The patient came to the clinic 24-April-2013 complaining of LBP for 15 years with  numbness both feet and hands for 10 years. The patient is a known hypertensive in medications for 15 years. Cardiocath done 2011 was uneventful. In warfarin. lanoxine, aldactone and concor.

MRI of lumbar spine done 24-October-2010 showing old fracture of D12 with spondylolisthesis L4-5 and extruded disc L4-5 with central upward migration.

On examination: The patient is limping with exaggerated scoliotic stance. There is ganglion dorsal aspect of the right wrist. Edema both forelegs. Pain when turning the head to all directions. SLRS was 20 degrees right side with pain and 70 degrees in the left with less pain. There is weak dorsiflexion right foot 3/5.

The patient was sent for new investigations and MRI lumbar spine performed 27-April-2013 showing spondylolisthesis L3-4, L4-5 with severe segmental stenosis with extruded disc L4-5. The old fracture of D12 is the same. There are small bulge disc of the cervical spine. Treatment of gout was started.

Using C-arm, laminectomy L4, upper half L5 and Lower 2/3 of L3 was done with foraminotomy both L5 roots. Discectomy L4-5 with cleaning of the space with insertion of Novel TL TLIF cage 10x15x25 mm from the right side with Vitoss bone graft to both sides. Using Isobar TTL Module In, 6 polyaxial 65x45 mm screws, transpedicular screw fixation was done to L3,4 and L5 with bended rods 73 mm length and cross connector 80 mm length. The mentioned bone graft was inserted lateral to the rods.

Routine closure of the wound. Smooth postoperative recovery. The patient had atrial fibrillation during surgery and the patient was sedated accordingly.

The patient several spine problems, which need surgical correction.