The patient came to the Emergency of Shmaisani hospital 10 days ago with agonizing bilateral sciatica for 1 week.

On examination: the patient was unable to walk with SLRS 30 degrees both sides with pain. There was severe weak dorsiflexion both feet more weak at the left side 3/5. There was weak planterflexion both feet 4/5. The patient was complaining of paresthesia below the knees both legs.

MRI lumbar spine done 25-December-2013 showing bulge L3-4, L4-5 with spondylolisthesis L4-5 with severe segmental stenosis at both levels.

Using C-arm, the L4-5 level was identified. Decompressive laminectomy L3,4 and upper third of L5. Foraminotomy L4 and L5 roots was achieved at both sides. Using ISIS Inomed IOM, with transpedicular set, the roots were responding to 2mA DNS. Discectomy of L4-5 from the right with insertion of TLIF cage Novel TL 9x5x288 mm dimension. 2 polyaxial screws Isobar TTL module in 6.2x45 mm inserted to L4 body. 4 monoaxial screws 6.2x45 mm inserted to L3 and L5 bodies. 2 rods 100x5.5 mm were bended to accept the natural curve of the spine and cross connector, transpedicular fixation of L3,4 and L5 was done with slight compression between L4-5 level. Bone graft was applied where necessary. At all stages of surgery the roots were responding to 2 mA DNS and screws showed no response even to 15 mA DNS. Routine closure of the wound.

Smooth postoperative recovery. The power of  feet dramatically improved.

The patient has severe canal stenosis with spondylolisthesis at L4-5. All presenting problems must be taken to consideration and surgically corrected.

Using Inomed ISIS at all stages of surgery, permit to catch the moment when any neurologic deterioration took place and why.