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01-APRIL-2008  KHALED FAT'HI ABU-NUWWAS  48 YEARS  SUBLUXATION OF C3-4 AND C4-5 WITH DEFORMITY OF C5 AND C6 WITH MALACIA OF THE CERVICAL SPINAL CORD.

Anamnesis:

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The patient came to the clinic 24-February-2008 complaining of neck pain for 2 years with numbness four limbs with inability to walk for 1 week. Cervical X-ray done 1994 showed dislocated C4-5.

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The patient was operated by me 1995, 1997 and 2000 for PLD L4-5.

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On examination: the patient had Lhremitte sign when extending the neck upward. Hoffmann was positive both sides with weak both deltoids biceps brachii  and triceps 4/5. The grip right hand was 3/5 and grip left and extension both hands were 2/5. There was generalized weak all muscles lower limbs 3/5. Analgesia of the neck and right side of the body and left arm and left lower limb below the inguinal region. Spastic both lower limbs with exaggerated deep reflexes and Babinski positive both sides. The patient was sent for investigations.

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MRI cervical spine performed 01-March-2008 showed dislocation of C3-4 and to lesser degree of C4-5 and deformity of C5 and C6 with malacia of the cervical spinal cord at C3-4 level. MRI of the brain was normal.

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The patient is diabetic for 6 months in glunil 5 mg per day, hypoten 50 mg once daily, Low-lip and angiotec 10 mg once daily and in baby aspirin. He underwent stinting for coronary artery disease 2002.

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Discectomy of C3-4, C4-5 and C5-6 was performed. Partial coporectomy of C5 and upper third of C6 was done, using the high-speed drill. Preoperatively, it was decided to use the fibular graft, but during surgery, tricortical iliac bone graft was sufficient. It was harvested from the right. The graft was remolded to accept the bony tunnel and drilling was performed, so that with traction of 8-10 Kg was sufficient to hold the construct with the aid of impactor.

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Trying different miniplates, it was decided to use 3 level fusion miniplate with 2 screws in the C3 body and 2 screws in C4 body and 2 screws in C7 body. The 2 screws at C4 were forced so that, they could regain some reduction of the subluxation. All measures were applied to regain normal cervical curvature of the spinal column. Image-intensifier was used at steps of the operation.

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Routine closure of the wound with smooth postoperative recovery.

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Considerable improvement of the power of the four limbs.

Comments

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Anterior approach to cervical spine is mandatory, when the correction is impossible from posterior.

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All the compressive elements must be eliminated during surgery, even if coporectomy is needed. During Coporectomy a ridge must be left underneath to prevent slipping of the graft.

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Subluxation, compression, and mechanical factors must be resolved during surgery.

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