Most of the site will reflect the ongoing surgical activity of Prof. Munir Elias MD., PhD. with brief slides and weekly activity. For reference to the academic and theoretical part, you are welcome to visit
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19-OCTOBER-2011 ALFATEH HAMAD ALNEEL 73 YEARS
HUGE EXTRUDED DISC C3-4, 4-5, 5-6 AND C6-7 WITH SEVERE SPINAL CORD COMPRESSION.
patient came to the clinic 12-October-2011 complaining
of unsteady gait for 15 months and fainting
examination: Romberg position is stable. There
is fine horizontal nystagmus when looking to
both sides. There is weak grip both hands 4/5,
extension right hand 3/5, left hand 4/5, and
both triceps muscles -4/5. Weak both lower limbs
-4/5 all muscles, except the left foot dorsi and
planterflexion, which is 3/5. There is
hypalgesia right hand and ulnar side right upper
limb and hypalgesia both lower limbs. Hoffmann
positive both sides more pronounced in the left
MRI brain performed 12-October-2011 showing
dilated ventricle with small scattered lacunar
infarctions both cerebral hemisphere, compatible
with age. MRI cervical spine 11-October-2011
showing huge PCD C3-4, 4-5 and 5-6 with lesser
at the C6-7 with malacia of the spinal cord at
these levels with severe cervical canal stenosis
at these levels. OPLL having place, which must
be taken into consideration and corrected
In supine position with Hallo
traction 5 Kg applied, in neck neutral position,
discectomy C3-4, C4-5, and C5-6 was done until
the dura was seen all over the entire disc
spaces. Fidji cervical cage 15x12x6.9 was
inserted to C3-4 disc space with Novabone.
Another one 17x12x5.3 was inserted to C4-5. The
third 17x12x6.1 was inserted to C5-6. Trinica
plate 80 mm 4 level cervical plate was used to
fix C3-4-5-6 and C7 using screws 4.2x14 for C3
and C4 and Trinica fixed screws 4.2x16 mm for
C5,6 and C7. All the stages of the surgery was
done under C-arm guidance.
closure of the wound. The patient took 3
hours to recover after what he started to
response to verbal command and speak and count,
but with dense tetraplegia. The patient then
start to move the upper limbs after 5 hours but
with the left upper limb weaker than the right.
All vital signs were acceptable. The patient
could move the right foot at 21.00 P.M. 8
hours after surgery. The patient was transferred
to the clinical department.
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The patient has malacia of the spinal cord at
multiple levels and the major compression is
anterior, for what anterior decompression is the
appropriate option for decompression.
Posterior decompression will cause complete
tetraplegia with respiratory arrest in high
percent of cases. ( more than 95%). Anterior
decompression could cause transient
deterioration as in this case, because the
spinal cord is in critical position, even with
The patient got clear deterioration of the left
upper and lower limbs and the cause is not
understood. If to blame traction, only 5 Kg were
applied to the Hallo traction. The traction was
applied in neutral position and hyperextension
was avoided. We use traction of both shoulders
for proper screening of the C6and C7 level. This
could be blamed, because there is no measurement
for this type of traction. This could cause
brachial plexus traction and subsequent traction
of the spinal cord. We use very tiny instruments
when dissecting the posterior longitudinal from
the dura to avoid mechanical compression to the
already compressed spinal cord. The extradural
part of the operation ran smoothly during
It could be that the age of the patient,
diabetes mellitus, cardiovascular problems and
severe malacia of the spinal cord, all together
with minimal traction applied by Hallo and
traction of the brachial plexuses, all
accumulate to give such deterioration.
In this case we did not use Inomed ISIS
intraoperative monitoring. In the future, in
such a case it is mandatory to perform such
surgery with this facility, at least to catch
the moment and cause of deterioration.
The patient progressed 26-October-2011 sudden
onset hematoma at the operative site three days
after starting aspirin 75 mg daily. The patient
was taken urgently to the operating room and
evacuation of the hematoma was performed and
inspection for the carotid was negative. The
source of bleeding was due to hypocoagulation.
Precautionally, all the suspected small veins
were coagulated. The patient was put in
ventilator for 2 days until the swelling in the
neck to resolve.
The patient was neurologically improving in the
ventilator and he was disconnected and was sent
to the ward one day later.
Four hours after transfer, the patient showed
difficulty in breathing and the patient
progressed massive left sided pulmonary
embolism. He was urgently taken to the ICU and
during transfer, "we are talking about several
seconds", he progressed bilateral pulmonary
embolism and all efforts for CPR failed and
brain death was declared 4.20 P.M.
The patient has high index of postoperative
complications. In the future, it is better not
to operate such a case, unless the family insist
to operate such a case and the family must be
warned about this high index of mortality.
Short neck and difficult intubation played
negative role in all stages of the surgeries and
resuscitation, During the second surgery, it was
impossible to insert the endotrachial tube,
instead, the laryngeal mask was used, and then
after evacuation of the hematoma and closure of
the wound, careful intubation with endotrachial
tube was inserted with difficulty, but
succeeded. During resuscitation also this matter
played a fatal sequence.
It is the first case during 32 years of surgical
activities with cervical spine surgery to have
this catastrophic evens in a fragile patient
with potentially multi organ and systemic
failure. There are no statistic, but to my
guising this mortality is the first among more
than 3000 such similar operations personally
operated by me.
Notice: Not all operative activities
can be recorded due to lack of time.
Notice: Head injuries and very urgent surgeries are also
escaped from the plan .