The patient a Yemeni citizen came to the clinic 17-March-2004 complaining of LBP for 4 months with exacerbation last month with with bilateral sciatica with pareasthesia and intermittent claudication. MRI lumbar spine performed 14-March-2004 showing extruded disc L4-5 with segmental instability with compression more the left side. The patient is hypertensive for 25 years and had non-Hodgkin lymphoma 5 years ago treated accordingly.

On examination: the patient is limping with exaggerated scoliotic stance. SLRS was 85 degrees in the right and 80 degrees in the left with pain. There is weak dorsi and planterflexion left foot 4/5 with hypalgesia left L5 territory.

The patient was sent for thorough investigations and there is wide based extruded disc L4-5 with fracture of the left L4-5 isthmus.

Foraminotomy both L5 roots with removal of the extrusion lateral to the axilla from both sides. After that, the roots became lax and bilateral intradiscal cleaning L4-5 disc space was done. Using miniscrews fusion of the fractured left isthmus was achieved and check for mobility was negative. The patient was put in Reverse Trendelenburg position with Valsalva maneuver and hyperventilation. No CSF leak. A fat with pedicle was transferred from the subcutaneous layer and covered the exposed parts of the root, to minimize postoperative scarring. Routine closure of the wound. Smooth postoperative recovery. The power of right foot normalized.

The patient came to the clinic 01-April-2004 with clean wound and SLRS 85 degrees left side without pain and normal power right foot and sensation.

The patient then came 18-April-2004  with the same condition. He was treated conservatively.

The patient then came 26-June-2005  with MRI done today showing no recurrence of L4-5. He was neurologically free.

The estimated postoperative recurrence is still ranking around 7%, because the disc space is still relatively not shallow.

This is the first surgery during which I am using miniscrews to fix the fractured isthmus.