The patient admitted to Shmaisani hospital transferred from Aqaba 12-May-2011 after suffering falling down 12 meters in elevator work with minor head injury and burst fracture L4 with bone compression and fracture both bones both forelegs. This event was happened 11-May-2011.

On examination: the patient in bed with POP above knee both forelegs and Foley's catheter with stable vital signs. The patient is unable to move his left toes up and down with severe weak dorsi and planterflexion right foot 2/5. There is hypalgesia right L5, S1 and below right side with analgesia left side. There is cauda equina syndrome.

Skeletonization of L3-4-5 laminae and facet joints with preservation of the intraspinous ligament. Using Expedium Depuy Spinal system 2 polyaxial screws 6X45 mm were inserted to L5 pedicles. 2 monoaxial pedicles 6X45 mm were inserted to L3 pedicles. Titanium 5.5 mm 60 mm length were used and loosely fixed to the screws by the Inne set. Using distraction for around 18-20 mm, the rods were tightened to the screws. Control X-ray showed complete reduction of the bony alignments. CrossLink connector was used to aid stability of both rods. 40 cc BoneSave was used.

Routine closure of the wound. The orthopedic team started their surgery for the forelegs.

The fracture of L4 is unstable and causing severe bony compression with cauda equina syndrome. Open reduction is mandatory with fusion. In this case distraction could achieve good reduction of the bony elements. If this goal was not achieved, then special measures must be performed to decompress the spinal canal.