The patient came to the clinic 07-January-2008 with LBP and right sciatica after suffering RTA 1999 in Cyprus with fracture pelvis at that time. He got exacerbation of the right sciatica the last three months. He is using crutches during this period. Lumbosacral X-ray done 05-October-2007 showed old wedging fracture of L2 with spondylolisthesis L5-S1. On examination at that time: SLRS was 45 degrees with pain in the right with weak dorsi and planterflexion right foot 4/5. The AJs were absent both  sides. He had scoliotic stance. CT-scan of the brain done 08-January-2008 was normal and MRI lumbar spine showed spondylolisthesis I degree of L5-S1 with old fracture L2 of no significance. The patient was treated conservatively.

The patient then came 12-September-2009 and 11-September-2012 with bilateral sciatica and investigations showed the same spondylolisthesis and stenosis at L4-5. The patient was willing for conservative treatment.

The patent then came 29-May-2013 after travelling to Malta, complaining that during travel, he got severe agonizing LBP with bilateral sciatica. He is diabetic for 3 years and cardiac cath done 3 years ago was normal.

On examination: The patient is limping with exaggerated scoliotic stance. SLRS was 70 degrees both sides. There is weak dorsiflexion both feet 4/5. All deep reflexes are absent. The patient was advised to perform radiologic studies in case of not improving.

MRI lumbar spine done 03-June-2013 showing the old wedged fracture of L2 of no clinical significance and spondylolisthesis II degree at L5-S1 with severe stenosis L4-5, L5-S1. Dynamic studies showed the spondylolisthesis with bilateral isthmolysis L5-S1.

After skin and facial incision, CSF came out before performing bone dissection from the space between L4 and L5 spinous processii. Laminectomy L4 and L5. Foraminotomy L5 and S1 roots both sides. The dura was deformed and there was a dural pouch which was extending between the L4-5 space. It was looking like a synovial cyst, but after dural dissection it turned to be a dural envelope which was preserved and was closed by 6 zero nylon. The L5 lamina and it lateral masses were fail and the upper edge of the lamia was tearing the dural sac, which caused the dural pouch. All these elements were removed. Right sided discectomy of L5-S1. A Novel TL TLIF cage 9x10x30 mm was inserted to the L5-S1 disc space. A bone graft was inserted in the disc space. Using C-arm and Isobar TTL Module In  6.2x45 mm polyaxial screws were inserted to L5 body and 6.2x40 mm screws to S1 body. 2 bended rods 5.5x25 mm and 60 mm length Easys cross connector were used to fuse the L5, S1 level with mild compression. Bone graft was added lateral to the rods.

Routine closure of the wound. Smooth postoperative recovery. The power of both feet became normal.

The patient has lumbar canal stenosis with spondylolisthesis. All components must be corrected.

The patient has CSF coming from the field before reaching the dura. This means that the patient had severe trauma recently. The dural defect was repaired accordingly.