The patient came to the clinic 15-November-2006 with left sciatica and LBP for 2 years with exacerbation of the left sciatica the last 2 weeks and inability to walk without help.

The patient is a known hypertensive with diabetes mellitus, rheumatoid and gout. Total knee replacement was done 2002 and 2006. The patient was limping with scoliotic stance.

On examination: the SLRS was 45 degrees in the left with weak dorsiflexion left foot 3/5. She had weak muscles four limbs -  4/5.

The patient was sent for investigation: MRI cervical spine performed 16-November-2006 showed PCD C5-6. MRI lumbar spine showed LCS L4-5 with spondylolisthesis L4-5 I degree by Meyrding. She had severe osteoporosis.

The patient was given medications and if she is not improving, then surgical treatment will be the alternative.

The patient then came 03-November-2007 with deterioration of her condition and heamarthrosis of the left knee due to heparin overdose  for three months.

SLRS was 5 degrees in both sides with drop left foot  and the left knee still swollen. She was bedridden for more than 6 months.

The patient was sent another time for investigations, which confirmed the increase of the stenotic component at L4-5 level.

Bilateral foraminotomy of L5 roots was performed and preservation of the spinous processii and interspinous ligament also. The compressing elements were removed, so that, all the compressed neural structures were released and the elements of instability were not violated.

The bone chips were used to obtain lateral fusion between the transverse processii.

Routine closure of the wound and smooth postoperative recovery with improvement of the power of both lower limbs.

The patient has a lot of medical problems, making hard what exactly most proper for her. The decompression with preservation of all bony and ligamentous structures is the only proper solution for such a case.

Using small instruments and different angles of bony decompression, it is possible to release all the neural structures with simultaneous preservation of all elements of stability.