The patient came to the clinic 30-August-2014 complaining of LBP for 15 years with right sciatica for 2 years with exacerbation of LBP.

On examination; the patient is not limping with exaggerated scoliotic stance. SLRS was 80 degrees right side with pain. Dorsiflexion right foot 4/5. The patient was sent for investigations and done the same day: Cervical MRI showing bulge multiple disci of no clinical significance. Lumbar spine showing II degree spondylolisthesis L4-5. Dynamic studies confirming these data with isthmolysis L4-5 both sides.

Skeletonization of L3,4 and L5. Decompressive laminectomy L4 with upper fourth of L5 and foraminotomy both L5 root. The lamina of L4 was completely flail due to bilateral isthmolysis. Discectomy of L4-5 with right sided insertion of TLIF cage 9x25x10x4⁰ . Using XIA 3 2 long polyaxial screws inserted to L4 and 2 monoaxial screws to L5 with 6.5x45 mm dimensions. Using Inomed ISIS the roots were responding well to 1-2 mA DNS stimulation. The screws were not responding even to 15 mA DNS. Only local muscle response was seen due to leakage of the current to nearby muscles. 5 cm rods bended to accept the natural curve of the spine were applied and MAC cross connector 38 mm were used to fuse L4-5 level with slight compression more from the right. The harvested bone was melted and applied near the TLIF inside the disc cavity and lateral to the rods. Routine closure of the wound.

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

The patient had spondylolisthesis and isthmolysis  with complete flail segment. Surgical stabilization after decompression is the only solution.