The patient came to Shmaisani hospital 09-September-2014 complaining of complete paraplegia below C5 with complete paraaneasthesia at the level of Th4. The patient is an Iraqi civilian and the victim of the dirty American-Iraqi war 26-June-2014 and received neck injury during air strike. He was operated in the American University in Beirut 2 months ago and was admitted to us in bad condition with bed sores and signs of septicemia.

On examination; the patient is bedridden, feverish with aphonia and swallowing difficulty. He has neck pain and weak deltoids 4/5, biceps 3/5 and unable to grip or extend the hands with severe atrophy. The triceps both upper limbs are 0/5 and below that also 0/5. There hypalgesia both upper limbs with complete paraaneasthesia below Th4. Septic work up was started and E. Coli was isolated and triple antibiotics were started immediately after admission and correction of homeostasis was achieved by transfusion of blood and plasma. Cervical X-ray showed cervical cage fulfilling the removed C6 and C7 vertebrae with 2 screws above and 2 screws below with signs of osteomyelitis. MRI done the day of admission showing pus extradural with osteomyelitic bone. It was evident that the construct is flail and of no usefulness.

New incision done antero-medial to the right sternocliedomastoid muscle. The cervical plate which was 48 mm length was exposed. The screws were loose and the plate was removed. The cage was inspected and it was acceptable, for what it was decided to leave it in place. The cage was positioned to the left half of the vertebral bodies of C6 and 7, that its right border was in the midline. Using Alphatec Spine cervical cage 95 mm long , bended to accept to lower curve of D1 and D2. Fusion of C3,4 and D1 and D2 was performed with variable angle 4 screws 4x16 mm below and 4 fixed angle 4x16 mm to the upper segments. Routine closure of the wound.

Smooth postoperative recovery.

The patient has a lot of problems which needed surgical correction. It was planned to perform posterior fusion of the spine, but after thorough thinking, it was decided to attack the anterior construct and explore it and correct the already troubleshooting segment.

One of the reasons to abandon the posterior fixation, is the possibility, that infection could involve the posterior construct adding to the patient double problems.