The patient came to the clinic 19-September-2012 complaining of difficult walking with severe pain in the right knee for 18 years, which increased after performed transpedicular fixation in Syria 7 years ago. The patient is a known diabetic and hypertensive for 1 year and she underwent cath 11 years ago which was normal. Exacerbation of the LBP and right sciatica the last 6 months.

LSS X-ray done immediately after the surgery and 23-June-2012 showing spondylolisthesis L3-4 with the right upper screw at L3 body out of the bone. The left lower screw which was inserted to the left L5 body was broken.

MRI lumbar spine done 23-June-2012 showing spondylolisthesis L3-4 and bulge L4-5 and L5-S1.

On examination, the patient is limping with exaggerated scoliotic stance with SLRS was 30 degrees both sides more painful in the right. The KJ was absent in the left(?). There is weak dorsi and planterflexion right foot 3/5. with hypalgesia right L5 and S1 territories.

The old incision refreshed. The screws were exposed with their knots. The left lower screw was flail, so the right upper screw. Both were removed with leaving the fractured part inside the L5 body in place, since it doesn't cause harm. Using Scientex Alphatec Spine screws ISO bar TTL module 6.2x40 mm fixed screws were inserted to the right L3 pedicle and to the left L4 body. The previously inserted screws were checked for looseness. They were solid stable, for what they were left untouched. The right side of the L3-4 of what to be supposed to be the ligamentum flavum was filled by the previous graft. It was drilled off with high speed drill and foraminotomy of the right L4 roots was achieved. Considering the solid bony fusion of the L3-4 by the bone graft, it was decided not to violate the L3-4 disc space and the idea about inserting the TLIF was withdrawn from the plan. The right L4 root was severely compressed by the bony elements. Two 5.5 mm rods bended to accept the natural curve of the spine were inserted and fusion of L3 and L4 was achieved.

Routine closure of the wound. Dramatic improvement of the right foot.

The patient underwent first surgery with the right upper screw inserted lateral to the right pedicle. It could irritate the the running L3 root and cause the pain of the right knee which appeared immediately after the first surgery. The second possible cause is the severe compression of right L4 root, which was decompressed by high speed drill.