The patient came 13-February-2013 complaining of LBP with bilateral sciatica for 20 years. He was operated 16 years ago for ganglion right L5-S1 facet. He go exacerbation of LBP with bilateral sciatica and numbness more to the right the last month with inability walk due to severe pain. The patient is hypertensive for 8 years.

On examination: SLRS was 60 degrees in the right with pain and 60 degrees in the left without pain. There is weak dorsiflexion both feet 4/5 and planterflexion right foot 4/5.

MRI lumbar spine done 12-February-2013 showing lumbar canal stenosis L3-4, L4-5 and L5-S1 with extruded disc L4-5 more to the left and L5-S1 with right downward migration with spondylolisthesis L3-4 and L4-5 .

Decompressive laminectomy L3, 4, 5 and upper sacrum and flavotomy L2-3. Foraminotomy right S1 and left L5 roots. There is a scar at the right L5 root axilla, which mostly due to previous surgery. The extruded disc of L5-S1 was hard in consistency and it was removed to decompress the right S1 root. The disc space of L5-S1 was very shallow, that it was impossible to perform intradiscal cleaning. The disc of L4-5 was cleaned from the left side and TLIF cage Novel TL 7x5x12x21 mm was inserted from the right side. Bone graft BCB was inserted to the disc space. Six polyaxial Isobar Scientex 6.2x40 mm transpedicular screws were inserted to the L3, L5 and S1 with the aid of C-arm. 2 monoaxial 6.2x45 mm screws were inserted to L4 body. 2 bended rods 5.5 mm thickness were used to fuse L3,4,5 and S1. Cross connector was added to achieve more stability to the construct. Slight distraction was done from the right side  to correct the scoliotic deformity. Further bone graft was applied lateral to the rods.

Routine closure of the wound. Smooth postoperative recovery. The power of left foot became normal and planterflexion right. Still have weak dorsiflexion right foot 4/5.

The patient had several problems which all need surgical correction: Lumbar canal stenosis when progressive needs surgical intervention. The earlier the surgery the better the outcome. Spondylolisthesis also needs fusion. The extruded disc must be cleaned to resolve the extrusion compression to the running roots.