The patient is a Syrian doctor, known diabetic for 5 years with arterial hypertension with history of CABG done 10 years ago came to the clinic 01-June-2011 complaining of LBP for 4 years with bilateral sciatica with inability to walk more than 100 meters with numbness both feet. The patient claiming that his condition is deteriorating. Cervical MRI 22-December-2008 showing severe cervical stenosis C4-5, 5-6 and C6-7 with malacia of the spinal cord. MRI lumbar spine performed 09-May-2010 showing spondylolisthesis L4-5 with segmental stenosis.

On examination, at that time, he had shuffling gait with exaggerated scoliotic stance. He had weak grip right hand and extension both hands and triceps both arms -4/5. He had Hoffmann sign more pronounced in the right side. The muscles both legs were weak -4/5 more weak in the right side. Babinski was positive in the right side and there was diabetic neuropathy both feet. SLRS was 65 degrees both sides. The patient was sent for new MRI of the cervical, lumbar with LSS X-ray dynamic study. The investigations done 02-June-2011 confirming severe stenosis C4-5, 5-6 and C6-7 and stenosis at L3-4, L4-5. The patient was advised to undergo surgery for CCS , but he escaped.

The patient then came 01-December-2011 flying from Syria, claiming that he was doing well, but yesterday, he got sudden onset LBP with inability to stand and walk. He performed the posterior cervical decompression in Syria in July-2011.

On examination, the power of both upper limbs was 5/5, but SLRS was 5 degrees both sides due to weakness. All the muscles both lower limbs were weak and the dorsiflexion both feet was 3/5. There was analgesia both L4 roots with preservation of sensation of both feet and below. There was no micturition or defecation problems.
New MRI of the dorsal and lumbar spine were performed , showing complete stenosis at L3-4, L4-5 and mild one at L2-3.

Skeletonization of L2-3-4-5 spinous processii. The lamina of L4 was checked for unstable elements or overmobility. All data were negative, nor isthmolysis was present. Decompressive laminectomy of L3,4 and partial of L2 and L5. The epidural fat was missing at the L2-3, 3-4 and L4-5 levels. Foraminotomy of L3,4,5 roots was achieved in both sides. Special attention was paid to seek the sudden onset of his LBP with severe weakness. It was found that, there is hemorrhage intraligmental in the left side of the L3-4 facet, triggered with the presence of huge vein. The hematoma was 24-36 hours age. All the compressive elements were removed. At all stages of surgery, check for instability was performed at L4-5 level, which was proved to be negative.

Smooth postoperative recovery with improvement of the power of both legs.
 

The patient had cervical canal stenosis with lumbar canal stenosis, which are both progressive in course. The cervical decompression must take precedence, which was the case.

The cause of sudden deterioration, was not spondylolisthesis of L4-5, but the hemorrhage in the L3-4 level which took place intraligamentally and was the cause of his sudden deterioration.

In retrospective analysis and interrogation, the patient felt down 2 days ago to the left side and chest X-ray showed fracture of the 9th rib left side without hemo or pneumothorax.