Confirming a C5 Palsy with a Motor Evoked Potential Trending Algorithm during Insertion of Cervical Facet Spacers: A...

The use of cervical facet spacers has shown favorable clinical results in the treatment of cervical spondylotic disease; however, there are limited data regarding neurological complications associated with the procedure. This case report demonstrates the specificity of multi-myotomal motor evoked potentials (MEPs) in detecting acute postoperative C5 palsy following placement of facet spacers. A posterior cervical fusion with decompression and instrumentation involving DTRAX (Providence Medical Technology; Lafayette, CA) was used to treat a patient with cervical stenosis and myelopathy. Intraoperative neurophysiological monitoring (IONM) consisting of MEPs, somatosensory evoked potentials (SSEPs), and free-run electromyography (EMG), was used throughout the procedure. Immediately following the placement of the DTRAX spacers at C4-5, a decrease in amplitudes from the right deltoid and biceps MEP recordings (>65%) was detected. All other IONM modalities remained stable; it is noteworthy that there was an absence of mechanically elicited EMG. A novel post-alert regression analysis trending algorithm of MEP amplitudes confirmed the visual alert. This warning along with an intraoperative computed tomography (CT) scan of the cervical spine subsequently resulted in the decision to remove one of the facet spacers. Surgical intervention did not result in recovery of the aforementioned MEP recordings, which remained attenuated at the time of wound closure. Postoperatively, the patient exhibited an immediate right C5 palsy (2/5). A post-surgery application of the trending algorithm demonstrated that it correlated to the visual alert until the end of monitoring.