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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17-JANUARY-2008 MUSAAB MUHAMED DEEB 28 YEARS SEVERE
SCOLIOTIC DEFORMITY OF THE CERVICO-DORSAL SPINE WITH TREATED SYRINGOMEYLIA 2004.
The patient came to the
clinic 23-September-2004 from Syria with a
history of convulsions since birth and he could
walk at 5 years age. At 15 years age, he
progressed scoliotic deformity and the
walking deteriorated the last 3 years.
The patient was operated by
me 2004 for huge Syringomeylia at the
cervico dorsal spinal cord and a shunt was
inserted between the syrinx cavity and subdural
The patient showed slight
improvement and the power of both lower limbs
and left upper limbs dramatically improved. The
power of the distal muscles of the right upper
limb slightly improved, but the power of the
proximal muscles remained the same. The
sensory deficit starting from the C3 down to
include both upper limbs and the left chest wall
remained the same.
The scoliotic deformity still
the same and the patient was able with
difficulty to walk using the crutch with the
tendency to fall foreword.
The patient was put in
laminectomy position and Gardner-Well tongs were
applied with 6 Kg traction to keep the head with
neutral position. Registration of the Inomed
ISIS SEP recordings were obtained as base
line before doing anything.
It was noticeable that the
amplitude of the right upper and lower limb were
diminished from the start, in comparison to the
left and there was continuous spontaneous
fibrillation of the muscles of the right upper
and lower limbs in the EMG recordings.
Skeletonization of D1-5 was
performed far to include the costo-transverse
joints. A heavy scar was left over the cervical
dura to avoid any surgical trauma to this
portion. The lateral masses were skeletonized
Drilling of the posterior rim
of the foramen magnum and laminectomy of C1 with
decompression of all elements from the right
side as seen by the MRI. During all these stage
the intraoperative monitoring was showing no
deviation of the trend and the SEP parameters
were within acceptable range.
Using the Medtronic Vertex
Max occipital plate rods, remolded to accept the
alignment of the patient , fixation of the
occiput with the lateral masses of C2 and right
C7 and left C6 was performed, using polyaxial
lateral mass screws 14 mm length. Distraction
about 10 mm was performed from the left, after
what, mild compression about 5 mm was performed
from the right.
After performing this
procedure, print of the IOM data was done to
confirm, that no functional deterioration of the
spinal cord and the brainstem could have place.
Using rod connector, both
sides a dorsal rod was bended to accept the
alignment of the dorsal curvature and fixed to
the occipital rods. Using dorsal sublaminar
hooks, the right rod was fixed with distraction
between the D3 and D6 laminae. The left side was
fixed, using the sublaminar hooks between D3 and
D5 with compression.
Check image-intensifier was
performed all the time and an acceptable, even
not complete reduction of the scoliotic
deformity was achieved and the IOM was showing
all the way acceptable data.
Routine closure of the wound
and the blood loss was around 750 ml and the
patient received 2 units of blood.
The patient was awake and
responded to verbal stimuli and moved all limbs
in the same position.
The endotrachial tube still
in place, turning of the patient to the ward bed
Immediately, after turning
the patient, he became cyanosed and massive
pulmonary edema with cardiac arrest took place.
Despite the performance of all resuscitative
measures during 90 min, no cardiac rhythm could
be achieved and death was recorded at 22.45 p.m.
The length of the operation
was around 11 hours.
The patient is a young chap,
and it is hard to believe that, massive
pulmonary edema could lead to such catastrophe
as in this case.
IOM could keep under
observation, the neurological status of the
patient during surgery, but the unexpected event
such as massive pulmonary edema with
irreversible cardiac arrest are not included in
We are planning to have the
BrainLab suite, but the essential part it will
be the whole body MRI with the 3 tesla with
whole body MRV and MRA, to avoid such events and
in the future, these protocols must be
implemented to avoid such sad scenarios.