The patient came to the clinic 01-February-2015 complaining of neck pain for 20 years with progressing weak and numbness four limbs the last 3 months after performing lumbar fixation elsewhere. The patient is a known diabetic, hypertensive and has gout. MRI lumbar spine done 18-November-2014 showing lumbar canal stenosis L4-5. Cervical spine showing severe stenosis at C2-3, C3-4 with malacia of the spinal cord at these levels. The patient using walker for 5 months.

On examination, the patient standing with difficulty, walking and setting with the help of 2 persons. There is hypalgesia below C2 level with profound weak all four limbs ranging fro 0 to 3/5 more weak in the right side. Hofmann's sign positive both sides with exaggerated deep reflexes. Urgency and frequency for 6 months.

The patient sent for investigations: MRI of the brain ruled out the possibility of ALS.  Cervical spine done 18-February-2015 showing spondylolisthesis C2-3 with severe segmental stenosis and malacia of the spinal cord with extruded disc C3-4 not causing significant compression. The patient when came after investigations was completely paralyzed in wheel chair. Now he is using Foley's catheter for several days.

Discectomy C3-4 until the dura was seen entirely with osteophytectomy. Discectomy of C2-3. Insertion of cages No 5 to C2-3 and C3-4 with bone graft. Using Medtronic 2 level Atlantis cervical plate 42.5 mm length with 6 screws fusion of C2-3-4 was achieved. Reduction of the spondylolisthesis C2-3 was achieved. Routine closure of the wound.

Smooth postoperative recovery. The neurologic status still the same and sent to the ward. After 4 hours the patient showed low O2 saturation and somnolence for what he was sent to the ICU. The patient after several hours became alert and sent to the ward the next day with slight improvement of his neurologic status.

The patient has profound damage to the spinal cord due to overmobility at C2-3 and C3-4, the last was noticed during surgery. The aim of the surgery to prevent further damage of the spinal cord with possible respiratory complications and even respiratory arrest.

Time will tell how he will improve after such bad neurologic status before surgery.