Most of the site will reflect the ongoing surgical activity of Prof. Munir Elias MD., PhD. with brief slides and weekly activity. For reference to the academic and theoretical part, you are welcome to visit
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29-MARCH-2010 ABDEL-HALEEM KHASEEB YASEEN 56 YEARS
EXTRUDED DISC C4-5 AND C5-6 WITH SECONDARY CANAL STENOSIS AND MALACIA OF THE
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patient came to the clinic 22-March-2010
complaining of neck pain and pain and numbness to the ulnar
territory both sides for 3 years and numbness
both L5 territories more the right for 2 years.
Exacerbation of neck pain the last week.
MRI cervical spine
performed 2 years ago showed PCD C4-5 and C5-6
with elements of stenosis.
On examination: the
patient is deaf in the right ear since
childhood, has hypotrophy of the interossii both
hands with weak grip both hands 3/5 and extension
3/5 and the both triceps 3/5. There is pain and
limitation of movement of the neck when looking
down and bending the head to both sides and
sign. There is
hypalgesia both ulnar distribution both hands.
MRI of the cervical
spine performed 25-March-2010 showing
wide-based extrusion of C5-6 with stenosis of
C4-5 and C5-6 with malacia of the spinal cord at
the last mentioned level.
Discectomy of C4-5 and C5-6
was achieved with removal of the anterior and
posterior osteophytes . The dura was seen at the
depth of the fields both sides. PEEK-OPTIMA
cervical cages 14X11X7 mm were inserted at both
levels with NANOSTEM synthetic bone paste and
using Medtronic Atlantis 2 level plate 47.5
mm length, fusion of C4-5-6 was done. All stages
of the operation were controlled using
Routine closure of the wound.
the patient showed profound weak right lower
limb with improvement of the triceps both upper
limbs and grip left hand. The patient was put in
steroids and Somazina.
The extruded disc of C5-6 was
an old with new recent one triggering the course
of the disease and causing Lhermitte's sign. The atrophy of the interossii of
both hands confirming that the extrusion was
an old one, but escalation of the pain is a
In the industry, there are a
lot of options to deal with such situation, and
performing such a procedure is one of the
The use of cages with maximum
height 7 mm in the 2 levels will decrease the
degree of the cervical stenosis by stretching
the relaxed ligamental tissues.
The cages increased the
height for around 3-4 mm. This local traction
could be the result of the spinal cord reaction.
Preoperative MRI showing the severe stenosis with
malacia of the spinal cord.
Postoperative X-ray showing the
MRI of the brain with
contrast with MRA of the brain and carotids and
MRI of the cervical spine were performed
31-March-2010 demonstrating old scattered
infarction both cerebral hemispheres with recent
infarction in the left hemisphere near the
internal capsule and the GPI. The vascular
system was normal except for narrowing of the
left vertebral artery at its origin. The
cervical spine showed only the old malacia
changes, which were noted before surgery. The
usual artifacts were noted due to implants, but
it was possible to see that the spinal cord has
no major morphological changes.
In retrospective analysis the
patient progressed CVA of the left cerebral
hemisphere during surgery with recent tiny
infarct near the left internal capsule. That
explain why the recovery process is of
supratentorial lesion, not a spinal one.
CT-scan of the cervical construct showing the perfect
alignment, requested by the family. Done 01-April-2010.
Absent both Posterior Communicating arteries
provoking the insult.
Postoperative MRI confirming the elimination of
compression with slight edema.
Postoperative MRI confirming the presence of old lacunar
infarctions and recent infarction in the left cerebral
In retrospective analysis
after this case, more than 100 of several
patients were evaluated for MRA data for
the presence of the PcoAa performed in 1.5
tesla and some of 3 tesla MRI machines available
in the market. It was found that, it is missing
in all of them. The AcoA was found in 43% of
them. This means that the MRA data are not
realistic for evaluation of the true situation.
This means that our case and the above mentioned
author came to the wrong conclusion and other
causes must be sought. These data also trigger
the requirement to improve the realistic quality
of the MRA data or to perform angiography so as
not make these misinterpretations. 27-May-2010.
Notice: Not all operative activities
can be recorded due to lack of time.
Notice: Head injuries and very urgent surgeries are also
escaped from the plan .