The patient came to the clinic 24-January-2015 complaining of LBP for 3 years with right sciatica. Exacerbation of bilateral sciatica the last year more the left side. He can walk more than 1 Km but with pain. MRI lumbar spine done 23-April-2011 showing extruded disc L3-4 with huge right downward migration. LSS X-ray dynamic done 22-November-2014 showing vacuum phenomenon at the shallow L3-4 with spondylolisthesis L3-4 I degree. MRI lumbar spine done 24-November-2014 showing severe stenosis L3-4 with bulge all disci in the lumbar spine. Neck and left upper limb pain for 3 months.

On examination, the patient is in agonizing pain, limping with exaggerated scoliotic stance. There is pain when turning the head to the sides and downward. There is weak grip and extension left hand and the left triceps muscle 4/5. SLRS was 80 degrees with pain in the right. There is weak dorsi and planterflexion left foot 4/5.

Using C-arm the level of L3-4 was identified. Skeletonization of L3 L4 lateral to reach the transverse processii of L3 and L4. Using Medtronic Legacy system, 2 M.A. screws inserted to L3  6.5x45 mm and 2 F.A. screws to L4 6.5x45 mm. Laminectomy of L3 and upper third of L4 was performed with foraminotomy both L4 roots. The disc level was inspected from both sides. Cross connector was applied between the inserted rods 40x5.5 mm. The harvested bone was melted and applied lateral to the rods. Routine closure of the wound.

Smooth postoperative recovery. The power of the left foot became normal.

The patient has several bulges above and below. It is reasonable to include one nearby bulge to avoid future escalation, but including all the levels with fusion to prevent this added stress is not practical and meaningless. For that only the L3-4 was fused.