C5 palsy (C5P) is a common, yet poorly understood complication of cervical decompressive surgery, causing substantial disability and impacting postoperative quality of life. Despite extensive research, the actual incidence and distribution of C5P across different cervical surgical approaches over the past decade remain unclear. A comprehensive literature search was conducted on October 15, 2024, across Google Scholar, Embase, PubMed, Web of Science, and Cochrane Library databases. Studies reporting C5P incidence following surgery for degenerative cervical conditions, published until 2024, were included, excluding reviews, opinions, letters, and non-English manuscripts. Ninety-seven articles were included, encompassing 21,231 patients undergoing decompressive cervical surgery for degenerative cervical myelopathy. The overall incidence of postoperative C5P was 7% (95% confidence interval [CI], 4%–10%). The highest incidence was observed with circumferential fusion (combined anterior-posterior approach) at 16% (95% CI, 8%–24%), while the lowest was with anterior cervical decompression and fusion at 4% (95% CI, 3%–5%). Incidence rates following laminoplasty and laminectomy and fusion were 6% (95% CI, 5%–7%) and 10% (95% CI, 8%–12%), respectively. Recovery time ranged from 20.9 to 35 weeks, with 19.1%–33% of patients experiencing residual weakness. Significant risk factors included male sex, preoperative intervertebral foraminal stenosis, ossified posterior longitudinal ligament, open-door laminoplasty, laminectomy (with/without fusion), and excessive spinal cord shift. The role of C4–5 foraminotomy remains contested. Our meta-analysis identifies the posterior surgical approach as a significant risk factor for C5P. Circumferential fusion poses the highest risk, while laminoplasty can reduce the risk compared to laminectomy (alone or with instrumented fusion).

Lumbar canal stenosis (LCS) is a common degenerative pathology in middle-aged patients. Symptoms of LCS arise from compression of the traversing root due to narrowing of the lateral recess, which is attributed to hypertrophy of the ascending facet and thickened ligamentum flavum. Decompression of these structures is the main management goal for these patients. However, in patients with neurological deficits, recovery of motor weakness remains uncertain despite adequate decompression. We report a case of a 52-year-old female patient diagnosed with L4–5 LCS and right foot drop (L4:2/5, L5:0/5 Medical Research Council [MRC] grade) who underwent surgical decompression using unilateral biportal endoscopy. Intraoperatively, we observed that even after adequate decompression of the neural elements, there was persistent blanching of the L5 root. Upon further evaluation, we noted periradicular fibrous tissue encasing the L5 root. Careful removal of these fibrous tissues improved the vascular supply of the L5 root, demonstrating that the tissues had exerted a compressive effect on the nerve root. Postoperatively, motor power partially recovered (L4, L5: MRC grade 3/5) at the 6-week follow-up. Our case highlights the importance of careful attention to fibrous elements in the epidural space using endoscopy, which could enhance the overall outcomes following decompression in LCS.

Despite the favorable postoperative prognosis of C5 palsy (C5P), a certain proportion of these patients have less satisfactory outcomes. The current systematic review and meta-analysis thus aimed to comprehensively evaluate existing literature and identify the onset, recovery patterns, and outcomes of C5P following diverse surgical approaches. Five different databases (Google Scholar, Embase, PubMed, Web of Science, and Cochrane Library) were thoroughly searched for relevant literature on October 15, 2024. Studies reporting on incidences of C5P following surgery for degenerative cervical conditions with recovery data published until 2024 were scrutinized. Narrative or systematic reviews, opinions, letters to the editor, and manuscripts published in non-English languages were excluded. A total of 30 articles involving 8,116 patients who underwent undergoing surgery for degenerative cervical myelopathy with 748 reported C5P cases were included for analysis. The overall time to palsy reported in the included studies was 3 days (95% confidence interval [CI], 2.56–3.60). Palsy occurred earliest with anterior cervical decompression and fusion (ACDF) at 2 days (95% CI, 0.35–4.54), followed by laminoplasty (LP) at 3.2 days (95% CI, 2.02–4.34) and posterior cervical decompression and fusion (PCDF) at 3.6 days (95% CI, 2.81–4.37). Patients with palsy showed improved recovery with time. At the 1-year follow-up, the reported recovery rates were 100%, 52.9%, and 50% for ACDF, LP, and PCDF, respectively. C5P demonstrated a delayed presentation, with mean onset of 3 days after surgery, which can range from 2 days for ACDF to 3.6 days for PDCF. Recovery improved progressively with time and varied for different surgical procedures, with ACDF showing the best recovery and PDCF for cervical myelopathy showing the poorest recovery.