The patient came to the clinic 12-October-2011 complaining of unsteady gait for 15 months and fainting attacks.

On 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 side.

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.

Routine 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.

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 brilliant surgery.

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 surgery.

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.  29-October-2011.

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.