The patient came to the clinic 20-December-2013 complaining of LBP for 6 months without sciatica. MRI lumbar spine done 12-November-2013 showing bulge disci L3-4 and L4-5 with segmental stenosis both levels. He could walk more than 1 Km with numbness anterior left thigh.

On examination; the patient is limping due short right lower limb from childhood with old fracture right tibia. SLRS was 85 degrees without pain with weak dorsiflexion right foot 4/5 and left foot -4/5. The patient was advised to keep in conservative treatment.

The patient then came 30-March-2014 confirming that his clinical condition dramatically deteriorated and he cannot walk more than 100 meters with numbness both lower limbs  with bilateral sciatica more the left.

On examination: the patient is limping, with exaggerated scoliotic stance. Walking bended anterior. SLRS was 75 degrees with pain both sides. There is weak dorsiflexion both feet and planterflexion right foot -4/5. There is hypalgesia both L5 and S1 roots both sides. LSS X-ray done 23-March-2014 showing spondylolisthesis L3-4 II degree. New MRI of the lumbar spine requested and done the same day, confirming the presence of spondylolisthesis L3-4 with complete stenosis at this level with slight stenosis at L4-5 with right foraminal occlusion.

Using C-arm, the L3-4 level was identified. Decompressive laminectomy L4, lower 2/3 of L3 and upper third of L5. The L3-4 segment is flail, but the L4-5 is stable. Using Vitatech 4 transpedicular screws monoaxial 6.5x4.5 were applied to L3 and L4 levels. 2 rods 5.6x60 mm were slightly bended and used to fuse L3-4 with slight compression with cross connector. All stages of surgery were guided with the C-arm. The harvested bone was milled and used lateral to the rods. Routine closure of the wound.

Smooth postoperative recovery. The power of the feet became normal.

The patient  had stenosis with instability of L3-4. All elements were corrected. Considering that the disc space of L3-4 was very shallow, it was decided not to violate the disc space.

The L4-5 was stable, for what it was not included in the fusion.