The patient came to the clinic 01-November-2011 complaining of LBP for 1 month with left sciatica for 4 months. On examination at that time she was not limping, with minimal scoliotic stance. SLRS was 90 degrees both sides without pain and there was weak dorsiflexion left foot 4/5. MRI lumbar spine done 23-November-2011 showed mild spondylolisthesis L3-4 with bulge L4-5 and L5-S1 with stenosis at L3-4. She was advised to keep in conservative treatment. The patient then came 22-February-2014 complaining of LBP for 2 days without sciatica. The patient is a known hypertensive under treatment for 5 years.

On examination; the patient is in pain, limping, with exaggerated scoliotic stance. SLRS was 80 degrees both sides with pain. There is weak dorsiflexion right foot 4/5 and left foot 3/5.

MRI of the lumbar spine done 22-February-2014 showing spondylolisthesis L3-4 and retrolisthesis L4-5 with severe segmental stenosis.

Using C-arm, the L4-5 level identified. Decompressive laminectomy L3, L4 and upper third of L5. Foraminotomy left L4 and L5 roots. Inspection of the disci. They were glistening normal. The left isthmus of L3-4 was completely destroyed with a lot of hypertrophic bone fragments compressing the root and they were flail. All these elements were removed.  Using Isobar TTL Module in system, 6 monoaxial screws 6.2x45 were used to obtain transpedicular fixation of L3,L4 and L5. The rods were bended to adopt the natural curve of the area. Around 12 mm distraction was applied from the left side to correct the scoliotic changes. Cross connector was not applied, because the supporting company did not provide this item. The bone graft was added lateral to the rods and routine closure of the wound. All stages of surgery were performed with C-arm guide.

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

The patient  has a progressive course of instability of different nature. All must be corrected.

We usually include connector to the construct, but the providing company did not provide it. This is not critical, but it was more preferable to have it.

It was not necessary to violate the disc spaces, since the annulus fibrosis of both disci were intact.