Prophylactic C4/5 foraminotomy for the prevention of C5 palsy following posterior cervical decompression: a systematic review and meta-analysis

C5 palsy is a common and disabling complication of posterior cervical decompression, impairing shoulder function, prolonging rehabilitation, and reducing patient satisfaction. Prophylactic C4/5 foraminotomy has been proposed as a preventive strategy, but its effectiveness and safety remain uncertain.

To systematically assess the impact of prophylactic C4/5 foraminotomy on the incidence of C5 palsy and postoperative outcomes.

We conducted a systematic review and meta-analysis of 12 comparative cohort studies (n = 2,023) following PRISMA guidelines. The primary outcome was incidence of postoperative C5 palsy. Secondary outcomes included functional scores, sagittal alignment, and perioperative parameters.

Prophylactic foraminotomy significantly reduced C5 palsy risk by 67% (RR = 0.33, 95% CI: 0.21–0.52; p < 0.0001) with consistent effects across surgical techniques (I² = 0%). Modest improvements in JOA (SMD = + 0.14, p = 0.028) and NDI (SMD = –0.15, p = 0.032) were observed, without adverse effects on sagittal alignment or blood loss. Operative time increased moderately (SMD = + 0.47, p = 0.0003).

Prophylactic C4/5 foraminotomy is associated with a substantial reduction in the risk of postoperative C5 palsy, with moderate-certainty evidence supporting its clinical effectiveness. Future randomized studies may be valuable to refine patient selection and confirm generalizability across broader populations.