Morphology of cervical periradicular fibrous sheath and nerve roots in relation to postoperative C5 palsy

BACKGROUND CONTEXT: C5 palsy is a major complication of cervical spine surgery, however, its exact pathogenesis remains unclear. Some studies have shown that the superficial layer of the posterior longitudinal ligament extends laterally and forms the periradicular fibrous sheath (PFS), and envelopes the nerve roots. However, the anatomical relationship between the PFS and nerve root at each cervical level has not been fully revealed. PURPOSE: To examine the difference of the PFS that covers the nerve root at each cervical level, and to consider its potential in the onset of postoperative C5 palsy. STUDY DESIGN: Anatomical study of cervical dissection of 13 embalmed cadavers. METHODS: Thirteen human formalin-fixed cadavers were dissected from posterior approach, and were observed their cervical nerves bilaterally from C3 to C8 (the total number of nerves was 156). The bare area length (BAL), which is the distance between the medial posterior edge of the PFS and the bifurcation of the nerve and dura mater, was measured by using electronic calipers. Thus, BAL is the uncovered area of the nerve root by the PFS. We examined whether BAL significantly varied at each cervical level. RESULTS: We confirmed the PFS macro-and/or microanatomically in all cadavers. The average BAL gradually increased craniocaudally, and there was a significant step between that of C5 and C6 level. CONCLUSION: The average BAL of the C5 root was significantly shorter than that of C6, C7, and C8, suggesting that C5 root was more tightly anchored. This could be one reason for C5 palsy, making C5 nerve root vulnerable to the traction caused by the postoperative spinal cord shift. CLINICAL SIGNIFICANCE: This study provides clinicians an additional understanding of the anatomical factor of C5 palsy. Consideration of the anchoring effect of the PFS for nerve roots, release of the PFS could be a preventive procedure for C5 palsy. (C) 2021 Elsevier Inc. All rights reserved.

Automated summary

This study examined the anatomical relationship between the periradicular fibrous sheath (PFS) and nerve root at each cervical level and its potential role in the onset of postoperative C5 palsy. The results showed that the average uncovered area of the C5 root by the PFS was significantly shorter than that of the C6, C7, and C8 roots, indicating that the C5 root was more tightly anchored. This finding may contribute to the vulnerability of the C5 nerve root to traction caused by postoperative spinal cord shift.