phenomenon may be relevant to both cases, where use of a full constrained device (Case 1) or anterior placement of the device\u0026rsquo;s IAR to the disc\u0026rsquo;s natural IAR (Case 2) could lead to abnormal disc kinematics with dynamic encroachment and compression of the C5 nerve root.\u003c/p\u003e\n\u003cp\u003eSecond, both patients demonstrated a classic presentation of C5 palsy with delayed onset weakness followed by relatively rapid return of arm function. \u0026nbsp;Although multiple factors predict recovery after C5 palsy, spontaneous full recovery is the general natural history of the phenomenon, especially in patients without bicep involvement and partially preserved deltoid strength\u0026nbsp;[12]. \u0026nbsp;Our cases of C5 arthroplasty demonstrate a similar recovery trajectory to those following other forms of neck surgery. \u0026nbsp; Although posterior foraminotomy represents a biomechanically sound way to salvage post-operative radiculopathy following cervical arthroplasty, our experience suggests against its routine usage in the management of C5 palsy after cervical arthroplasty\u0026nbsp;[13]. \u0026nbsp; Although standard protocols for C5 palsy do not exist, non-operative management consisting of physical therapy and steroids provided rapid resolution of symptoms in both patients.\u003c/p\u003e\n\u003cp\u003eIn summary, we present a novel presentation of a well characterized complication of cervical spine surgery. \u0026nbsp;Although increasingly well-established, cervical arthroplasty represents a relatively novel surgical technique with different complication profiles compared to other forms of surgical decompression. \u0026nbsp;Our experience illustrates that cervical arthroplasty is not exempt from the possibility of C5 palsy and that expectant management remains an appropriate management strategy with the potential for excellent outcomes.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe present two independent cases of C5 palsy after CDA performed by independent surgeons using independent device classes. \u0026nbsp;Both cases resolved with expectant management, suggesting that C5 palsy after disc replacement may be managed in similar fashion to C5 palsy following other cervical procedures.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eACDF= Anterior Cervical Discectomy and Fusion\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eC5P= C5 Palsy\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCervical disc arthroplasty = CDA\u003c/p\u003e\n\u003cp\u003eNSAID= non-steroidal anti-inflammatory drug \u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePOD= Postoperative day\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eNo funding was received to assist with the preparation of this manuscript and the authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003eDisclosure of Funding: No funding or financial support was received for this study.\u003c/p\u003e\n\u003cp\u003eConflict of Interest: The authors report no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are not openly available due to reasons of sensitivity and to preserve patient\u0026rsquo;s privacy. The reason for this is that this is a case report and patient identifiable information will always be protected.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors confirm contributions for the paper and all the members contributed to the realization of this study. Their contributions are as follows: study conception and design: C.C, E.H, data collection: C.C, E.H, G.F, N.B, analysis and interpretation of results: C.C, E.H, M.G, P.A, draft manuscript preparation: C.C, G.F, E.H, N.B, M.G, P.A, figure preparation C.C. All authors reviewed the results and approved the final version of the manuscript. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the study subjects were consented at an academic institution and were consented for their described surgical procedure and participation for this study. Participants agreed, understood, and signed the informed consent.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBydon, M., G.D. Michalopoulos, and R.J. Spinner, \u003cem\u003ePostoperative C5 Palsy: Apples, Oranges, and Rotten Tomatoes\u003c/em\u003e. World Neurosurg, 2021. 151: p. 145\u0026ndash;146.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShou, F., et al., \u003cem\u003ePrevalence of C5 nerve root palsy after cervical decompressive surgery: a meta-analysis\u003c/em\u003e. Eur Spine J, 2015. 24(12): p. 2724\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang, T., et al., \u003cem\u003eIncidence of C5 nerve root palsy after cervical surgery: A meta-analysis for last decade\u003c/em\u003e. Medicine (Baltimore), 2017. 96(45): p. e8560.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnderson, P.A., et al., \u003cem\u003eLaminectomy and fusion for the treatment of cervical degenerative myelopathy\u003c/em\u003e. J Neurosurg Spine, 2009. 11(2): p. 150\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTanaka, N., et al., \u003cem\u003ePostoperative segmental C5 palsy after cervical laminoplasty may occur without intraoperative nerve injury: a prospective study with transcranial electric motor-evoked potentials\u003c/em\u003e. Spine (Phila Pa 1976), 2006. 31(26): p. 3013\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTsuzuki, N., et al., \u003cem\u003eParalysis of the arm after posterior decompression of the cervical spinal cord. II. Analyses of clinical findings\u003c/em\u003e. Eur Spine J, 1993. 2(4): p. 197\u0026ndash;202.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUematsu, Y., Y. Tokuhashi, and H. Matsuzaki, \u003cem\u003eRadiculopathy after laminoplasty of the cervical spine\u003c/em\u003e. Spine (Phila Pa 1976), 1998. 23(19): p. 2057\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAiba, A., et al., \u003cem\u003eCharacteristics of Postoperative C5 Palsy Following Anterior Decompression and Fusion Surgery for Cervical Degenerative Disorders: Trends Associated with Advancements in Surgical Technique\u003c/em\u003e. World Neurosurg, 2023. 176: p. e232-e239.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJack, A., et al., \u003cem\u003eFactors Associated With C5 Palsy Following Cervical Spine Surgery: A Systematic Review\u003c/em\u003e. Global Spine J, 2019. 9(8): p. 881\u0026ndash;894.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBydon, M., et al., \u003cem\u003eIncidence and prognostic factors of c5 palsy: a clinical study of 1001 cases and review of the literature\u003c/em\u003e. Neurosurgery, 2014. 74(6): p. 595\u0026ndash;604; discussion 604-5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatwardhan, A.G. and R.M. Havey, \u003cem\u003eBiomechanics of Cervical Disc Arthroplasty-A Review of Concepts and Current Technology\u003c/em\u003e. Int J Spine Surg, 2020. 14(s2): p. S14-S28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePennington, Z., et al., \u003cem\u003eTime to recovery predicted by the severity of postoperative C5 palsy\u003c/em\u003e. J Neurosurg Spine, 2019. 32(2): p. 191\u0026ndash;199.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStaudt, M.D., et al., \u003cem\u003eBiomechanical evaluation of the ProDisc-C stability following graded posterior cervical injury\u003c/em\u003e. J Neurosurg Spine, 2018. 29(5): p. 515\u0026ndash;524.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"C5 Palsy, Arthroplasty, ACDF","lastPublishedDoi":"10.21203/rs.3.rs-4113763/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4113763/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eCDA has become an alternative for the treatment of cervical spondylosis with radicular or myelopathic symptoms, however there is limited literature regarding its complications and outcomes. We present two cases of C5 nerve palsy (C5P) following cervical disc arthroplasty (CDA).\u003c/p\u003e","manuscriptTitle":"C5 Palsy after Cervical Disc Arthroplasty: Case Reports and Literature Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-30 14:47:28","doi":"10.21203/rs.3.rs-4113763/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e9c31a52-8f3d-42ec-92d5-4920465c450a","owner":[],"postedDate":"May 30th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-07-04T06:31:21+00:00","versionOfRecord":[],"versionCreatedAt":"2024-05-30 14:47:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4113763","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4113763","identity":"rs-4113763","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}