Network Meta-Analysis of C5 Palsy After Anterior Cervical Decompression of Three to Six Levels

Study Design. Systematic review and meta-analysis. Objective. Using a network meta-analysis, this study aimed to compare the risks of C5 palsy after three different procedures of anterior cervical decompression. Summary of Background Data. C5 palsy is a well-known complication affecting quality of life after anterior procedures. Due to the limited evidence on the various procedures available, we evaluate the basis for selection to prevent palsy and achieve maximal decompression in cases spanning 3-6 levels. Methods. We conducted a comprehensive search for C5 palsy and complications after three representative procedures, including anterior cervical discectomy and fusion (ACDF), anterior cervical corpectomy and fusion (ACCF), and their combination (Hybrid), involving 3-6 intervertebral levels. The incidence of C5 palsy was compared using a network meta-analysis. Results. We identified 1655 patients in 11 studies that met inclusion criteria. Sixty-nine patients (4.2%) developed delayed C5 palsies. The incidences among ACDF, ACCF, and Hybrid cases were 2.3% (16/684, 95% confidence interval [CI] 1.4−3.8%), 6.4% (39/613, 95%CI 4.7−8.6%), and 3.9% (14/358, 95%CI 2.3−6.5%), respectively ( P <0.01). A network meta-analysis was performed for 15 pairwise comparisons across the three procedure arms: ACDF versus Hybrid, 7/232 (3.0%) versus 11/234 (4.7%); Hybrid versus ACCF, 14/301 (4.3%) versus 18/224 (8.0%); ACCF versus ACDF, 38/523 (7.8%) versus 16/619 (2.6%). Compared with ACDF, the risk of C5 palsy was significantly higher in ACCF (odds ratio [OR] 2.72, 95%CI 1.47−5.01), while ACDF versus Hybrid did not significantly differ in risk (OR 1.56, 95%CI 0.68−3.60). Conclusion. We determined that ACCF was associated with a higher risk of postoperative C5 palsy than ACDF in cases spanning 3-6 intervertebral levels. If practicable, ACDF surgery may be an appropriate choice for cases requiring anterior decompression of 3-6 levels. Level of Evidence. 3