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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 9  |  Issue : 2  |  Page : 128-133

Delayed C5 palsy following anterior cervical discectomy and arthroplasty – Rare presentation of two cases by an unusual phenomenon of “flosealoma”


1 Department of Neurosurgery, Aster CMI Hospital, Bengaluru, Karnataka, India
2 Department of Neuropathology, NIMHANS, Bengaluru, Karnataka, India

Date of Submission08-Jan-2022
Date of Acceptance03-Mar-2022
Date of Web Publication31-May-2022

Correspondence Address:
Akshay Hari
Department of Neurosurgery, Aster CMI Hospital, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joss.joss_3_22

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  Abstract 


Hemostatic agents are commonly used in neurosurgical procedures with often exceptionally low complication rates. Rarely, they may cause neurological deficits secondary to pressure effect on neurologic structures, especially when applied within narrow bony cavities. We would like to report two cases of delayed unilateral C5 palsy following anterior cervical discectomy and arthroplasty for a C5–C6 cervical disc herniation. Clinical presentation was identical in both cases, with left deltoid and bicep weakness and left-arm pain without myelopathy symptoms, although with the unusual imaging findings of a new left C4–C5 foraminal lesion. An additional emergency posterior minimally invasive cervical laminoforaminotomy was carried out to decompress the nerve. The weakness improved fully within 2 months after the second surgery. This case report highlights the importance of strong clinical suspicion for a possible lesion as a cause of postoperative C5 palsy. In this case, it was due to an unusual phenomenon where flowable hemostatic agent used in the first surgery had migrated superiorly leading to nerve compression away from the primary level.

Keywords: Anterior cervical discectomy, cervical arthroplasty, delayed C5 palsy, epidural hematoma, hemostatic agent, postoperative complication


How to cite this article:
Srikantha U, Hari A, Lokanath YK, Somasundar D, Rao S. Delayed C5 palsy following anterior cervical discectomy and arthroplasty – Rare presentation of two cases by an unusual phenomenon of “flosealoma”. J Spinal Surg 2022;9:128-33

How to cite this URL:
Srikantha U, Hari A, Lokanath YK, Somasundar D, Rao S. Delayed C5 palsy following anterior cervical discectomy and arthroplasty – Rare presentation of two cases by an unusual phenomenon of “flosealoma”. J Spinal Surg [serial online] 2022 [cited 2022 Jul 7];9:128-33. Available from: http://www.jossworld.org/text.asp?2022/9/2/128/346361


  Introduction Top


The use of hemostatic agents to control intraoperative bleeding is a common practice in neurosurgical procedures.[1] Due to their relatively low complication rate and high bioabsorbability, they have a low-risk profile.[2] Yet, judicious usage is warranted, especially when applied in closed bony spaces and near to neurological structures due to mass effect causing neurological deficits.[3] In cervical spine surgeries, one of the dreaded complications has been postoperative C5 palsy. It is defined as new-onset weakness of the deltoid or biceps muscles by more than one grade, without any sensory or myelopathy symptoms after cervical spine surgery.[4] It may often appear either immediately or sometimes even after several days following surgery.[4] The most common hypothesis is the nerve root tethering produced by spinal cord shifting after spinal cord decompressive surgery.[5] However, the exact cause of C5 palsy is still controversial.

Although there is a greater predilection after posterior cervical surgery, it is also known to occur following anterior cervical procedures.[5],[6] With only few reported cases in the literature, the incidence is quite low of approximately 0.1%–7% as compared to 8%–30% in posterior cervical surgeries.[7] It becomes, therefore, very critical to evaluate for any identifiable cause of this condition in an otherwise successful anterior cervical spine surgery.

We report two consecutive cases of unilateral delayed C5 palsy following C5-6 anterior cervical discectomy and arthroplasty due to a fresh C4-5 lesion as a result of using flowable hemostatic agent. Till date, there have been no such cases reported in literature.


  Case Reports Top


Case 1

A 40-year-old female presented with gradually progressive neck pain, left upper limb radicular pain, and weakness associated with numbness affecting her daily activities. She had undergone left C5–C6 laminoforaminotomy 2 years prior but presented with recurrent symptoms with failed conservative management for 6 months. Examination revealed motor power of Grade 3 in her left triceps, loss of hand grip (50%) with left C6 dermatomal hypoesthesia, and absent triceps reflex. There was normal power (Grade 5) in deltoid and biceps with no signs of myelopathy. Magnetic resonance imaging (MRI) of cervical spine revealed C5-C6 left-sided paracentral disc bulge with left foraminal narrowing and C4-5 intervertebral level was unremarkable [Figure 1]. The patient was planned for a cervical arthroplasty procedure and underwent routine anterior cervical discectomy at C5–C6. Intraoperatively, there was diffuse and brisk epidural bleeding after left C5-6 foraminotomy. Flowable hemostatic agent (FloSeal®) was used to aid in hemostasis which was achieved successfully. Subsequently, arthroplasty device (artificial disc – PRESTIGE™ LP CERVICAL DISC SYSTEM, Medtronic, Memphis, TN, USA) was inserted in standard fashion with confirmation of range of movements intraoperatively. Intraoperative neuromonitoring – transcranial motor-evoked potentials (TcMEPs) and Somatosensory Evoked Potentials (SSEPs) was employed throughout the surgery which did not reveal any change from baseline even at the end of the procedure. Postoperatively, the patient had good relief in terms of left upper limb pain and radiculopathy. During subsequent follow-up after 1 week, motor power in her triceps was 4+ with around 30% improvement in hand grip.
Figure 1: Magnetic resonance imaging of the cervical spine (Left: Sagittal T2WI; right: Axial T2WI) showing a C5-6 left paracentral disc prolapse compressing the C6 exiting nerve root at the foramen and no disc prolapse at C4-5

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On the 10th postoperative day, she complained of neck pain and left upper limb pain and weakness which had gradually worsened. Motor power had deteriorated to grade 0 in her left deltoid, Grade 2 in biceps, triceps remained Grade 4+, with no change in hand grip. A clinical suspicion of C5 palsy was made and further evaluation with imaging was contemplated to rule out any fresh lesion including disc material or hematoma or infection. A cervical spine MRI showed a hyperintense lesion (T2WI) extending from C5-6 disc space on the left side upwards as a narrow band, and increasing in thickness around the left C4-5 foraminal area, causing severe left foraminal exiting nerve root compression [Figure 2]. Differential diagnosis included either an infection or hematoma due to the delayed presentation. In view of her neurological condition and MRI showing a demonstrable lesion compressing the left C5 nerve root, the patient was planned for a posterior cervical minimally invasive tubular decompression (laminoforaminotomy) procedure. After performing a laminotomy at C4, ligamentum flavum was removed to expose the dura and C5 nerve root. No hematoma was seen but instead, multiple adhesions were noted, and powdery granular yellowish-white material compressing the nerve root was seen. Nerve root was decompressed circumferentially from pedicle to pedicle and there was no evidence of any purulent material. Intervertebral disc and annulus appeared normal. Tissue cultures were negative for infection. Histopathology revealed features of inflammatory granulation tissue with intense foreign body reaction. Postoperatively, the patient had significant improvement in terms of pain relief. Two months postsurgery, she had excellent neurological recovery with grade 4 power in left deltoid, biceps, and Grade 5 power in triceps along with normal hand grip.
Figure 2: Magnetic resonance imaging of the cervical spine (Left: Sagittal T2WI; right Axial T2WI) showing a well-delineated lesion at C4-5 level extending from C5-6 disc space as a thin sliver along the lateral recess with compression over the left C5 exiting nerve root at the foramen

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Case 2

A 52-year-old female presented with stiffness in both lower limbs, especially while walking and progressive neck pain following a neck injury. There were no upper limb symptoms and no improvement despite conservative management for 6 months. Examination revealed normal power in limbs, yet there were subtle signs of myelopathy including exaggerated deep tendon reflexes and positive Romberg's sign. MRI of cervical spine revealed C4-C5, C5-C6, and C6-7 disc osteophyte complexes with severe asymmetric (Left > Right) cord compression at C5-6 level [Figure 3]. The patient was planned for a single level cervical arthroplasty procedure at C5-C6. Intraoperatively, brisk epidural bleeding occurred after removing the large left C5-6 foraminal osteophyte. Flowable hemostatic agent (FloSeal®) was used to aid in hemostasis which was achieved successfully [Video Part 1]. Subsequently, arthroplasty device (artificial disc – PRESTIGE™ LP CERVICAL DISC SYSTEM, Medtronic, Memphis, TN, USA) was inserted in standard fashion. Intraoperative neuromonitoring (TcMEP and SSEP) did not reveal any change from baseline during the entire procedure. Postoperative period was uneventful, and the patient was discharged on 2nd postoperative day.
Figure 3: Magnetic resonance imaging of the cervical spine (Left: Sagittal T2WI; right: Axial T2WI) showing a C5-6 left paracentral disc osteophyte complex compressing the spinal cord near the foramen and broad disc prolapse at C4-5 with no nerve root compression

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Like the first case, on the 7th postoperative day, she complained of severe neck pain and left upper limb pain which suddenly worsened on the 10th day with weakness of left deltoid (Grade 0 motor power) and biceps (Grade 3). On similar lines, MRI of her cervical spine showed a hyperintense lesion (T2WI) extending from C5-6 disc space on the left side upward as a narrow band and increasing in thickness around the left C4-5 foraminal area, causing severe left foraminal exiting nerve root compression [Figure 4]. Based on our experience from the previous case, strong suspicion of the hemostatic agent causing compression was considered. The patient was taken up for an emergency posterior cervical minimally invasive tubular decompression (laminoforaminotomy) procedure. Once again, no hematoma was seen but instead, multiple adhesions were noted, and powdery granular yellowish-white material compressing the nerve root was seen [Video Part 2]. Nerve root was circumferentially decompressed. No other lesion was noted. Histopathology revealed features of inflammatory granulation tissue with foreign body reaction to the hemostatic material [Figure 5]. There were no organisms detected on special stains for acid–fast bacilli or fungal hyphae. Postoperatively, the patient had significant improvement in terms of pain relief. One month postsurgery, she had excellent neurological recovery with grade 4 power in left deltoid and biceps.
Figure 4: Magnetic resonance imaging of the cervical spine (top Left: Sagittal T2WI; top right: Coronal T2WI; bottom left: Axial T2WI; bottom right: Axial T1WI) showing a well-delineated epidural lesion at C4-5 level with compression over the left C5 exiting nerve root at the foramen

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Figure 5: Histopathology: Photomicrographs show foreign body material (a, H, and E, ×40) inciting a dense lymphocytic inflammatory response (b, H, and E, ×100)

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  Discussion Top


Development of any fresh neurological deficit post an initially successful spine surgery can be very disconcerting for both patient and surgeon. The technique of anterior cervical arthroplasty has developed over the last few years, and it is now a commonly accepted surgical alternative to fusion.[8],[9],[10] However, C5 palsy is a serious and uncommon complication of anterior cervical surgery.[6],[7] Hence, due consideration must always be given for exploring the possibility of a compressive lesion causing neurological impairment.[11],[12]

In the cases presented here, there was a delayed presentation of ipsilateral C5 palsy. Both patients had successfully recovered from the first surgery only to develop new-onset symptoms suggestive of C5 root compression 10 days later. Possibilities that were considered included ruling out an epidural hematoma, a de-novo disc fragment or, more so, an infective pathology – because of delayed presentation and MRI appearance of collection. The decision to re-explore was made when the MRI confirmed a new lesion at C4-5 level, compressing the left C5 nerve root. Intraoperatively, it was suspected that the lesion was an inflammatory reaction with the FloSeal (Baxter, Inc., Deerfield, IL, USA) hemostatic matrix that was injected during the primary surgery, which had migrated superiorly along the spinal canal– leading to a “flosealoma” of sorts. The same was confirmed on histopathology which revealed inflammatory granulation tissue with foreign body reaction.

Intraoperative bleeding from epidural venous plexus can be difficult to control, especially while working in narrow corridors such as near the neural foramen. When conventional methods such as mechanical tamponade and diathermy coagulation are ineffective to achieve bleeding control, hemostatic agents may be used.[13],[14],[15]

Hemostatic matrix agents include thrombin-gelatin sealants that are used regularly in neurosurgical and spinal procedures.[1] The mechanism of action begins with mixing gelatin and thrombin components together, which then becomes activated, facilitating clotting when in contact with blood.[1],[15],[16],[17] The median degradation time for this product is 30 days in comparison to oxidized cellulose and collagen products that have median degradation of 60 days and 90 days, respectively.[3],[16] Complications and adverse effects due to hemostatic matrix are rare; however, these are known to occur under certain scenarios.

Thrombin-gelatin matrix materials such as FloSeal (Baxter, Inc., Deerfield, IL, USA) and Surgiflo (Johnson and Johnson, Somerville, NJ, USA) tend to swell by up to 20% following application, with maximum volume being achieved within 10 min of application.[3],[16] Thus, if the material is used to achieve hemostasis arising near small cavities and enclosed spaces, such swelling can exert considerable compressive force.[18],[19] In the spinal canal, bony walls restrict the space available for any expansile force which may then lead to pressure on the neural elements. If the pressure is severe enough, it may result in a neurologic deficit. Studies provide level 5 evidence warning against leaving hemostatic agents in situ next to neural foramina after hemostasis since potential swelling may result in nerve damage due to mechanical compression within a bony confined area.[20] Hence, it is vital to wash off any excess hemostatic material after bleeding has been controlled.[18]

A brief review of the literature reveals few cases of hemostatic agents such as sponges (e.g., Gelfoam [Pharmacia and Upjohn, Kalamazoo, MI]) and Oxidized Regenerated Cellulose (e.g., Surgicel [ Johnson and Johnson, Somerville, NJ]) that have caused neurological deficits after being left behind over neural tissue.[3],[16],[18] In all these cases, neurological deterioration was noted after the primary surgery – either intraoperatively, detected by neuromonitoring, or in the immediate postoperative period ranging from few hours to a day, and re-operations were performed following which functional recovery occurred.

However, in the present case, more perplexing was the fact that the onset of neurological deficit was delayed by nearly a week to 10-day postsurgery. No reports exist with such a delayed response. One observation was the presence of intense foreign body inflammatory reaction with granulation tissue surrounding the compressed nerve that was noted during the re-operation procedures in both the cases. The phenomenon seen here is noteworthy, despite evidence in literature to the contrary, that hemostatic agents do not cause tissue reaction and are safe to use in neurosurgical and spinal practice.[2],[13],[14],[17] This could be one possible explanation for the delayed deficit, which probably caused a further compromise of the neurological structures over a period of time.

Further, no reports exist regarding the potential of material migration. As in the case presented here, the mass effect occurred at a site away from the primary region where the agent was applied. Injecting the agent under pressure may also possibly force entry into locations distant from the area of application.

Since this is a novel phenomenon, not reported in the literature till now, exact cause of the delayed presentation could only be hypothesized. It is likely that during application at the primary surgery, a thin sliver of the flowable hemostatic agent migrated along the paracentral epidural venous system superiorly and formed a small collection at the left C4-5 foramen, not significant in the immediate postoperative period to cause any mass effect or symptoms of any sort. Owing to an intense and delayed inflammatory response, this small collection later formed a sizeable and firm mass, which caused the delayed compressive symptoms.

Furthermore, it is noteworthy that, both the delayed presentations occurred after a motion preserving surgery (Artificial Disc Replacement or ADR). The authors have frequently used “FloSeal” for several procedures such as Anterior Cervical Discectomy and Fusion, corpectomies, posterior cervical, and other ADR procedures. There was no difference in the manner of application or the quantity of FloSeal injected in both the reported cases, in particular, as compared to the other cases.


  Conclusion Top


This report depicts an interesting case of flowable hemostatic agent causing delayed onset postoperative C5 palsy following C5-C6 anterior cervical arthroplasty due to superior migration along the foramen and causing a “flosealoma,” due to foreign body inflammatory reaction, leading to compression of the left C5 nerve root. This case brings out two important highlights:

  1. Use of any hemostatic matrix, especially flowable agents in the spinal canal must be done very judiciously, more so because the epidural space is very narrow, and any expansile lesion can cause serious neurological complications due to nerve root or cord compression
  2. Any postoperative C5 palsy following anterior cervical surgery must be evaluated thoroughly due to its low incidence, and a strong suspicion of a lesion must be explored. Surgical decompression by a foraminotomy can help relieve the symptoms if done early.


Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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Menovsky T, Plazier M, Rasschaert R, Maas AI, Parizel PM, Verbeke S. Massive swelling of Surgicel® Fibrillar hemostat after spinal surgery. Case report and a review of the literature. Minim Invasive Neurosurg 2011;54:257-9.  Back to cited text no. 3
    
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Odate S, Shikata J, Yamamura S, Soeda T. Extremely wide and asymmetric anterior decompression causes postoperative C5 palsy: An analysis of 32 patients with postoperative C5 palsy after anterior cervical decompression and fusion. Spine (Phila Pa 1976) 2013;38:2184-9.  Back to cited text no. 5
    
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Bydon M, Macki M, Kaloostian P, Sciubba DM, Wolinsky JP, Gokaslan ZL, et al. Incidence and prognostic factors of c5 palsy: A clinical study of 1001 cases and review of the literature. Neurosurgery 2014;74:595-604.  Back to cited text no. 7
    
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Kim JE, Yoo HS, Choi DJ, Park EJ, Hwang JH, Suh JD, et al. Effectiveness of Gelatin-Thrombin Matrix Sealants (Floseal®) on postoperative spinal epidural hematoma during single-level lumbar decompression using biportal endoscopic spine surgery: Clinical and magnetic resonance image study. Biomed Res Int 2020;2020:4801641.  Back to cited text no. 17
    
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Brodbelt AR, Miles JB, Foy PM, Broome JC. Intraspinal oxidised cellulose (Surgicel) causing delayed paraplegia after thoracotomy – A report of three cases. Ann R Coll Surg Engl 2002;84:97-9.  Back to cited text no. 20
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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