The authors report a case of man-in-the-barrel (MIB) syndrome occurring after an extensive revision involving thoracoilium instrumentation and fusion for iatrogenic and degenerative scoliosis, progressive kyphosis, and sagittal imbalance. Isolated brachial diplegia is a rare neurological finding often attributed to cerebral ischemia. It has not been previously reported in patients undergoing complex spine surgery. This 70-year-old woman, who had previously undergone T11-S1 fusion for lumbar stenosis and scoliosis, presented with increased difficulty walking and with back pain. She had junctional kyphosis and L5-S1 pseudarthrosis and required revision fusion extending from T-3 to the ilium. In the early postoperative period, she experienced a 30-minute episode of substantial hypotension. She developed delirium and isolated brachial diplegia, consistent with MIB syndrome. Multiple studies were performed to assess the origin of this brachial diplegia. There was no definitive radiological evidence of any causative lesion. After a few days, her cognitive function returned to normal and she regained the ability to move her arms. After several weeks of rehabilitation, she recovered completely. Man-in-the-barrel syndrome is a rare neurological entity. It can result from various mechanisms but most commonly seems to be related to ischemia and is potentially reversible.96566569Bell, H.S., Paralysis of both arms from injury of the upper portion of the pyramidal decussation: "cruciate paralysis" (1970) J Neurosurg, 33, pp. 376-380Benito-Leon, J., Munoz, A., Ruiz, J., Gomez-Fuentes, J.R., 'man-in-the-barrel' syndrome: Mri and spect imaging (1997) European Journal of Radiology, 24 (3), pp. 260-262. , DOI 10.1016/S0720-048X(96)01119-9, PII S0720048X96011199Berg, D., Mullges, W., Koltzenburg, M., Bendszus, M., Reiners, K., Man-in-the-barrel syndrome caused by cervical spinal cord infarction (1998) Acta Neurologica Scandinavica, 97 (6), pp. 417-419Bhatoe, H.S., Multicentric glioma presenting as man-in-the-barrel syndrome (2005) Neurol India, 53, pp. 371-372Clerget, L., Lenfant, F., Roy, H., Giroud, M., Salem, D.B., Freysz, M., Man-in-the-Barrel syndrome after hemorrhagic shock (2003) Journal of Trauma - Injury, Infection and Critical Care, 54 (1), pp. 183-186. , DOI 10.1097/00005373-200301000-00024Crisostomo, E.A., Suslavich, F.J., Man-in-the-barrel syndrome associated with closed head injury (1994) J Neuroimaging, 4, pp. 116-117Deleu, D., Salim, K., Mesraoua, B., El Siddig, A., Al Hail, H., Hanssens, Y., "Man-in-the-barrel" syndrome as delayed manifestation of extrapontine and central pontine myelinolysis: Beneficial effect of intravenous immunoglobulin (2005) Journal of the Neurological Sciences, 237 (1-2), pp. 103-106. , DOI 10.1016/j.jns.2005.05.012, PII S0022510X05001930Dide, M.L.J., La diplegie brachiale spasmodique consecutive aux blessures par coups de feu de la region cervicale (1917) Progr Med (Paris), 1, pp. 1-3Elting, J.W., Haaxma, R., Sulter, G., De Keyser, J., Predicting outcome from coma: Man-in-the-barrel syndrome as potential pitfall (2000) Clinical Neurology and Neurosurgery, 102 (1), pp. 23-25. , DOI 10.1016/S0303-8467(99)00067-0, PII S0303846799000670Georgiadis, D., Schulte-Mattler, W.J., Cruciate paralysis or man-in-the-barrel syndrome? Report of a case of brachial diplegia (2002) Acta Neurologica Scandinavica, 105 (4), pp. 337-340. , DOI 10.1034/j.1600-0404.2002.1c127.xHurley, J.P., Wood, A.E., Isolated man-in-the-barrel syndrome following cardiac surgery (1993) Thorac Cardiovasc Surg, 41, pp. 252-254Katz, J.S., Wolfe, G.I., Andersson, P.B., Saperstein, D.S., Elliott, J.L., Nations, S.P., Brachial amyotrophic diplegia: A slowly progressive motor neuron disorder (1999) Neurology, 53, pp. 1071-1076Mohr, J., Distal Field Infarction (1969) Neurology (Minneap), 12, p. 279Moore, A.P., Humphrey, P.R., Man-in-the-barrel syndrome caused by cerebral metastases (1989) Neurology, 39, pp. 1134-1135Olejniczak, P.G., Ellenberg, M.R., Eilender, L.M., Muszynski, C.T., Man-in-the-barrel syndrome in a noncomatose patient: A case report (1991) Arch Phys Med Rehabil, 72, pp. 1021-1023Paulin, M., De Seze, J., Wyremblewski, P., Zephir, H., Leys, D., Vermersch, P., Man-in-the-barrel syndrome caused by a pontine lesion (2005) Neurology, 64 (10), p. 1703. , DOI 10.1212/01.WNL.0000149910.96498.46Sage, J.I., Van Uitert, R.L., Man-in-the-barrel syndrome (1986) Neurology, 36, pp. 1102-1103Shaw, P.J., Tharakaram, S., Mandal, S.K., Brachial diplegia as a sequel to cardio-respiratory arrest: 'man-in-the-barrel syndrome' (1990) Postgrad Med J, 66, p. 788Wahl, C.C., "Man-in-the-barrel" syndrome after endoscopic sinus surgery (1998) Anesth Analg, 87, pp. 1196-1198Yerdelen, D.M.K., Mehmet, M.D., Pourbagher, Aysin, M.D., "Man-in-the-Barrel Syndrome" owing to cervical spinal cord metastases: Case Report and Review (2008) Neurosurg Q, 18, pp. 74-76