The patient was operated 2 months ago for metastatic adenocarcinoma of the prostate, elsewhere, after what he deteriorated dramatically with subsequent paraplegia both lower limbs and severe weak both upper limbs. Immediate postoperative X-rays were unacceptable with upper screws are in the left soft tissues. The patient was in agonizing pain and he was unable to move his neck and he was bedridden. The patient was not informed that he had metastatic tumor as his sons claim and MRI performed 15-November-2007, showing the presence of the tumor and graft harvested from the right iliac bone compressing and fracturing the bodies of C4,5 and 6. with further compression of the spinal cord by the tumor mass.

The relatives were urging for urgent surgery and he was admitted with disinformation and he was brought to the operating room one week ago. During the check up and further questioning, because the patient did not show to the clinic, the fact about the metastatic nature of his disease became evident, and to patient was sent back without operation and he was advised to undergo radiation and chemotherapy. The sons came another time urging for fixation of the spine, because the patient is in agonizing pain. It was explained to them, that such surgery is not curable and his problem more wide than his cervical spine, but they insisted to be operated.

10 cm length incision done parallel to the anterior border of the right SCMM. Dissection was performed from the healthy tissues and directed to the scarous one. The flail construct was removed in one piece. Using high-speed drill, the bony tumor and the graft with the soft tissues of the tumor were removed until the dura was seen from C3 down to C6. Part of the inserted graft was fused with the C3 and it was acceptable and left in place. The removed construct was of Stryker brand with 68 mm length and three level type. Part of the C7 was left in place because the bone was acceptable. A fibular graft was harvested with 70 mm length from the right leg. It was reshaped to accept the bony defect, which was 65 mm length.

5 level 82 mm length cervical miniplate was used and three screws were fixed to the graft and 2 screws with 18 mm length were inserted to C3 body and one screw to the previously inserted graft in the right upper corner. One screw was inserted to the D1 and 2 screws were inserted to D2 bodies to obtain rigid fixation of the whole construct.

Smooth postoperative recovery.
 

The next day, the patient got slight improvement of his four limbs power, and X-rays were acceptable. Despite that, the patient was sent for CT-scan of the lower construct, which confirmed, that the lower 2 screws were not reaching the bone, which is unacceptable.

The patient was sent to the operating room and the incision was extended down for further 2 cm. The construct was removed and the fibular graft was cut to obtain an angle of 20 degrees at its lower third, without removing the screws from it. The cervical plate was bended at its lower third for the same degrees, so that the device is stuck with anterior surface of the bodies of D1 and 2. It was necessary to drill the upper edge of D1 to have the perfect alignment. Four screws were applied to the lower part for D1 and D2 and the previous upper four screws were reinserted to the same place.

Smooth postoperative recovery.

The patient came 13-October-2008 with full power of his four limbs walking with complaining of a scar at the operative site, disturbing him when looking upward. He has also numbness of the four limbs. He was advised to undergo scar release.
 

The patient has metastatic adenocarcinoma of the prostate. During the first operation the graft pushed the bodies down, without removing the extradural part, causing further compression and subsequent deterioration.

If the fixation was acceptable, it was meaningless to reoperate the patient, but the loose device and the urge of the family, forced me to operate him. Partial removal of the tumor with the aim to decompress the spinal cord was achieved before providing slid fixation, using the fibular graft.

This action, could help the patient to have the opportunity to undergo radio and chemotherapy.

Routine X-rays are not reliable for check at the level of D1-2. In the next operation, we avoided the traction of the shoulders, so as to have several check X-rays in different positions. The swimmer view was not informative, but pushing the shoulders upward, let us name it the Bayyati view was excellent to demonstrate the construct and bony alignment of D1 and 2.