The patient came to the clinic 29-November-2003 complaining of LBP with left sciatica for 15 days. She had also right knee pain for 6 months. MRI lumbar spine done 11-November-2003 showed extruded disc L4-5 with left upward migration. On examination at that time, she was limping with exaggerated scoliotic stance with SLRS 70 degrees in the left with pain. There was hypalgesia left L5 territory with weak dorsiflexion left foot 4/5. The patient was operated by me 01-December-2003. Discectomy L4-5 was done.  The patient then came 19-January-2005 complaining of neck pain with radicular pain to the right upper limb. She had swollen right foot. MRI cervical spine done 27-December-2005 showed small extrusions C5-6, C6-7. ANA was positive. The patient was treated conservatively. The patient then came 08-October-2008 complaining of right sciatica for one week and she was limping. She came 27-February-2013 complaining of right knee pain for three days with feeling of crack in the right knee. The patient was seen by orthopedic surgeon and treated conservatively for he right knee problem. The patient last came 12-October-2013 complaining of LBP with right sciatica for 5 days.

MRI lumbar spine done 07-October-2013 showing spondylolisthesis L4-5 with mild extrusions L3-4 and L5-S1.

On examination: the patient is limping, in agonizing pain, with exaggerated scoliotic stance. SLRS was 60 degrees with pain right side. There is weak dorsiflexion right foot 3/5 with hypalgesia right S1 territory.

MRI lumbar spine done 06-November-2013 showing II degree spondylolisthesis L4-5 with severe stenosis at this level.

Laminectomy L4, L5 and upper part of the sacrum. Foraminotomy right S1  and both L5 roots. The disc space of L4-5 was attacked from the right with insertion of TLIF cage Novel TL 8x23x10 mm inserted to the disc space from the right. Transpedicular fixation Isobar TTL module in was done at L4, 5. A ployaxial screw 6.2x45 mm was used to L5 body. Polyaxial  6.2x45 mm to L4 level. 2 bended rods 5.5x40 mm and cross connector were used to fuse L4,5 levels.  All stages of surgery were done with the use of C-arm. Bone graft was added lateral to the rods. Routine closure of the wound. The patient was very obese, that C-arm was difficult to interpret.

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

The patient has unstable spondylolisthesis L4-5 with instability.