Guna Pratheep Kalanchiam

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).

Case: We report a 55-year-old woman with bull gore trauma to the lower neck who developed dysphagia and airway compromise due to a retropharyngeal chyle collection. Imaging revealed a prevertebral fluid collection. Surgical drainage, which confirmed chyle, followed by thoracic duct ligation through video-assisted thoracoscopic surgery, was required due to a persistent high-output leak. Conclusion: Thoracic duct injury at the cervicothoracic junction is an uncommon but serious complication of trauma. High suspicion, timely diagnosis, and surgical intervention ensure favorable outcomes especially in cases with isolated retropharyngeal collection without chylothorax.

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.

The surgical technique of L2- L5 Oblique Lumbar Interbody Fusion (OLIF), including the exposure of the surgical corridor, preparation of the disc space, and placement of the interbody cages, followed by pedicle screw fixation, is presented. To perform this technique, the patient is positioned in right lateral decubitus on a radiolucent table, and an oblique incision is made 3-5 cm anterior to the middle of the L3-L4 disc space. After dissecting the subcutaneous fat, the external oblique aponeurosis is cut along the line of the incision and the oblique muscles (external and internal), and the transversus abdominis muscles are split along the direction of the muscle fibers. Peritoneal fat is gently swept anteriorly until the psoas muscle is visualized. The psoas muscle is then retracted posteriorly to reveal the underlying disc space. A guide wire is inserted into the disc, followed by sequential dilators and placement of expandable retractors. After confirming the retractor position, annulotomy is performed, and the disc space is prepared using a combination of Cobb's elevator, curettes, and pituitary rongeurs, employing an orthogonal maneuver. Under the fluoroscopy guidance, serial trials are introduced, and an optimal-sized cage packed with bone graft substitutes is implanted into the disc space. The same steps are repeated at two adjacent levels (L2-L3, L4-L5), and the wound is closed in layers. The patient is turned into a prone position and pedicle screws are placed to complete the construct. The results of 30 patients who underwent this OLIF procedure were analyzed. The mean disc height was 7.47 ± 2.3 mm, which significantly increased to 10.9 ± 2.7 mm postoperatively (p < 0.0001). Similarly, the mean disc angle improved from 7.26° ± 6.2° to 9.81° ± 4.1° (p = 0.0065). At the final follow-up, both disc height and angle were maintained, along with satisfactory bony fusion, with no cases of pseudoarthrosis or implant failure.

Study Design: Scoping review. Objective: To review the literature on complications related to uniportal and unilateral biportal endoscopic techniques for lumbar spinal stenosis, identify areas needing further clarification, and enhance the understanding of these techniques. Methodology: A scoping review was conducted in September 2024 across five databases (Google Scholar, Medline, Embase, PubMed, and Web of Science) on complications related to uniportal and unilateral biportal interlaminar endoscopic decompression for lumbar spinal stenosis. Descriptive characteristics, trends, and regional distribution of studies were summarized. Study types, findings, and complications for each technique were tabulated. A comparison of complication rates was performed between the two techniques to assess their relative safety and outcomes. Results: A total of 38 studies involving 2426 patients (17 Uniportal, 17 Biportal, 4 comparing both) were analyzed, with L4-L5 being the most common level operated. The overall complication rate was 2.7% for uniportal and 2.2% for biportal, with reporting inconsistencies noted. Persistent symptoms after surgical decompression were more common in the uniportal group ( P = 0.003), while postoperative headaches were higher in the biportal group ( P = 0.007). However, the number of studies reporting these complications was limited. Conclusion: Both uniportal and unilateral biportal endoscopic techniques are effective for lumbar spinal canal decompression, with no significant difference in complication rates. However, inconsistent reporting across studies limits meaningful meta-analyses. Future research should standardize the reporting of complications to ensure more reliable results and improve research quality.

Background: Adult Spinal Deformity (ASD) is one of the challenging conditions to treat for spine surgeons. One of the important dilemmas in the management of these patients is the decision on the number of levels of instrumentation and the overall length of the construct. OLIF has the advantage of providing a minimally invasive approach to address this complex pathology also allowing us to stage the procedure and thus help clinicians reassess if the patient requires an additional decompression, long fusion lengths, or need for osteotomies. Aim: Our study aims to evaluate the possibility of minimizing the construct length following a staged OLIF approach in ASD patients and also to analyze the clinical and radiological outcomes following a staged OLIF surgery. Methods: We present three cases of ASD, where the patients had a significant imbalance in either the coronal/ sagittal profiles, and by using a staged approach, the surgeon was able to reduce the construct lengths and also operate on these deformities using an all Minimally Invasive Surgical (MIS) approach. Results: Overall sagittal and coronal profiles improved in all three cases with satisfactory fusion rates and VAS scores (back pain) post-operatively. Two of the three patients had an all-MIS approach (OLIF with MIS Ponte osteotomy and robotic guided pedicle screw instrumentation) and in one patient a four-rod construct was preferred to improve the stability. No complications were observed during a mean follow-up period of 4 years. Conclusion: A staged approach in ASD (lateral OLIF and posterior instrumentation) is a valuable surgical strategy for better correction of the coronal and sagittal plane deformities with relatively lesser construct length. It reduces the problems associated with prolonged anesthesia, in addition, it helps the surgeon in reassessing the pelvic parameters, thereby helping to decide on the need for additional osteotomies during the second procedure.

Kalanchiam GP, et al. Korean J Neurotrauma. 2025 Oct;21(4):255-264. https://doi.org/10.13004/kjnt.2025.21.e32

Introduction: Surgeries in the occipitocervical and upper cervical region are always quite challenging and need adequate surgical experience and expertise. Especially in cases, where both anterior and posterior surgical access is required, complication rates could be significantly high. The transoral approach for the ventral pathologies of the upper cervical region has been previously described using the conventional open technique where post-operative morbidity is a concern. Moreover, problems such as dysphagia, risk of injury to the oral components, and surgical site infection are always an issue. In patients requiring a combined posterior approach, surgical morbidity, and post-operative recovery is always an area of concern. We describe a case report of upper cervical myelopathy managed under full navigation using a combined tubular transoral (minimally invasive) and posterior approach. Case Report: A 74-year-old male patient presented with myelopathy and weakness in bilateral upper and lower limbs (MRC Grade 4/5) due to a cystic lesion at C1 causing ventral cord compression. A staged anterior (minimally invasive transoral tubular approach) – posterior procedure was performed under full navigation for decompression and stabilization of C1-C2. Postoperatively, the patient showed neurological improvement (MRC Grade 5/5) in all four limbs. Conclusion: A 360° navigation-guided approach to the upper cervical spine is a safer and more effective procedure with less risk of neurological and vascular complications. Furthermore, combining minimally invasive access anteriorly to the odontoid ensures reduced surgical morbidity of the overall procedure. Keywords: Upper cervical, circumferential, navigation, minimally invasive, transoral.

Study design: Prospective analysis of retrospective data. Objectives: To analyse the clinical and radiological outcomes of thoracic and thoracolumbar TB kyphosis by a posterior-only approach using kyphosis classification. Methods: Patients with thoracic and thoracolumbar spinal TB who underwent posterior-only surgical correction for kyphotic deformity >30° were categorized into Group: A (Active TB) and Group B (Healed TB). Demographic, clinical and radiological data were collected, and kyphotic deformity was classified according to Rajasekaran classification. Results: 52 patients with a minimum 2-year follow-up were included. Group A included 25 patients with mean preop kyphosis of 39.5° (31.2°-53.7°), and Group B included 27 patients with mean preop kyphosis of 85° (44.2°-125.2°). Among 25 patients in Group A, 19 were Type IIIA, and 6 were Type IIA kyphosis. In Group B, 18 patients were Type IIIB, 5 were Type III C, 3 were Type IIA, and 1 was IIIA kyphosis. All patients in group A underwent posterior column shortening by Smith-Peterson Osteotomy, with 14 patients requiring additional anterior column reconstruction. Patients in Group B required Closing-Opening Wedge Osteotomy (18), Halo followed by vertebral column resection (6), disc bone osteotomy (2) and pedicle subtraction osteotomy (1). Mean kyphosis at 2 years follow-up was 20.8° (11.2°-32.8°) in Group A and 53.5° (8.1°- 96.4°) in Group B. Conclusions: Correction of kyphosis in spinal TB involves completely different strategies in active and healed disease. Hence, a posterior-only treatment approach using Rajasekaran’s kyphosis classification can help surgeons in appropriate decision-making.