A 51-year-old lady presented with left arm pain more than neck pain for 10 years. Her BMI was 35 and she had a short neck, nearly the chin touching the chest. Examination revealed no apparent signs of myelopathy but restricted range of motion of the cervical spine.

X-ray revealed advanced degenerative changes with 20° kyphosis. MRI showed cervical spondylotic myelopathy with cord signal changes at C5. CT scan revealed segmental OPLL from C3–C6 with a high probability of intradural OPLL mass (double density sign).

Although conventional wisdom suggested anterior surgery (due to K-line, kyphosis, anterior pathology), the risk of dural laceration and complications like pseudomeningocele or meningitis led to a decision for posterior decompression and fixation.

Pre-op CT angio showed bilateral high-riding vertebral arteries, so C2 pars/pedicle screws were avoided. The patient was positioned prone; LM screw entry points made at C3–6 with Grade 1 facet resection at C3–4, C4–5, and C5–6 bilaterally. Further lordosis was achieved via head manipulation and osteotomy gap closure.

LM screws (C3–6), a laminar screw at C2, and pedicle screws at T1–T2 were connected with rods. A C3–6 laminectomy was performed and bone graft mixed with vancomycin was applied laterally.

Post-op X-ray showed adequate lordosis (~10°). The patient reported complete pain relief in the left shoulder and arm. On day 4, mild C5 palsy (left elbow flexion weakness) was observed, which resolved by day 10 with full recovery and complete relief of pre-operative arm pain.