The patient a Yemeni citizen came to the clinic 30-June-2012 complaining of LBP for 4 months with bilateral sciatica more the right.

The patient is a known diabetic for 20 years and he underwent surgery in Saudi Arabia 35 years ago for an extruded disc L3-4.

MRI lumbar spine done in Yemen 17-June-2012 showing huge recurrence of L3-4 with right downward migration. 

On examination, the patient is limping using crutches with exaggerated scoliotic stance. SLRS was 90 degrees in the right with weakness and 90 degrees in the left with pain. There is weak dorsiflexion right foot -3/5 and planterflexion same foot 3/5 with absent AJ both sides. Weak right quadriceps 3/5  and abduction both knees 3/5 and dorsi and planterflexion left foot 3/5. There is hypalgesia right L5 root territory. There is brisk Babinski in the right side and questionable one in the left.

The patient was sent to MRI investigation, which was done 01-July-2012 showing normal MRI of the dorsal spine with extruded disc L3-4  with right downward migration with retrolisthesis L3-4. Dynamic studies confirm the instability of the retrolisthesis. Bone scan showed only increase uptake of the left tibia at the ankle due to old trauma. The patient had Hb 9.0 for what 1 unit of blood was given before surgery and the another planned to be given during surgery.

The old wound used with slight extension upward to skeletonize the L3 and partial of L2. The L2-3 and L3-4 lateral masses exposed until the transverse processes of L3 and L4 were seen both sides. The right L4 root was identified after scarolysis and the huge downward migrating recurrence was removed from under axilla and the lateral to the axilla. The disc space of L3-4 was cleaned from the right side and TLIF cage 8x5x30 mm with bone graft were inserted to the L3-4 disc space. Using IsoBar Scientex pedicular screw system, 6.2x40 mm monoaxial screws were inserted to the L4 body and 6.2x40 mm ployaxial screws were inserted to L3 body. ISIS Inomed transpedicular screw protocol was used and the root was responding only to 4 mA. Using up to 15 mA DNS did not got any response from the screws. Using 55 mm bended rods and two DLT straddler connecting bars were used to fix the 2 rods by 40 mm connector. All stages of surgery were done under image-intensifier control.

Routine closure of the wound. Smooth postoperative recovery with dramatic improvement of the power of both legs.

The patient have several problems which needs surgical correction. That is the huge extrusion and the instability.