The patient came to the clinic 27-June-1999 complaining of LBP since 1986. The patient was operated by me 17-August-1999 for PCD C3-4. He came another time 05-May-2003 with numbness both hands and feet, one year duration and MRI lumbar spine showed lumbar canal stenosis, for what, he was operated 29-April-2003. The patient then came 01-July-2003 with a huge PCD C5-6 which caused to him slight quadriparesis and urinary problems with overflow incontinence. He underwent surgery for PCD C5-6 13-July-2003 and came to the clinic 13-October-2003 without Foley's catheter. He came with other patients walking and free neurologically several times, after that. The patient came 16-July-2007 walking with clumsiness both hands with edema both hands with mild weak proximal muscles upper limbs and dorsiflexion right foot. Uric acid was very high and he was given medication for osteoporosis and gout and pain-killers.

The patient came 16-September-2007 in wheelchair with dense quadriparesis for three weeks after chiropractor manipulation. MRI cervical spine done recently showing severe cervical canal stenosis with the stenotic elements from the posterior elements.

On examination: the deltoid muscles were 0/5 both sides with dense quadriparesis below with sensory loss below C5 both sides.

Great attention was given to the head positioning before induction of anesthesia and the patient was intubated and positioned in supine position in neutral alignment of the cervical spine with traction 5 Kg applied. Inomed Highline ISIS IOM was applied with TES-MEP protocol. The right limbs were showing more damage according to the amplitude and latency in comparison to the already compromised left limbs. After removal of the spinous processii of C3-4-5-6 and 7, drilling of the laminae was performed with partial drilling of the lower part of the C2 and upper part of C7. The drilling was proceeded until the remnant parts of the laminae were transparent. Control of the electrophysiological parameters were the same. Further drilling caused the compressing soft tissues, i.e., the ligamentum flavum to bulge out. The bony part were removed using tiny elevators and sometimes the small size Smith-Kerrison. All the compressive elements were removed. The dura was transparent, that the spinal cord was seen through it. Electrophysiological control showed considerable improvement of the curves and decrease in latency and increase in the amplitude. Routine closure of the wound.

Smooth postoperative recovery and dramatic improvement of the power of four limbs. 

The patient had several surgeries for his spine and the last picture was unusual, that OPLL usually affect the spinal cord anteriorly, but here let us say HLFPC (Hypertrophic Ligamentum flavum Posterior Compression) was the cause of quadriparesis, compressing the spinal cord from behind.

It is well known, that posterior decompression of the cervical spine is full of hazards and complications and most of the patients deteriorate after the surgery, for what special attention was paid for positioning and drilling so to bring the surgical trauma to zero.

So as to catch the complication, Inomed highline ISIS IOM was used to know exactly what is the cause of the possible complication, but here we were lucky to catch the opposite, that dramatic improvement was noted immediately after decompression, before the patient was extubated, which consequently was confirmed after the patient awakening.