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 space.

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 and identified.

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 was performed.

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 this monitoring.

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.

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