The 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 Lhermitte's sign  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 image-intensifier.

Routine closure of the wound.

Smooth postoperative recovery, but 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 recent event.

In the industry, there are a lot of options to deal with such situation, and performing such a procedure is one of the acceptable options.

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.

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.

The case is supporting the data published by Drummond et.al.

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.