The patient was operated by me 24-August-2005 for PCD C4-5 left side and PCD C5-6 right side. Discectomy both levels with fusion of C4-5-6 was performed at that time. The patient showed dramatic improvement of her neurological deficit, but she came 15-October-2005 claiming of left sided hemihypalgesia without motor deficit. Migraine was considered as the cause of her complains and she was sent for MRI of the brain and MRA of the brain and carotids, which proved to be normal.

The patient escaped and reappeared 27-October-2006 after undergoing elsewhere, left CT release and an incision in the posterior aspect of the cervical spine with severe atrophy of the the paraspinal muscles left side with agonizing pain, that it was impossible to touch her left upper limb. No documents available explaining what was done in the posterior cervical spine. Sympathetically mediated pain was suspected and the patient was already addict for several medications, including Tramal. All the time check MRI of the cervical spine was performed , confirming that the construct is in place and no compression was noted.

The patient came 28-August-2007 with severe bilateral radicular pain more severe in the left side with frozen shoulder both sides . She felt down 06-May-2007 with fracture right foot and underwent hysterectomy 18-August-2007. SLRS was 20 degrees both sides and she was sent for MRI lumbar spine and dynamic study for the cervical spine was requested 01-September-2007. MRI lumbar spine showed bulge disc L4-5. X-rays of the cervical spine showed missing lateral masses of the left C4-5 and C5-6. It became clear that the next surgery was wide foraminotomy for left C5 and C6 roots without leaving any bony elements to preserve stability of the cervical spine.

Several times a detailed discussion was performed with her and her husband, that the patient has multiple problems and the only surgical interventions, which could be suggested is posterior fusion for the posterior instability of the spine and left sided sympathectomy for the sympathetically mediated pain. Resolving the addiction was advised to postponed 6 months after surgery. Both agreed and understood the situation and they were willing to proceed with surgical treatment.

The surgery was performed in the supine position, under the electrophysiological control using ISIS Highline Inomed SEP - EMG protocol. Skeletonization of C3 down to D3 was performed. It was noticed that overmobility of the cervical spine was maximal at C7-D1 and C4-5 levels. The lateral masses of left C4-5 and C5-6 were missing. Sympathectomy of left upper dorsal D2 and D3 was performed. Both ganglia with their rami albicans and greysii were removed in one block and the satellite rami were also coagulated and bisected. Using OA System Stryker lateral mass screws 12 mm length, under image-guided intensifier the normally looking C3-4 both sides masses were used for upper fixation. The C6 lateral masses were also used for insertion the middle row. The infer row was the insertion of 18 mm length transpedicular screws to the body of D1. Using rods and bridge the posterior fusion was achieved after performing slight distraction of the left rod to resolve possible collapse and compression of the nerves in the left side.

Routine closure with smooth postoperative recovery.
 

The case is very difficult and complicated and it is the first case in my life, see a such case with the lateral masses removed at 2 and possible 3 levels in one side.

If foraminotomy was intended to perform in the second operation with absent records, it was more wise to perform it, keeping during that the bony alignments to preserve stability.
The presence of the previous anterior fusion between C4-5-6 is not sufficient to provide such stability, that allow the surgeon to perform such a procedure, as in this case.

The left C5 and C6 running roots were seen and no attempt for neurolysis was performed to avoid further damage to them.

Left side sympathectomy was performed to grant lower tuning of her pain-sympathetically mediated volleys down.

Time will tell if such strategy was wise, and this will be clear after long time, after withdrawal from addiction.

The neurosurgeon love to operate in straight forward clear situations with granted results and try to avoid such complicated cases with unknown results, which could be masked by the addiction of the patient. The presence of convincing morphological data about the instability and the clinical arguments confirming the presence of sympathetically mediated pain, forced me to perform such surgery to help the patient even the improvement could be minimal. Future will tell.