The patient came to the clinic 09-April-2012 complaining of  LBP for 18 years with left sciatica. The condition deteriorated the last 4 years and she is unable to walk more than 200 meters. MRI lumbar spine done 25-June-2011 showing spondylolisthesis L3-4 with extruded disc L3-4 with left foraminal occlusion and bulge L4-5. 

On examination, the patient is limping with exaggerated scoliotic stance. SLRS was 90 degrees in both sides with tightness. There is almost drop both feet with weak planterflexion -4/5 with absent AJ both sides.

The patient sent for new investigations and MRI lumbar spine done 13-April-2012 showing the same data as before.

Decompressive laminectomy L3, L4 and upper half of L5. Foraminotomy L4, L5 roots both sides. Discectomy L3-4 from the left with insertion of TLIF cage 9x10x28 mm dimensions with bone graft. Using Scientex Alphatec Spine system, Isobar TTL pedicular screw system,  2 polyaxial screws 6.2 x 40 mm inserted to the L4 body and 2 monoaxial 6.2x40 mm screws to the L3 body. The right pedicle of L5 received ployaxial screw and the left side a monoaxial one. During insertion of the right L3 pedicular screw the first turn was noted to cut the lateral wall of the root. It was removed and the 2 mm surgical cut was stitched by 6 zero nylon.  The position of the screw was corrected to be away from the root. Using bended 2 rods 5.5 mm thickness and connector, fusion of L3,4 and L5 was done. Mild compression was applied between L3 and L4 level. All surgical steps were done with image-intensifier. The ISIS Inomed navigation was ready to use, but it was not performed, because the roots were brought to under direct visual control.

Routine closure of the wound. Smooth postoperative recovery. The power of both feet became better.

The patient has spondylolisthesis of L3-4. It needs correction and fixation. The small extruded disc L4-5 was included in the operative activity to avoid future escalation of this segment after fixation of the above level.