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Dr. Ali Al-Bayyati and Dr. Munir Elias

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

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06-OCTOBER-2012  AMAL MUHAMED ALFAQIR  48 YEARS  FAILED NECK SYNDROME AFTER SEVERAL SURGERIES.

 

Anamnesis

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The patient came 20-August-2005 complaining of severe neck pain with bilateral radicular syndrome for more than 15 years. Exacerbation for the last 4-5 months with inability to rotate the head for all directions and fainting attacks with weak grip, extension and triceps both upper limbs with hypalgesia of the left C4 and 5 dermatomes. The patient was operated 24-August-2005 and discectomy of the C4-5 disc done, where a fresh fragment came from a defect in the PLL after applying traction and the C5-6 was old, requiring drilling with osteophytectomy. Syntex cervical miniplate with 6 screws 14 mm length were applied to fuse the C4-5-6 with traction of 12 Kg applied during that.
The patient showed dramatic improvement of her neurological deficit, but she came 15-October-2005 claiming of left sided hemihyplagesia without motor deficit. Migraine was considered as the cause of her complains and she was sent for MRI of the brain and MRA of the brain and carotids, which proved to be normal.
The patient escaped and reappeared 27-October-2006 after undergoing elsewhere, left CT release and an incision in the posterior aspect of the cervical spine with severe atrophy of the the paraspinal muscles left side with agonizing pain, that it was impossible to touch her left upper limb. No documents available explaining what was done in the posterior cervical spine. Sympathetically mediated pain was suspected.
All the time check MRI of the cervical spine was performed, confirming that the construct is in place and no compression was noted.
The patient came 28-August-2007 with severe bilateral radicular pain more severe in the left side with frozen shoulder both sides . She felt down 06-May-2007 with fracture right foot and underwent hysterectomy 18-August-2007. SLRS was 20 degrees both sides and she was sent for MRI lumbar spine and dynamic study for the cervical spine was requested 01-September-2007.
MRI lumbar spine showed bulge disc L4-5. X-rays of the cervical spine showed missing lateral masses of the left C4-5 and C5-6.
It became clear that the next surgery was wide foraminotomy for left C5 and C6 roots without leaving any bony elements to preserve stability of the cervical spine.
Several times a detailed discussion was performed with her and her husband, that the patient has multiple problems and the only surgical interventions, which could be suggested is posterior fusion for the posterior instability of the spine and left sided sympathectomy for the sympathetically mediated pain.
Both agreed and understood the situation and they were willing to proceed with surgical treatment.
The surgery was performed 18-October-2007 in the supine position, under the electrophysiological control using ISIS Highline Inomed SEP - EMG protocol.
Skeletonization of C3 down to D3 was performed. It was noticed that overmobility of the cervical spine was maximal at C7-D1 and C4-5 levels. The lateral masses of left C4-5 and C5-6 were missing.
Sympathectomy of left upper dorsal D2 and D3 was performed. Both ganglia with their rami albicans and greysii were removed in one block and the satellite rami were also coagulated and bisected.
Using OA System Stryker lateral mass screws 12 mm length, under image-guided intensifier the normally looking C3-4 both sides masses were used for upper fixation. The C6 lateral masses were also used for insertion the middle row. The infer row was the insertion of 18 mm length transpedicular screws to the body of D1. Using rods and bridge the posterior fusion was achieved after performing slight distraction of the left rod to resolve possible collapse and compression of the nerves in the left side.
Routine closure with smooth postoperative recovery.
The patient came to the clinic 05-February-2008 still complaining of agonizing neck pain and unable to move her left upper limb. CT-scan performed 05-December-2007 showing good alignment of the four lower screws, but with partial slipping of the upper two screws. She was advised to keep in medications and protelose to accelerate the bony fusion.
The patient was advised to be seen after 4-5 months.
MRI lumbar spine performed 22-April-2008 showed good alignment of the spinal cord and the bony structures, but did not gave information about the position of the posterior fusion screws.
The patient then came 17-May-2008 and there was some improvement of her condition, but limitation of the neck movements and the feeling that the upper screws are pushing the upper cervical spine anteriorly, causing massive muscle spasm.
The patient was sent for CT-scan of the cervical spine and simple cervical X-rays, which confirmed further slipping of the upper screws.
Considering that, a sufficient time elapsed since the last surgery, and the necessity of the upper screws is null and in contrary, they are causing such muscle spasm and limitation of neck movement, the patient was advised to undergo partial removal of the upper third of the construct.
In the laminectomy position, 24-May 2008, posterior approach was refreshed and the rods were exposed, just above the level of the middle screws. The connecting bridge was removed. Drilling of the rods was performed, as demonstrated in the postoperative pictures. The flail screws were removed together with rods.
Routine closure of the wound with smooth postoperative recovery.
The patient showed dramatic improvement after the surgery, that myself could not believe in that. With gradual decrease of pain killers.
The patient came to the clinic 29-July-2009 complaining increased pain in the left shoulder with limitation of neck movement. She underwent several surgeries for her cervical spine with anterior and posterior fixation.
The patient was advised to repeat cervical X-rays of the spine and CT-scan of the cervical spine with 3D reconstruction.
The devices were in place and no convincing data were to be suggested surgically, for what block of the left C6-7-8 was suggested.
Under G.A. with the use of image-intensifier the left lateral mass of C5 was reached and using marcain 0.25% with Diprofos was injected there and 1cm away. The second target was the left lateral mass of C7 and the third was the lower left screw 1 cm lateral to it. The total volume was 2 vials of Diprofos and 40 ml of marcain.
Upon weaning of the patient, she progressed respiratory failure, for what reintubation was performed and waiting for 60 min until she became alert and acceptable respiratory drive. The paresis of the left upper limb persisted for 5-6 hours with pain free in the left shoulder.
The patient then came several times complaining of agonizing pain of the left shoulder and several investigations were performed and the only non-destructive solution - spinal cord stimulation to the C3-5 levels was suggested. For more information about the suggested procedure please visit: https://www.functionalneurosurgery.net/spinalcordstimulation.htm
The patient then came 16-July-2011 complaining of the same agonizing left upper limb and the only solution was suggested to undergo insertion of neurostimulator implant device to the C3-5 level, since no other destructive options remain in the recent status of neurosurgery.
The patient was reevaluated 16-January-2012 and CT-scan with MRI of the cervicodorsal spine was performed 18-Jaunary-2012 which ruled out the presence of any loosening of the fixating devices. Now she is receiving Lyrica 150 mg twice daily, Nexium 40 mg once daily for long time.
The patient against my personal advice underwent surgical removal of the posterior fusion in Bahrain after what her condition deteriorated more.

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MRI of the cervical spine done 26-June-2012 showing mild concavity at C5-6. CT-scan showed absent lateral masses at left C4-5, C5-6 and C6-7 with questionable status of C3-4.

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On examination, the patient dramatically deteriorated after removal of the posterior fixation. After long evaluation and studying the case it was decided to stabilize the whole area anteriorly.

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The old anterior incision was refreshed and exposure and removal of the Syntex plate was achieved. Discectomy of C3-4 and C6-7 was done. A Scientex Alphatec Spine cage 17x15x5 mm was inserted to the C3-4 level. Another cage 17x15x7 mm cage was inserted to C6-7 level. Trestle cervical plate 4 level 69 mm length was used to fuse the C3-4-5-6-7 levels. 4 screws 4.5x14 mm were used for C3 and C4. 4 screws 4.0x14 mm were used for C5 and C7 bodies. All stages of surgery were done with C-arm control.

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Routine closure of the wound. Smooth postoperative recovery.

 

Please! wait for 3-5 min till the video start to load. It depends upon the internet connection.

Comments

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The patient underwent several surgeries and the main complain is due to instability of C3-4 and C6-7 in the left side. Doing surgery from behind was estimated to be the less optimal solution. Anterior fusion of C3-7 is the best option to eliminate micromotion in the lateral masses of the involved segments.

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There is problem with most medical companies, that they are lacking support for their old versions. When trying to remove an old Zimmer product, the new screw driver will not be able to remove the old implant. So the Syntex Alphatec Spine as happened in this case. The companies and their dealers must take this problem into consideration and not to put the surgeon in a miserable condition, trying to resolve his problem by his own means.

Conclusion

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The patient underwent several surgeries and the major problem was after the second surgery performed elsewhere. The surgeon refused to tell the patient what he did, but after several investigations it seems the he drilled out most of the C6-7, C5-6, C4-5 left lateral mass and to lesser degree of the C3-4. This kind of surgery is missing in the medical archives and it triggered disaster to the patient and confusion to the surgeons.

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Trying to fuse the segments from behind gave only partial improvement. Removing the fusion device in the last surgery triggered the problem.

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During this surgery after removal of the old construct, it became clear that the C4-5-6 bodies were calcified in one piece. This gave the conclusion that the major pain generator was the C6-7 totally eaten lateral mass  and C3-4 both in the left side. Fusing of C3 down to C7 gave a dramatic improvement of the patient and she no more complaining of her agonizing pain in her left upper limb.

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This case is rare and to reach to the ideal solution required a lot of reinvestigations and surgeries to reach.

 

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Notice: Not all operative activities can be recorded due to lack of time.
Notice: Head injuries and very urgent surgeries are also escaped from the plan .

  

 

 

 

 

 

 

 

 

 

 

 

 

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[2012] [CNS CLINIC - NEUROSURGERY - JORDAN]. All rights reserved