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Dr. Ali Al-Bayati

 
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  neurosurgery.tv

 

The patient  came to the clinic  23-February-2006 complaining of weak right UL with numbness of the right median nerve distribution. The patient suffered RTA 16-October-2005 without LOC, but he immediately started to complain of the above mentioned. He is  a known diabetic  for 5 years.

MRI done 28-November-2005  showing PCD C5-6 with wedge fracture of C5. Repeat MRI done 16-February-2006 showing deterioration of the condition with PCD C5-6. C6-7  with the cervical X-rays demonstrating overmobility of C3 down to C7.

On examination: The patient had neck pain when looking to right  up and down with weak grip, extension of the right hand and right triceps muscle with hypalgesia of the second and third finger right hand. The patient was sent for further studies and PCD C4-5 was also confirmed and wedging of C4 was noted.

The patient was operated. Discectomy C4-5, 5-6, 6-7 was done with removal of the right extrusion at the right side of C6-7. Using Stryker reflex hybrid ACP system, fusion of C3 down with C7 was performed, using four level fixation.

Immediate postoperative recovery was uneventful, but the patient progressed severe oedema at the site of the surgery with and sent for ICU care 03-March-2006 at 1.00 p.m. and given 2 units human albumin. No surgical emphysema and laryngeal oedema is the predominant picture.

The patient's condition deteriorated and he was taken at 3.00 p.m. to the operating room. During intubation the epiglottis and the surrounding tissues were swollen. Exploration of the wound revealed moderate hematoma overlying the construct  about 7-80 ml thick in consistency without active bleeding. It was removed and all the seen veins coagulated. Inspection of the esophagus and the trachea for possible tears were negative. The carotid sheath was intact and the thyroid  also.

The wound was washed with saline and gentamicin and ready-vac drain No 10 was inserted and the patient left in ventilator to the next day. 1 unit blood and 6 units FFP were given for the possible unrecognized coagulopathy. 

The next morning 04-March-2006 the patient progressed left sided pneumothorax for what UWS was applied to the left side. CT-scan performed at 9.30 a.m. showing no haematoma at the operative site and mild bilateral heamothorax. It was decided to keep the patient in ventilation for further 2 days.

The patient was extubated after 2 days and the chest tube removed the next day and the patient was transferred  to the ward 8-March-2006 and discharged in good condition with improved neurologic condition 12-March-2006. 

Comments:

1. The patient got rupture of the OPLL at all the mentioned levels due to severe hyperflexion injury. This was the cause of his ruptured disci and overmobility of all these segments. It was possible to find the site of the ruptures.

2. Conservative treatment is unlikely will resolve his problem, and surgical decompression and fixation, put the patient in the safe side from developing myelopathic syndrome.

3. It is the fist time in my 26 years of personal experience seeing a case with  a slowly progressive hematoma progressing to that degree, that evacuation of the hematoma was needed and for extreme  precaution putting him in sedation with muscle relaxants after such surgery. The most possible cause of the haematoma was a torn small vein , which was silent during surgery , but escalated and gradual enlargement of the oozing mass  several hours after the operation.

4. Tow signs must be focused to attention: The patient was unable  to breath in the supine position, for what he refused the CT-scan. This could be explained retrospectively, that when the patient extend his head, the trachea suffer more compression from behind. If you pay attention to the below picture in lateral view, you can see some distance between the construct and the trachea, which was in evolution at that time.

5. When inserting a such large device, a huge traction is needed. It is preferable to coagulate and sharp cut all the running small veins in the route and at construct site, so as to avoid such complication.

 

AP-view Lateral-view
Postoperative check X-ray showing the alignment  of the device

 
Check X-ray done 06-July-2006


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[2006] [CNS CLINIC - NEUROSURGERY - JORDAN]. All rights reserved