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The patient came came to the clinic 08-August-2004 complaining of
neck pain for 30 years with difficulty in walking and micturition
problems. He was operated 1977 in Germany for anterior decompression
at C5-6, after what he improved. Stenting of the coronaries 1999.
The last 18 months, he showed gradual deterioration. On examination,
the gait was shuffling, but Romberg was stable. He had weak grip,
extension and triceps both upper limbs with hypalgesia of median
nerve distribution both sides. He had limitation of neck movement to
all directions. Hoffman sign was positive both sides. Babinski was
positive in the left side with exaggerated deep reflexes both
lower limbs and weak quadriceps fomoris and dorsi and planterflexion
of the right foot. The old incision was strikingly low, as the
incision usually used 2 cm above the right clavicle for the TOS
syndrome.
The patient was sent to investigations and the wife came
came back 06-December-2005 with MRI of the cervical spine showing
severe cervical canal stenosis at C3-4, C4-5 and C5-6 levels. The
pros and cons of surgery were explained to the family and they
disappeared another time.
The patient came 10-June-2006 with rapid deterioration of his
condition with almost quadriparesis below C4 and dripping
urine for the last month. The patient was advised to undergo
surgery.
Through anterior approach corporectomy of C4-5-6 was done and the
hypertrophied OPLL was removed. A small bridge was left
intentionally in the C4 body about 7 mm height and 3 mm thickness to
prevent slipping of the 55 mm length remolded fibular graft
harvested from the right leg. The graft was reconstructed to
have some curvature resembling the curvature of the Hybrid Reflex
cervical plate and first a 4 level 58 mm length was used and the
fibular graft was attached to it by 2 screws 10 mm length.
The graft filled exactly the gap, but a problem came with screw
fixation, since he had previous surgery and the fused and
hypertrophied and calcified anterior longitudinal ligament.
Control images showed unacceptable alignment, for what it was
necessary to remove the device and de novo use 78 mm length plate
and the construct with traction and additional remolding got
acceptable position and acceptable screw fixation between C3 and C7.
Smooth postoperative recovery. The patient could walk and stay
without falling the next postoperative day, and he noticed dramatic
improvement of the sensation and power of four limbs. The patient
continued to improve neurologically and at the day of discharge
23-June-2006 start to complain of abdominal pain and distention. He
passed stool at the morning of that day, but the pain continued to
increase. The relatives told that he had similar attack several
months ago. Surgical consultation was achieved and the patient was
put under strict observation and CT-scan angiography ruled out
mesenteric artery thrombosis, but the patient got severe distension
and urgent laparatomy was performed 25-June-2006 , which confirmed
the presence of
acute necrotizing pancreatitis. The
patient showed mild improvement of his homeodynamic parameters in
ventilator, but the next day in the morning, he started to show
multiorgan failure with cardiac arrest and death 13.35 am
26-June-2006.
Comments: 1. The patient
operation took 8 hours. 4 hours of them to repeat the insertion of
the construct, to be acceptable as seen in the below figures. If you
see that, the construct is not satisfactory, do not hesitate to
change it even it needs further efforts. It seems that, the artistic
touch with engineering capabilities must be considered in such
surgeries. 2. From previous surgeries with fibular grafts, do not
force the insertion of the screws for fixation of the device to the
fibular graft. It happened that the fibula can easily break for 2 or
3 parallel fragments, if this done without taking precautions. 3.
Using the high-speed drill the graft must remolded, so as to accept
the cervical plate and at the same time, to keep it's strength. 3.
Do not ever be happy about your early results of surgery. Be happy
after one month at least, because your efforts are directed to
improve the condition of the patient for acceptable period of
survival. In this case even after detailed search to find any link
between the surgery and the acute necrotizing pancreatitis, failed
to show relation, even as triggering factor. Drug induced triggering
could have place, but most of the patients receive the same protocol
of treatment. At Last we are not the God to predict the future and
refine the preoperative selection of the patients. The neurosurgical
outcome was outstanding, but the neurosurgeon now in severe
depression, knowing that the patient dying several days later from
unpredictable cause coming accidentally at the day of discharge.
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