The patient is a Syrian citizen suffered gun shoot in Deraa Ocotber-2013, after what he was paralyzed below D10 and had severe destruction of L5 with longitudinal fracture of the sacrum with bullet anterior to the sacrum from the right side. He was operated urgently for internal bleeding 2 times within the first 3 days and then the bullet was removed with laparoscopic facility after one month. The patient was treated several months for severe infection and osteomyelitis.

On examination: The patient can walk with crutches, has anaesthesia at both L5, S1 roots  and around the anal region. There is dripping of urine but can control defecation. Weak dorsiflexion right foot -3/5, +3/5 left foot. Weak planterflexion right foot -3/5, +3/5 left foot.

The patient was sent for new MRI lumbar spine, which done 22-May-2013 showing resorption of 2/3 of L5 body with massive scar at L4, 5 and S1 area. ESR was 3 mm/h, CRP was negative.

Decompressive laminectomy L4, L5 with foraminotomy L5, S1 roots both sides with neurolysis of the massive scars. Using Isobar TTL module in, transpedicular fixation L4, L5, S1 was done. 6.2x40 mm monoaxial screws were used for L4, L5 bodies. 6.2x45 polyaxial screws were used for S1 level. 2 rods 5.5x60 mm bended to adopt the curve of the local area with Easys cross connector. Vitoss bone graft was aided lateral to the rods. All stages of surgery were done with C-arm control.

Routine closure of the wound. Smooth postoperative recovery. The patient  power and sensation both feet improved.

The patient has an acceptable alignment of L5 body, for what fusion must be achieved. During this neurolysis is a welcome step.

TLIF cage was not used, to avoid future escalation of infection.