The patient came to the clinic 03-April-2013 complaining of LBP with left sciatica. She performed bilateral carpal tunnel release 7 days ago with resection of basal cell carcinoma of the nose. The patient underwent total knee replacement 2003 and 2005. She underwent fixation of the spine with transpedicular screws of L3, L4 and L5 after what her condition deteriorated due to wrong screw placement of the left lower screw. The patient is using walker to ambulate. MRI of the lumbar spine done 17-March-2013 showing severe stenosis with spondylolisthesis of L4-5. The patient is a known diabetic for 35 years.

On examination: The patient is limping using walker and it is difficult to evaluate the scoliotic stance. Hoffman sign was positive both sides. SLRS was 45 degrees right side and 25 degrees in the left with pain. Babinski was positive both sides. Weak dorsiflexion left foot -4/5 and right foot 4/5 with weak planterflexion left foot 4/5. There is diabetic neuropathy both feet with decreased sensation below the ankle joints.

The patient was sent for more investigations. MRI of the brain and dorsal spine were uneventful. MRI of the cervical spine showed severe segmental stenosis C5-6 with malacia of the spinal cord at this level.

It was explained to the patient, that surgical elimination of the severe cervical stenosis taking precedence over the screws problems in the lower back.

Decompressive laminectomy of C4,5,6 and upper third of C7. During drilling a pin-point tear was noted at the left corner of C4. It was repaired with 4 zero nylon. The dura was very thin and there was no epidural fat with dura adherent to the connective tissues more to the left side. Check for CSF leak was negative.

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

The patient has several problems and the cervical stenosis taking precedence over others. It must be corrected first.