The patient came to the clinic 16-February-2014 from YAR complaining of LBP and right sciatica for 10 years with deterioration the last 2 years. Using crutches the last 2 months with inability to walk more than 200 meters with intermittent claudication. He was operated 1997 in Egypt 1997 for PLD L4-5 and then in Yemen 2004 for recurrence. He is a known diabetic for 10 years in treatment. LSS X-ray done 12-February-2014 showing II degree spondylolisthesis L4-5. MRI lumbar spine done 18-March-2012 and repeated 11-February-2014 showing spondylolisthesis L4-5 with severe segmental stenosis.

On examination; the patient is limping with exaggerated scoliotic stance. He has bilateral sciatica more the right with SLRS 70 degrees in the right and 80 degrees in the left with pain. The right AJ is absent. Complete drop right foot with weak planterflexion -4/5. Dorsiflexion left foot -3/5 and planterflexion 5/5. There is hypalgesia right L5, S1 roots territories.

Skeletonization of L3 lamina, upper sacrum, lateral masses of L4-5, L5-S1. Foraminotomy right L5 root. Discectomy L4-5 with insertion of TLIF cage Novel TL 6x23x5 mm wit bone graft from the right side. Using Isobar TTL Module in 2 monoaxial screws 6.2x45 mm inserted to L4 and 2 polyaxial screws 6.2x45 mm to L5 body. Rods 5.5x50 mm bended to accept the natural curve of the area with cross connector were used to achieve fusion of L4-5 with slight compression. The bone graft was added lateral to the rods. Routine closure of the wound.

Smooth postoperative recovery. The power of the left leg became normal and slight improvement of the drop right foot.

The patient mostly having iatrogenic spondylolisthesis after the 2 performed surgeries.

The lowest vertical TLIF cage was used to avoid overstretching the running nerves, since the disc space of L4-5 was very narrow.