C1-C2 Posterior Screw-Rod Fixation.

Multiple approaches for instrumentation of the upper cervical spine have evolved to treat atlantoaxial instability which, until the 20th century, was largely considered to be inoperable and managed nonsurgically with immobilization. Surgeons set out to provide safe and effective approaches in a clearly dangerous and technically complex anatomic region. It is important to provide a historical analysis of the evolution of techniques that have shaped C1-C2 instrumentation, and how the diligent efforts of surgeons to improve the biomechanical stability and fusion rates of their constructs eventually led to the prevailing Harms technique. This technique is explored by describing its surgical steps, alternative techniques, and associated outcomes. For successful instrumentation of the atlantoaxial joint, a comprehensive understanding of spinal biomechanics, surgical techniques, and anatomic variations is imperative for surgeons to develop a tailored plan for each patient's individual pathology and anatomy.

Management of concomitant scoliosis and tethered cord syndrome in non-spina bifida pediatric population.

BACKGROUND: The management of concomitant scoliosis and tethered cord syndrome in the non-spina bifida pediatric population is challenging. In the present study, we evaluate the efficacy of different treatment modalities and propose a treatment plan for the management of affected patients. METHODS: A systematic literature review was conducted by querying the MEDLINE, PubMed, Cochrane, EMBASE, Scopus, and Web of Science databases for papers published between January 1996 and June 2016 and reporting on concomitant scoliosis and tethered cord. We excluded animal studies, non-English papers as well as papers reporting on patients with multiple concomitant intraspinal anomalies such as spina bifida. RESULTS: Out of 1993 articles, only 13 met our inclusion criteria. These 13 articles described six main management approaches: Observation, cord untethering only, cord untethering followed by deformity correction, simultaneous cord untethering and deformity correction, and deformity correction without untethering. Selection of the best approach is a function of the patient's symptomatology and Cobb angle. CONCLUSION: We propose treatment plan for the management of patients with concomitant tethered cord syndrome and spinal deformity. Asymptomatic patients can be followed conservatively and managed as scoliosis patients with no need for untethering. Surgical management in a staged fashion seems appropriate in symptomatic patients with a Cobb angle less than 35°. In these patients, deformity can improve following untethering, thus sparing the patient the risks of surgical correction of scoliosis. Staged or non-staged cord untethering and curve correction seem to be adequate in symptomatic patients with Cobb angle >35° as these patients are likely to require both untethering and deformity correction.

Endovascular treatment of a complex bilobed left superior hypophyseal internal carotid artery aneurysm: a case illustration.

We report the case of a 62-year-old female who presented for stent-assistant coiling of an incidental 11-mm complex bilobed left superior hypophyseal internal carotid artery aneurysm. A microcatheter was navigated into the aneurysm and trapped by a 37-mm stent. Using three-dimensional and two-dimensional coils, the elongated aneurysm was coiled. The bigger lobe was coiled first followed by the smaller lobe. Minimal residual filling of the smaller lobe will be re-evaluated at 6-month follow up. The patient tolerated the procedure well and no complications were encountered. The video can be found here: http://youtu.be/TrXfsaICQVo .

Camptocormia in Parkinson's Disease: Systematic Review of Management Using Spine Surgery.

OBJECTIVE: Postural abnormalities are a debilitating symptom of Parkinson's disease (PD) that may require spinal intervention. Camptocormia is a unique abnormality most seen in PD, defined by a severe forward-flexion of the trunk that completely resolves when supine. The condition presents a challenge due to an undefined pathophysiology and optimal therapeutic approach in a high-risk patient population. In this study, the authors systematically reviewed the literature regarding the use of spine surgery for the treatment of camptocormia in PD. METHODS: PubMed, Embase, Web of Science, and Cochrane Library were systematically queried for studies involving spine surgery as treatment of PD-associated camptocormia. Studies involving nonsurgical management, deep brain stimulation (DBS), non-camptocormic PD patients undergoing surgery, or were out of scope were excluded. RESULTS: The search resulted in 5 studies, with a total of 19 PD patients with camptocormia who underwent spine surgery (73.7% female). The mean age was 69.5 years (range, 59 - 83), and mean PD duration was 69.5 months (range, 36 - 84). Out of 19 patients, 11 required surgical revision (57.9%), with an average of 0.68 revisions per patient (range, 0-2). Radiographic and patient-reported outcomes were inconsistently reported yet showed improvement. Ultimately, 18 patients were reported to have positive outcomes. CONCLUSION: Despite an increased risk of complication and revision that is inherent to PD patients, spine surgery has been proven as a reasonable alternative that should be prospectively studied further, as 18/19 patients had favorable outcomes.

Navigating the Neurosurgery Match Process: Insights from the National Resident Matching Program - Program Director Surveys.

OBJECTIVE: Neurosurgery is one of the most competitive specialties, and navigating the match process is often challenging for aspiring applicants. Here, we analyze insights from the National Resident Matching Program Director Surveys, illustrating evolving trends in applicant selection for interviews and for the ranking process, and providing a comparison with other specialties. METHODS: We evaluated 7 surveys administered from 2012 to 2022. Six biennial surveys reported on factors influencing interview and ranking processes, while all 7 surveys included data about the program director (PD)'s attitude toward United States Medical Licensing Examination (USMLE) test scores. RESULTS: The response rate of PDs decreased over the years. The most cited factor for interviews included specialty-specific recommendation letters (95%), USMLE Step 1 scores (91%), and interest in research (78%). A recent decline in emphasis on USMLE Step 1 scores coincided with a growing reliance on USMLE Step 2 scores. Award in basic science held significant esteem to a subset of programs. Personal characteristics dominated for ranking, with faculty interaction (89%), interpersonal skills (89%), and house staff interaction (85%) being the most important. Yet, PDs reported a difficulty in assessing interpersonal skills through virtual interviews. CONCLUSIONS: Our analysis revealed the pervasive importance of specialized endorsements and academic achievements when screening applicants for the interview process. A shift in emphasis toward the USMLE Step 2 became apparent. Personal characteristics, on the other hand, seemed crucial to make a match and rank high among the pool of interviewed applicants. We uncovered difficulties in assessing these characteristics through virtual interviews.

Evidence-based management of central cord syndrome.

OBJECT: Evidence-based medicine is used to examine the current treatment options, timing of surgical intervention, and prognostic factors in the management of patients with traumatic central cord syndrome (TCCS). METHODS: A computerized literature search of the National Library of Medicine database, Cochrane database, and Google Scholar was performed for published material between January 1966 and February 2013 using key words and Medical Subject Headings. Abstracts were reviewed and selected, with the articles segregated into 3 main categories: surgical versus conservative management, timing of surgery, and prognostic factors. Evidentiary tables were then assembled, summarizing data and quality of evidence (Classes I-III) for papers included in this review. RESULTS: The authors compiled 3 evidentiary tables summarizing 16 studies, all of which were retrospective in design. Regarding surgical intervention versus conservative management, there was Class III evidence to support the superiority of surgery for patients presenting with TCCS. In regards to timing of surgery, most Class III evidence demonstrated no difference in early versus late surgical management. Most Class III studies agreed that older age, especially age greater than 60-70 years, correlated with worse outcomes. CONCLUSIONS: No Class I or Class II evidence was available to determine the efficacy of surgery, timing of surgical intervention, or prognostic factors in patients managed for TCCS. Hence, there is a need to perform well-controlled prospective studies and randomized controlled clinical trials to further investigate the optimal management (surgical vs conservative) and timing of surgical intervention in patients suffering from TCCS.

Biological principles of adult degenerative scoliosis.

The global aging population has led to an increase in geriatric diseases, including adult degenerative scoliosis (ADS). ADS is a spinal deformity affecting adults, particularly females. It is characterized by asymmetric intervertebral disc and facet joint degeneration, leading to spinal imbalance that can result in severe pain and neurological deficits, thus significantly reducing the quality of life. Despite improved management, molecular mechanisms driving ADS remain unclear. Current literature primarily comprises epidemiological and clinical studies. Here, we investigate the molecular mechanisms underlying ADS, with a focus on angiogenesis, inflammation, extracellular matrix remodeling, osteoporosis, sarcopenia, and biomechanical stress. We discuss current limitations and challenges in the field and highlight potential translational applications that may arise with a better understanding of these mechanisms.

Outcome Reporting in Spine Surgery: A Review of Historical and Emerging Trends.

The general objectives of spine surgery are to alleviate pain, restore neurologic function, and prevent or treat spinal deformities or instability. The accumulating expanse of outcome measures has allowed us to more objectively quantify these variables and, therefore, gauge the success of treatments, ultimately improving the quality of the delivered health care. It has become increasingly evident that spinal conditions and their accompanying interventions affect all aspects of a patient's life, including their physical, mental, emotional, and social well-being. This underscores the challenge of creating clinically relevant and accurate outcome measures in spine care, and the reason why there is a growing recognition of the importance of subjective measures such as patient-reported outcome measures, that consider a patients' health-related quality of life. Subjective measures provide valuable insights into patient experiences and perceptions of treatment outcomes, whereas objective measures provide a reproducible glimpse into key radiographic and clinical parameters that are associated with a successful outcome. In this narrative review, we provide a detailed analysis of the most common subjective and objective outcome measures employed in spine surgery, with a special focus on their current role as well as the possible future of outcome reporting.

Misinterpretations of Null Hypothesis Significance Testing Results Near the P-Value Threshold in the Neurosurgical Literature.

BACKGROUND: Although statistical errors have been shown to be prevalent in the medical literature, there has been a paucity of studies focusing on the prevalence of statistical errors in neurosurgery. We examined the contemporary neurosurgical literature for a common statistical mistake, namely, misinterpretations of null hypothesis significance testing results near the P-value threshold by conveying the idea of a trend. METHODS: PubMed/Medline was used to identify all articles published in 6 major neurosurgical journals between 2000 and 2020. The abstracts of these articles were extracted and scrutinized to determine when the word "trend" was used to express near statistical significance. RESULTS: This study included a total of 45,244 articles. Of those, 461 (1.02% [95% confidence interval, 0.86%-1.18%]) employed the word "trend" to indicate near statistical significance, for a total of 3.8 (95% confidence interval, 2.93-4.75) errors per issue per year. The error under study occurred more frequently in Journal of Neurosurgery: Spine and less frequently in Acta Neurochirurgica (P = 0.007). On an annual basis, there was no linear correlation between the total number of articles published per journal and the number of such errors in that journal (r = 0.34, P = 0.01). CONCLUSIONS: Misinterpretations of null hypothesis significance testing results near the P-value threshold are present in at least 1% of the neurosurgical literature. While we believe that most statistical errors in medicine in general and neurosurgery in particular may be unintentional in nature, additional measures should be put in place to prevent the subsequent adoption of such undesirable methodological practices among future researchers.

Urothelial Carcinoma of the Bladder With Primary Metastasis to the Brain: A Case Report and Literature Review.

Brain metastases are the most common type of brain tumor in adults, commonly arising from primary tumor sites of the lung, breast, skin (melanoma), colon, and kidney. Isolated central nervous system (CNS) metastasis arising from urothelial carcinoma (UC) is a rare presentation yielding a poor prognosis. A 71-year-old male patient with a history of urothelial carcinoma, treated one year prior with partial cystectomy and adjuvant gemcitabine and cisplatin (GC) therapy, presented with worsening neurological symptoms, including progressively worsening dizziness, shuffling gait, drifting, expressive aphasia, and confusion. MRI revealed a left frontal 4.0 x 3.6 cm brightly contrast-enhancing tumor with possible hemorrhage, extensive vasogenic edema, and moderate mass effect. An additional smaller right cerebellar lesion was also noted. Outpatient CT of his chest, abdomen, and pelvis revealed no evidence of other malignant sites. He ultimately underwent a left craniotomy with a total resection of his left frontal mass. Pathological examination revealed a urothelial primary. Post-operative MRI revealed complete resection of the left frontal mass and the patient was discharged with no neurologic deficits on exam. In many cases, brain metastases may present years later following initial therapy of UC as the CNS may act as a sanctuary site during systemic chemotherapy. Chemotherapeutics such as gemcitabine with better penetration of the blood-brain barrier may be beneficial in delaying the onset of these metastases.

Dissemination Patterns and Short-Term Management of Multifocal Rosette-Forming Glioneuronal Tumors.

BACKGROUND: Multifocal rosette-forming glioneuronal tumors (RGNTs) are challenging to manage. Gross total resection is often impossible, and data on adjunctive therapies are limited. We reviewed cases of multifocal RGNTs in the literature with special focus on dissemination patterns and management. METHODS: A literature review was conducted using PubMed and the key words "(multifocal OR multicentric OR satellite OR dissemination) AND glioneuronal." RESULTS: There were 21 cases of multifocal RGNTs identified. Follow-up was available in 18 cases at a median of 17 months. Progression-free survival and overall survival at 1 year were 84% and 94%, respectively. Of all cases, 43% had cerebrospinal fluid (CSF) dissemination, 48% had intraparenchymal spread, and 10% had both. The presence of CSF dissemination led to palliative care and/or death in 20% of cases (n = 2). None of the cases with intraparenchymal spread progressed. Radiotherapy was used in 50% of cases with CSF dissemination, chemotherapy was used in 20%, and CSF shunting was used in 36%. No tumors with intraparenchymal spread required adjunctive therapy or shunting. CONCLUSIONS: RGNTs with CSF dissemination are more likely to behave aggressively, and early adjunctive therapies should be discussed with patients. Tumors with intraparenchymal spread grow slowly, and maximal safe resection followed by observation is likely sufficient in the short term. Long-term behavior of multifocal RGNTs is still unclear.

Perioperative Optimization of Senior Health in Spine Surgery: Impact on Postoperative Delirium.

BACKGROUND: Delirium is a common postoperative complication in geriatric patients, especially in those with underlying risk factors. Multicomponent nonpharmacologic interventions are effective in preventing delirium, however, implementation of these measures is variable in perioperative care. The aim of our study was to assess the impact of our Perioperative Optimization of Senior Health Program (UTSW POSH) on postoperative delirium in patients undergoing elective spine surgery. STUDY DESIGN: The UTSW POSH program is an interdisciplinary perioperative initiative involving geriatrics, surgery, and anesthesiology to improve care for high-risk geriatric patients undergoing elective spine surgery. Preoperatively, enrolled patients (n = 147) were referred for a geriatric assessment and optimization for surgery. Postoperatively, patients were co-managed by the primary surgical team and the geriatrics consult service. UTSW POSH patients were retrospectively compared to a matched historical control group (n = 177) treated with usual care. Main outcomes included postoperative delirium and provider recognition of delirium. RESULTS: UTSW POSH patients were significantly older (75.5 vs 71.5 years; P < .001), had more comorbidities (8.02 vs 6.58; P < .001), and were more likely to undergo pelvic fixation (36.1% vs 17.5%; P < .001). The incidence of postoperative delirium was lower in the UTSW POSH group compared to historical controls, although not statistically significant (11.6% vs 19.2%; P = .065). Delirium was significantly lower in patients who underwent complex spine surgery (≥4 levels of vertebral fusion; N = 106) in the UTSW POSH group (11.7% vs 28.9%, P = .03). There was a threefold increase in the recognition of postoperative delirium by providers after program implementation, (76.5% vs 23.5%; P = .001). CONCLUSIONS: This study suggests that interdisciplinary care for high-risk geriatric patients undergoing elective spine surgery may reduce the incidence of postoperative delirium and increase provider recognition of delirium. The benefit may be greater for those undergoing larger procedures.

The Use of 5-Aminolevulinic Acid in Low-Grade Glioma Resection: A Systematic Review.

BACKGROUND: For optimizing high-grade glioma resection, 5-aminolevulinic acid is a reliable tool. However, its efficacy in low-grade glioma resection remains unclear. OBJECTIVE: To study the role of 5-aminolevulinic acid in low-grade glioma resection and assess positive fluorescence rates and the effect on the extent of resection. METHODS: A systematic review of PubMed, Google Scholar, and Cochrane was performed from the date of inception to February 1, 2019. Studies that correlated 5-aminolevulinic acid fluorescence with low-grade glioma in the setting of operative resection were selected. Studies with biopsy only were excluded. Positive fluorescence rates were calculated. The quality index of the selected papers was provided. No patient information was used, so Institutional Review Board approval and patient consent were not required. RESULTS: A total of 12 articles met the selection criteria with 244 histologically confirmed low-grade glioma patients who underwent microsurgical resection. All patients received 20 mg/kg body weight of 5-aminolevulinic acid. Only 60 patients (n = 60/244; 24.5%) demonstrated visual intraoperative 5-aminolevulinic acid fluorescence. The extent of resection was reported in 4 studies; however, the data combined low- and high-grade tumors. Only 2 studies reported on tumor location. Only 3 studies reported on clinical outcomes. The Zeiss OPMI Pentero microscope was most commonly used across all studies. The average quality index was 14.58 (range: 10-17), which correlated with an overall good quality. CONCLUSION: There is an overall low correlation between 5-aminolevulinic acid fluorescence and low-grade glioma. Advances in visualization technology and using standardized fluorescence quantification methods may further improve the visualization and reliability of 5-aminolevulinic acid fluorescence in low-grade glioma resection.

The Hydrogel Endovascular Aneurysm Treatment Trial (HEAT): A Randomized Controlled Trial of the Second-Generation Hydrogel Coil.

BACKGROUND: Aneurysm recurrence after coiling has been associated with aneurysm growth, (re)hemorrhage, and a greater need for follow-up. The second-generation HydroCoil Embolic System (HES; MicroVention, Inc) consists of a platinum core with integrated hydrogel and was developed to reduce recurrence through enhancing packing density and healing within the aneurysm. OBJECTIVE: To compare recurrence between the second-generation HES and bare platinum coil (BPC) in the new-generation Hydrogel Endovascular Aneurysm Treatment Trial (HEAT). METHODS: HEAT is a randomized, controlled trial that enrolled subjects with ruptured or unruptured 3- to 14-mm intracranial aneurysms amenable to coiling. The primary endpoint was aneurysm recurrence using the Raymond-Roy scale. Secondary endpoints included minor and major recurrence, packing density, adverse events related to the procedure and/or device, mortality, initial complete occlusion, aneurysm retreatment, hemorrhage from target aneurysm during follow-up, aneurysm occlusion stability, and clinical outcome at final follow-up. RESULTS: A total of 600 patients were randomized (HES, n = 297 and BPC, n = 303), including 28% with ruptured aneurysms. Recurrence occurred in 11 (4.4%) subjects in the HES arm and 44 (15.4%) subjects in the BPC arm (P = .002). While the initial occlusion rate was higher with BPC, the packing density and both major and minor recurrence rates were in favor of HES. Secondary endpoints including adverse events, retreatment, hemorrhage, mortality, and clinical outcome did not differ between arms. CONCLUSION: Coiling of small-to-medium aneurysms with second-generation HES resulted in less recurrence when compared to BPC, without increased harm. These data further support the use of the second-generation HES for the embolization of intracranial aneurysms.

Hypoglossal schwannomas: A systematic review of the literature.

BACKGROUND: Schwannomas of the hypoglossal nerve are rare and account for a very small percentage of non-vestibular schwannomas. OBJECTIVES: In this systematic review of the literature, we examined the epidemiology, symptomatology, management, and outcomes of patients with hypoglossal schwannomas. METHODS: The electronic database Pubmed was searched for all reports of hypoglossal schwannomas with descriptions of symptoms, management, and outcome characteristics. Data was extracted from each study and compiled in a spreadsheet. Continuous variables were reported as means and medians. Categorical variables were reported as proportions. Additional analysis was not done due to inconsistent reporting of outcomes and small sample sizes. RESULTS: A total of 59 studies (94 total individual cases) were included. 64% of patients were female with mean age of 44.6 years. The majority were intracranial/extracranial (50%). The most common symptoms were tongue deviation or speech disturbance (38%) and headaches (33%). Hypoglossal nerve dysfunction was present in 80% of patients. Surgical excision was performed in 93%, with a 15% complication rate. Evidence of residual mass after surgery was noted in 29%. Permanent hypoglossal nerve deficits occurred in 67%. Recurrence of tumor burden was reported in 6 studies, with median time to recurrence of 16.5 months. CONCLUSION: Current evidence suggests overall favorable outcomes with surgical resection of hypoglossal schwannomas, with a large percentage of patients experiencing mild and usually well-tolerated neurologic deficit. Limitations of this study include the use of retrospective data taken from case reports/series with highly selected patients, selective reporting, and absence of control groups.

Stem cell injections for axial back pain: a systematic review of associated risks and complications with a case illustration of diffuse hyperplastic gliosis resulting in cauda equina syndrome.

OBJECTIVE: Axial low-back pain is a disease of epidemic proportions that exerts a heavy global toll on the active workforce and results in more than half a trillion dollars in annual costs. Stem cell injections are being increasingly advertised as a restorative solution for various degenerative diseases and are becoming more affordable and attainable by the public. There have been multiple reports in the media of these injections being easily available abroad outside of clinical trials, but scientific evidence supporting them remains scarce. The authors present a case of a serious complication after a stem cell injection for back pain and provide a systematic review of the literature of the efficacy of this treatment as well as the associated risks and complications. METHODS: A systematic review of the literature was performed using the PubMed, Google Scholar, and Scopus online electronic databases to identify articles reporting stem cell injections for axial back pain in accordance with the PRISMA guidelines. The primary focus was on outcomes and complications. A case of glial hyperplasia of the roots of the cauda equina directly related to stem cell injections performed abroad is also reported. RESULTS: The authors identified 14 publications (including a total of 147 patients) that met the search criteria. Three of the articles presented data for the same patient population with different durations of follow-up and were thus analyzed as a single study, reducing the total number of studies to 12. In these 12 studies, follow-up periods ranged from 6 months to 6 years, with 50% having a follow-up period of 1 year or less. Most studies reported favorable outcomes, although 36% used subjective measures. There was a tendency for pain relief to wane after 6 months to 2 years, with patients seeking a surgical solution. Only 1 study was a randomized controlled trial (RCT). CONCLUSIONS: There are still insufficient data to support stem cell injections for back pain. Additional RCTs with long-term follow-up are necessary before statements can be made regarding the efficacy and safety.

The natural history of complete spinal cord injury: a pooled analysis of 1162 patients and a meta-analysis of modern data.

OBJECTIVE The natural history of complete spinal cord injury (SCI) is poorly studied. The classically quoted rate of improvement or conversion for patients with American Spinal Injury Association (ASIA) grade A (ASIA A) injuries is 15%-20%; however, data supporting this rate are very limited. In this paper, the authors conducted a meta-analysis of modern data reporting on ASIA A patients and evaluated factors affecting the natural history of the disease. METHODS The authors conducted a systematic literature review of all randomized clinical trials (RCTs) and observational studies of patients with traumatic SCI. The Embase, MEDLINE, PubMed, Scopus, CINAHL, and Cochrane databases were reviewed for all studies reporting on SCI and published after 1992. A meta-analysis was conducted using the DerSimonian and Laird (random-effects) model with a summary odds ratio analysis. RESULTS Eleven RCTs and 9 observational studies were included in the final analysis. Overall, the 20 included studies reported on 1162 patients with ASIA A injuries. The overall conversion rate was 28.1%, with 327 of 1162 patients improving to at least ASIA B. The overall rate of conversion noted in cervical spine injuries was 33.3%, whereas that in thoracic injuries was 30.6%. Patients undergoing early surgery had a higher rate of conversion (46.1%) than patients undergoing late surgery (25%) (OR 2.31, 95% CI 1.08-4.96, p = 0.03). CONCLUSIONS The overall rate of conversion of ASIA A SCIs from pooled data of prospective trials and observational series is 28.1%. This rate of conversion is higher than what is reported in the literature. Early surgery is predictive of a higher conversion rate. However, there are not enough data to provide conclusions pertaining to the efficacy of biological and medical therapies.

C5 palsy following posterior decompression and instrumentation in cervical stenosis: Single center experience and review.

OBJECTIVE: Causation and avoidance of C5 palsy after laminectomy have proven elusive, with multiple factors incriminated including width of the laminectomy, spinal cord migration, C5 neural foraminal stenosis, or intraoperative C5 root traction. In an attempt to identify risk factors for C5 palsy after decompression in cervical stenosis and myelopathy, the following review was conducted. This report is from a single center with consistent criteria for diagnosis and management of cervical stenosis and myelopathy. PATIENTS AND METHODS: We retrospectively reviewed 63 patients with cervical stenosis and myelopathy who had been treated with laminectomy with instrumentation at the C4-6 level. Imaging studies reviewed included plain X-ray films, magnetic resonance imaging (MRI), and computed tomography (CT) scans of the cervical spine. Health-related outcomes were assessed before and at follow-up and included Visual Analog Scale (VAS) for pain (1-10), Japanese Orthopedic Association (JOA) score for myelopathy (0-18), and SF-36 physical functioning, energy and fatigue, and general health categories (0-100). RESULTS: In 53 patients (control group), decompression and instrumentation was accomplished without incident, but 5 patients developed lasting postoperative C5 palsy. At follow-up, there were overall significant improvements in VAS, JOA, and SF-36 physical functioning and general health domains. Subsequent to surgery, a loss of lordosis of 5° and an increase in C2 sagittal vertical axis (SVA) of 17 mm was significant. There was, however, no significant difference between control and C5 palsy patients in lordosis and C2 SVA, before or after surgery. Postoperative MRI studies were obtained in 15 of the control patients and 6 of the C5 palsy patients. Postoperative width of the laminectomy as well as the caliber of the C5 neural foramina in the control and C5 palsy cohorts were not statistically different. Though the posterior displacement of the cord in the C5 palsy cohort was larger than in controls, this difference was also not significant. CONCLUSION: The above findings suggest that the cause of C5 palsy remains elusive. Though our incidence of lasting C5 palsy subsequent to laminectomy and instrumentation was 8%, it is probably under-reported. In our experience, laminectomy and instrumentation failed to increase lordosis and, in fact, were associated with an increase in positive cervical balance. Complications with cervical laminectomy and instrumentation are not by any means rare, and need to be emphasized in counselling patients, and selecting the approach.