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The group in action.

 
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.fr

 
21-JUNE-2006 KHALEEL RASHID HMAMY 72 YEARS SEVERE CCS WITH OPLL AND COMPRESSION AT C3-4, C4-5 AND C5-6 LEVELS.
The patient came came to the clinic 08-August-2004 complaining of neck pain for 30 years with difficulty in walking and micturition problems. He was operated 1977 in Germany for anterior decompression at C5-6, after what he improved. Stenting of the coronaries 1999. The last 18 months, he showed gradual deterioration. On examination, the gait was shuffling, but Romberg was stable. He had weak grip, extension and triceps both upper limbs with hypalgesia of median nerve distribution both sides. He had limitation of neck movement to all directions. Hoffman sign was positive both sides. Babinski was positive in the left side  with exaggerated deep reflexes both lower limbs and weak quadriceps fomoris and dorsi and planterflexion of the right foot. The old incision was strikingly low, as the incision usually used 2 cm above the right clavicle for the TOS syndrome. 

The patient was sent to investigations  and the wife came came back 06-December-2005 with MRI of the cervical spine showing severe cervical canal stenosis at C3-4, C4-5 and C5-6 levels. The pros and cons of surgery were explained to the family and they disappeared another time.

The patient came 10-June-2006 with rapid deterioration of his condition with almost quadriparesis below C4  and dripping urine for the last month. The patient was advised to undergo surgery.

Through anterior approach corporectomy of C4-5-6 was done and the hypertrophied OPLL was removed. A small bridge was left  intentionally in the C4 body about 7 mm height and 3 mm thickness to prevent slipping of the 55 mm length remolded fibular graft harvested from the right leg.  The graft was reconstructed to have some curvature resembling the curvature of the Hybrid Reflex cervical plate and first a 4 level 58 mm length was used and the fibular graft was attached to it by 2 screws  10 mm length.

The graft filled exactly the gap, but a problem came with screw fixation, since he had previous surgery and the fused and hypertrophied  and calcified anterior longitudinal ligament. Control images showed unacceptable alignment, for what it was necessary to remove the device and de novo use 78 mm length plate  and the construct with traction and additional remolding got acceptable position and acceptable screw fixation between C3 and C7.

Smooth postoperative recovery. The patient could walk and stay without falling the next postoperative day, and he noticed dramatic improvement of the sensation and power of four limbs.

The patient continued to improve neurologically and at the day of discharge  23-June-2006 start to complain of abdominal pain and distention. He passed stool at the morning of that day, but the pain continued to increase. The relatives told that he had similar attack several months ago. Surgical consultation was achieved and the patient was put under strict observation and CT-scan angiography ruled out mesenteric artery thrombosis, but the patient got severe distension and urgent laparatomy was performed 25-June-2006 , which confirmed the presence of acute necrotizing pancreatitis. The patient showed mild improvement of his homeodynamic parameters in ventilator, but the next day in the morning, he started to show multiorgan failure with cardiac arrest and death 13.35 am 26-June-2006.

Comments:

1. The patient operation took 8 hours. 4 hours of them to repeat the insertion of the construct, to be acceptable as seen in the below figures. If you see that, the construct is not satisfactory, do not hesitate to change it even it needs further efforts. It seems that, the artistic touch with engineering capabilities must be considered in such surgeries.

2. From previous surgeries with fibular grafts, do not  force the insertion of the screws for fixation of the device to the fibular graft. It happened that the fibula can easily break for 2 or 3 parallel fragments, if this done without taking precautions.

3. Using the high-speed drill the graft must remolded, so as to accept the cervical plate and at the same time, to keep it's strength.

3. Do not ever be happy about your early results of surgery. Be happy after one month at least, because your efforts are directed to improve the condition of the patient for acceptable period of survival. In this case even after detailed search to find any link between the surgery and the acute necrotizing pancreatitis, failed to show relation, even as triggering factor. Drug induced triggering could have place, but most of the patients receive the same protocol of treatment. At Last we are not the God to predict the future and refine the preoperative selection of the patients. The neurosurgical outcome was outstanding, but the neurosurgeon now in severe depression, knowing that the patient dying several days later from unpredictable cause coming accidentally at the day of discharge.

For theoretical information about OPLL. click here!

Cervical X-ray: AP view   Cervical X-ray: Lateral view.
22-June-2006 Postoperative control cervical X-ray showing the construct and the fibular graft.


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