The patient came to the clinic complaining that he deteriorated after performing decompression for lumbar canal stenosis of L4-5 in 2006. The right sciatica increased and bilateral sciatica the last 4 years. The patient is using crutches for 3 years and cannot walk more than 50 meters. The patient is a known diabetic  with arterial hypertension.

L.S.S. X-ray done 30-September-2012 showing II degree spondylolisthesis of L4-5. MRI of the lumbar spine done 30-September-2012 showing severe stenosis L4-5 and old extruded disc L1-2 of no clinical significance.

On examination, the patient is limping with exaggerated scoliotic stance. SLRS was 60 degrees with pain in the right and 75 degrees in the left. There is severe weak dorsiflexion both feet 2/5 and planterflexion both feet -3/5. There is hypalgesia both feet at the level of the ankles with edema of both ankles. There is severe OA both knees.

The patient was sent for cardiologic and nephrologic consultation, because there were subclinical signs of renal failure with elevated all hepatic enzymes with uric acid reaching 13.4 mg/dL. The patient was admitted 3 days before surgery under the supervision of the nephrologist. MRI of the brain with MRA were compatible with age.

Skeletonization of L5, L3 and the remnant of L4. There is massive scar in the right side of L4-5. Foraminotomy of the right L5 root. There was severe compression of the root by extruded disc and destroyed right lateral mass. All compressive elements were eliminated. Discectomy of L4-5 from the right with meticulous cleaning. TLIF cage Novel TL 10x25 mm was inserted from the right to the disc space. Using Scientex Alphatec Spine Isobar  TTL, 2 polyaxial screws 6.5x45 mm were inserted to L5 body. 2 monoaxial screws 6.5x45 mm were inserted to L4 body. Rods 5.5 mm with Easys cross connector were used to obtain fixation with slight compression.  Life net bone graft was used to fill the disc cavity and the gaps lateral to the rods.

Routine closure of the wound. Smooth postoperative recovery.

The patient has many problems among them eminent renal failure. This and other pathologies will act negatively in the recovery process of the patient.