The patient came 22-August-2013 complaining of right sciatica for 4 years and LBP for 2 years with exacerbation of LBP the last year and right sciatica the last 2 months.

MRI lumbar spine performed 26-June-2013 showed bulge L4-5 and L5-S1 with I degree spondylolisthesis L5-S1. Dynamic studies confirmed the last data.

On examination the patient cannot walk more than 400 meters with occasional episodes of agonizing LBP and conservative treatment fail to relief the pain. SLRS was 80 degrees with pain in the right. Despite the reluctant attitude of the surgeon, i.e., me, the patient is urging for surgery.

Exposure of L4,5 and upper sacrum and lower half of L3 laminae. The lamina of L5 is fail, floating to all directions. The flail lamina removes and foraminotomy both S1 roots achieved. Discectomy L5-S1 was performed from the right side and Novel TL TLIF cage 10x15x50 mm inserted from the right side with Stryker BoneSave. Using Isobar TTL module In, transpedicular screws 6.2x45 monoaxial was inserted to L4 and L5 both sides. 2 polyaxial 6.2x50 mm screws were inserted to the upper sacrum. Using 2 rods bended 5.5 x 50 mm length and cross connector were used to fix L4,L5 and S1 with slight compression at L4-5 and L5-S1 levels. His own harvested bone and BoneSave were used lateral to the rods.

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

The patient is urging for surgery, despite the scant radio-neurologic data. It could be that some dynamic trigger pain factors are playing a role and they are not will seen in the radio-neurologic setup of the patient.

The flail lamina of L5 was the source of pain.