The patient came to the clinic 17-May-2014 complaining of neck pain for 2 years with left upper limb pain and numbness I and II fingers left hand for 2 months. MRI cervical spine done 02-May-2013 showing extruded disc C4-5 and C5-6 with left foraminal occlusion. MRI cervical spine repeated 17-April-2014 showing the same extrusions and assimilation of C7 and D1.

On examination; The patient has weak grip and extension of fingers  and left triceps muscle 3/5.There is hypalgesia of the left C5,6,7 roots to include the median territory left hand.

Discectomy of C5-6 and C4-5. During intradiscal removal of C4-5 CSF came out. The head was put slightly down. The discectomy of C4-5 was continued until the dura was seen. There was a pin-point dural defect, which seem that it was adherent to disc material during intradiscal removal. Coagulation of the point did not stop the leak, which hold possibility of presence of other points. The dura was very thin. The CSF leak stopped and a Samarys cervical cage 17x13x5 was inserted to the C4-5 disc space with Stryker BoneSave, which snuggly filled the space to prevent possible postoperative CSF leak. Another cage 17x15x6 mm was inserted to C5-6. Using Trestle cervical plate 2 level 30 mm and 2 fixed 4x14 screws applied to C5 and 2 variable 4x14 mm screws to  C4 and 6, Fusion of C4-5 and C6 done with guidance of C-arm. Routine closure of the wound.

Smooth postoperative recovery. The power of the both upper limbs dramatically improved.

The patient mostly have an old inflammatory process, that the intradiscal material was adherent not only with annulus fibrosis, but extended beyond to be adherent to the dura. Discectomy still not reaching the annulus fibrosis, triggered CSF leak. This event I am seeing the first time during 35 experience. Discectomy was continued and the very transparent dura was seen and having pin-point dural defect. Putting a piece of muscle was not done, because the cage itself will provide a sort of closure and it is not clear how the cage will push the piece of the muscle if it was inserted.