A 27 years old female patient presented with kyphotic deformity of 86.6 degree at the thoracolumbar area from thoracal (Th)10 - Lumbar (L) 2, with destruction of Th11, 12, and L1 due to spine tuberculosis as demonstrated in Fig. 1. Preoperative evaluation showed her neurologic status was without abnormality. She underwent laminectomies, PVCR, one level Smith Peterson Osteotomy (SPO), posterior instrumentation by pedicle screws from Th 8,9,10 and L2,3,4, and fusion by local bone graft.
Intraoperatively, the intraoperative nerve monitoring (IONM) showed normal finding without any disturbance, with SSEP (somatosensory-evoked potential) and TcMEP (trans cranial motor-evoked potential) values were as baseline and FrEMG (free-running electromyography) value was without spontaneous activity throughout the operative procedure (Fig. 2). Pedicle screws insertion were confirmed by fluoroscopic guidance and were in good position, the correction was performed by cantilever technique. After the procedure, there were no pathological changes in SSEP, and TcMEP was preserved. A piece of absorbable gelatin sponge approximately in the size of laminectomy defect was applied over the exposed dura in order to control bleeding and prevent adhesion of soft tissues. During surgery the haemodynamic was good. Blood loss during surgery was 1500 cc, and packed cells replacement of 1500 cc was given. The wound was closed and a drain was placed properly beforehand. Five h postoperatively after patient woke up, motoric power grade 5 was scored for both lower extremities with no abnormalities and with good hemodynamic status. Drain output was recorded to be 480 cc for 24 h, with continuous flow and with no obstruction.
Early during postoperative care within 24 h, patient showed gradual neurological deficit. In left lower extremity, the muscle power decreased from grade 5 to 2, whereas the muscle power of right lower extremity was still normal. Within 48 h after surgery, the muscle power score of 2 involved the right lower extremity, following the contralateral side.