The patient was operated by me 10-October-2015 for spondylolisthesis L3-4 and L4-5. The patient then came to the clinic 23-May-2018 complaining of back pain without sciatica after falling down 2 weeks ago and using crutches for 1 week. Investigations showed wedge fracture L1. She was treated conservatively. The patient then came 06-July-2021 after falling down with agonizing mid dorsal spine pain with inability to sleep due to pain. She was sent for investigations, but she disappeared. The patient was urgently admitted to Shmaisani hospital 7 days ago. due to severe dorsal spine pain.

On examination, the patient in agonizing pain and cannot find position to alleviate the pain. Under G.A. the previously requested investigations showed complete destruction of the D6 body anterior 2/3 and the posterior third slipped to the vertebral canal compressing the spinal cord. There is hypalgesia below the nipples and weak proximal muscles both lower limbs. There is intrapleural collection both sides and ESR was 40 mm/h and CRP was 162 mg/L. Septic work up done showing staphylococcus coagulase negative (Oxacillin resistant). During stay in hospital she progressed bowel obstruction for what the general surgeons and proctologists with nephrologist were involved with the problem and proctoscopy done 2 days ago resolved the problem. Lab repeated the day before surgery showing decrease of CRP to 30 mg/L  and ESR down to 30 mm/h. CT-scan of the dorsal spine done 08-October showing the height of D5 and D7 are 19.5 mm. The D5-6 disc height is 2.3 mm and Cobs angle at the deformed D6 was 60 degrees.

With the patient in the left side position, using double lumen endotracheal tube, right sided thoracotomy was achieved between D5 and D6 ribs. The right lung was collapsed. Dissection of the anterior border of the D5, D6 and D7. It was difficult to dissect the sympathetic chain due to massive scar and a huge amount of intrapleural fluid came out. The right D7 rib was harvested for subsequent graft. Using the C-arm the level of D6 was identified and removal of the osteomylitic bone and the fluids was achieved and sent for CXS and histologic verification. Using ANTARES Medtronic system distraction of the affected area was achieved and the dissection was carried out until the dura was seen in the posterior aspect of the resected pathological parts. The resection was carried out so that the healthy endplates were seen at both sides. Using The vertespan thoracic extra small was inserted into the cavity and it was expanded to reach 26 mm in anterior height after filling it with bone graft obtained earlier from the rib. For achieving the proper stabilization the caudal and rostral plates were applied to the D5 and D7 bodies with CD HORIZON 6.5X 35 mm length for distracting and and stabilizing the construct. Cross connector 13 mm length was applied between the rods 5.5 mm width. Check by the C-arm from different angles showed acceptable reduction and fixation of the dorsal spine. Routine closure of the wound with under-water seal inserted to the right intrapleural space. Smooth postoperative recovery. She was sent to the ICU.

Too early now.

There was difficulty in inserting the nuts to the Upper and lower plates, despite there proximity and as be ease to implement fixation. There was also difficult in applying cross connector.