The patient came to the clinic 20-April-2015 complaining of LBP for three years with neck and left shoulder pain for 3 years. The patient was not limping with no scoliotic stance at that time, but had neck pain when looking to right and up. There was weak extension right hand and right triceps muscle. There was hypalgesia of the left median distribution. There was hypalgesia of the left L5 territory and weak dorsiflexion left foot. 4/5. The patient had DVT of the left leg 8 months ago in warfarin 3 mg twice daily. The patient was sent for neuro-radiologic evaluation. The patient then came 10-May-2015 with agonizing pain and right sciatica with limping and exaggerated scoliotic stance for the last 10 days. Investigations done the same day of this visit showing severe stenosis at L3-4 and spondylolisthesis L5-S1. There is bulge C3-4, 4-5 and C5-6. Dynamic studies confirmed the L5-S1 spondylolisthesis with bilateral isthmolysis.

On examination; the patient is limping with exaggerated scoliotic stance. SLRS was 10 degrees with pain in the right. There is weak dorsiflexion both feet -4/5. The patient was sent for cardio evaluation.

Using the C-arm, the L3-4 level was identified. Using Legacy CDH MAS screws 6.5x45 mm 8 screws inserted to L3.4.5 and S1 levels. The L5 lamina was flail and there is instability at L3-4 level. Decompressive laminectomy L3 and upper third of L4. 100 mm bended rods were used and cross connector 22 were applied to obtain fusion and distraction about 5 mm both sides between L5-S1. All stages of surgery were done with C-arm control. The harvested bone was milt and applied to the rods. Routine closure.

Smooth postoperative recovery. The power both feet became normal.

The patient has multiple problems and all must be resolved during surgery.