C5 palsy following esophageal diverticulum resection

Abstract

Background:

C5 palsy (C5P) is a recognized potential postoperative complication of cervical spine surgery but has rarely been reported following an open esophageal diverticulectomy.

Methods:

A 61-year-old underwent an open esophageal diverticulectomy for symptomatic Zencker’s diverticulum.

Results:

Postoperatively, she presented with right upper extremity weakness and sensory deficits consistent with a C5P that was later confirmed by electromyography.

Conclusion:

The potential for C5P after esophageal diverticulectomy for symptomatic Zencker’s diverticulum is rare. Postoperative recognition and appropriate management are critical to recovery.

INTRODUCTION

C5 palsy (C5P) is a well-documented potential complication following cervical spine surgery, occurring in 0–30% of patients.[4,8,10] While cases of C5P following anterior and posterior cervical spine surgery have been widely described,[2,3,6,7,9] cases following open esophageal diverticulectomy are rare.

CASE PRESENTATION

A 61-year-old female with a history of Crohn’s disease presented initially with 1 year of dysphagia and a 40 lb weight loss. A barium esophagram revealed a Zencker’s diverticulum just above the thoracic inlet. The patient agreed to proceed with a transoral stapling with possible open diverticulectomy. Under general endotracheal anesthesia (i.e., Macintosh blade under direct laryngoscopy), she underwent flexible upper gastrointestinal endoscopy. A 2.5 cm Zencker’s diverticulum was identified above the cricopharyngeus muscle. A resolution clip was placed in the diverticulum apex. Stapling attempts using a rigid endoscope to place the bivalved diverticula blade into both the diverticula and esophagus were unsuccessful. The procedure was aborted and converted to an open repair utilizing a left anterior sternocleidomastoid approach; the diverticula was removed, and the esophagostomy was oversewn in a two-layer fashion. The final endoscopy confirmed the diverticulum was excluded, the esophagus patent and the leak test was negative.

Postoperative course

Immediately postoperatively, the patient awoke with significant proximal right upper extremity weakness (manual muscle testing grade ⅕ in deltoid and biceps) and near-complete sensory loss from the right shoulder to the elbow. She was diagnosed clinically with a right C5P. The brachial plexus magnetic resonance was normal [Figure 1]. The magnetic resonance imaging of the cervical spine, however, documented multilevel cervical spondylosis with moderate C4–5 right and severe left C4–5 foraminal stenosis, with foraminal spondylotic encroachment at the C5–6 and C7–T1 levels [Figure 2]. Her symptoms gradually improved within 4 postoperative months, with sensory deficits resolved and right deltoid and biceps strength recovered to the 4/5 level. In addition, the electromyography confirmed normal motor unit recruitment.

Figure 1:

Coronal brachial plexus magnetic resonance imaging short-tau inversion recovery sequence showing grossly normal appearance without associated signal change throughout the brachial plexus.

Figure 2:

(a) Sagittal T2-weighted magnetic resonance imaging (MRI) of the cervical spine showing multilevel spondylotic changes. (b) Axial T2-weighted MRI of the cervical spine at the C4–5 level showing severe left and moderate right foraminal stenosis.

DISCUSSION

Laryngoscopy and basic airway maneuvers may result in sufficient extension of the cervical spine to result in neurological damage.[1,5] A summary table of pertinent references describing C5 palsy incidence, diagnosis, and injury mechanisms is provided in Table 1. Notably, identifying signs and symptoms of cervical spondylosis preoperatively and avoiding perioperative cervical hyperextension maneuvers should help avoid the new onset of C5 root and/or cord compromise postoperatively.

Table 1:

Reference summary table.

CONCLUSION

In patients with severe pre-existing cervical spondylosis, care should be taken to avoid excess shoulder retraction and stretch injuries during intubation, laryngoscopy/endoscopy, and, in this case, open esophageal diverticulectomy for symptomatic Zencker’s diverticulum.

Ethical approval

The Institutional Review Board approval is not required.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

Disclaimer

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