The patient came to the clinic 21-November-2017 complaining of difficult walking for 1 years with ataxic gait. His relatives came first 27-September-2017 telling that he he has bilateral sciatica with "fainting attacks". MRI lumbar spine performed 19-October-2016 showing minimal spondylolisthesis L5-S1. Creatinine Kinase was 2365 U/L and ESR was 30 mm/h. EMG done 06-Novemebr-2016 demonstrating sensory  and motor axonal neuropathy. The patient in Kuwait. The sons of the patient were advised to be reevaluated there to rule out UMN disease. The patient then came with MRI of the brain performed 07-October-2017 showing mild brain atrophy compatible with age. MRI of the cervical spine showing as be extruded disc C3-4, 4-5 with severe spinal cord compression and malacia of the spinal cord at C3-4 level. There is assimilation of C6+7.  The patient is a known diabetic for 20 years with arterial hypertension for 10 years.

On examination; the patient is walking with help and using crutches. There is weak both deltoid , biceps brachii 4/5. Flexion and extension both hands -4/5 with the right hand weaker then the left. Both triceps 3/5. The right quadriceps muscle power -4/5, the left 4/5. Abduction of the right Knee was 3/4, left -4/5. Adduction both knees 4/5. Drop both feet with weak planterflexion right foot -3/5 and left 4/5. Sensation for pin-brick was normal. Hoffmann was positive both sides with SLRS of the right side 60 degrees due weakness. The right KJ was exaggerated. 

The patient was sent for investigation. MRI whole spine was performed 22-November-2017 and showed severe cervical stenosis C3-4  more from the posterior elements with malacia of the spinal cord and to lesser degree stenosis of the C4-5. There is assimilation of C4-5-6. Dorsal spine showed PDD D2-3. Lumbar spine showed stenosis of  L4-5 and L5-S1. Dynamic studies ruled out presence of overmobility. ESR was 95 mm/h and CRP was 20 mg/L. Zinnat 500 mg twice daily was started and the patient was sent for cardiac evaluation.

Skeletonization of lower part ofC2, complete of C3,4 and upper part of C5. Decompressive laminectomy of C3 and C4 was performed after drilling of the bone until it became transparent and started to bulge out by itself. Routine closure of the wound.

Smooth postoperative recovery. The power of the upper limb normalized and dramatic improvement of the lower limbs more the right, except the long standing bilateral drop feet. He was sent to the ward.

The patient having severe stenosis of the cervical spine with malacia of the spinal cord with progressive deterioration. Surgical decompression is the best solution to prevent further deterioration.

The fist MRI showed as be the patient needs anterior approach, but the last MRI confirmed that the best option is posterior approach.