Fig. 2

A 68-year-old man had numbness and acratia in the upper extremities and neurogenic claudication. Preoperative magnetic resonance imaging (MRI) showed listhesis at L4 and grade 3 stenosis at L4–5 (a, b) and disc herniation at C4–5 associated with grade 3 compression (c, d). The biceps brachii showed motor unit potentials (MUP) with a prolonged duration, increased amplitude, and a simple-mixed phase in the recruitment order (e). A bilateral tibial nerve H-reflex was not elicited (f). The simultaneous operation was performed using ACDF first and PLIF next, with protection of the neck collar (g). Postoperative x-ray of the whole spine showed internal fixators in both the cervical and lumber spine (h)