The patient was operated by me 09-May-2001  for huge extrusion L3-4 with left downward migration. The patient then was operated by me 18-August-2003 for huge extruded disc C4-5 severely compressing the spinal cord. The patient is a known diabetic with rheumatoid manifestations and has gout under treatment. The patient then came 06-November-2013 with left knee pain and partial tear of the ACL was established. The patient then came 14-February-2015 telling that she was admitted to Islamic hospital in Amman with weak left upper and lower limbs for 2 weeks. MRI cervical done 01-February-2015 showing severe cervical stenosis C3-4 and C4-5 with spondylolisthesis L1-2  with old infarction of the left fronto-parietal lobes. CXR showing cardiomegaly.

On examination: the patient is in wheelchair for 2 weeks with weak all muscles left upper and left lower limb 2-3/5with preserved sensation and pathologic reflexes in the left side. Exacerbation of deep reflexes left side. Micturition was normal. Considering the bad quality of the MRI and lack of information about the dynamic status of the neck, another MRI investigation and dynamic studies were performed the day before surgery. MRI data support the severe stenosis at C3-4 with hint spondylolisthesis. Dynamic studies confirmed the presence of considerable spondylolisthesis more in flexion position.

Using the C-arm, the level of C3-4 was identified and discectomy of C3-4 was achieved until the dura was seen all over. To achieve overdistraction of the posterior elements an anatomical cage 6 mm height was inserted. Using Atlantis cervical plate 25 mm length one level and 4 screws 4x15 mm, fusion and reduction of C3-4 was achieved. The wound was closed and the patient was sent for intraoperative MRI. The stenosis was resolved and the CSF was seen anterior and posterior to the spinal cord. After that, the patient was extubated.

Smooth postoperative recovery. The power of left upper limb improved considerably.

The patient the second postoperative day showed considerable deterioration of the left lower limb power distal parts and to lesser degree of the left upper limb. Decadron was started and the patient showed considerable improvement at the end of the day.

With bad information, the surgeon could go to wrong surgical decision. It is a rule to check several times and perform proper clear investigation to achieve the best results with minimal intervention.

It was planned before surgery, that if the stenosis persist, then to perform posterior decompression. Intraoperative MRI ruled out the necessity for the later procedure.