The patient came to the clinic 30-September-2013 complaining of LBP for several years with exacerbation of the LBP with bilateral sciatica more the right for one year. The patient is a known diabetic, with arterial hypertension for 10 years. Bilateral renal stones with acceptable kidney function.

On examination at that time: the patient was limping with exaggerated scoliotic stance. SLRS was 75 degrees with pain in the right. Weak dorsi and planterflexion right foot 4/5 and +4/5 left foot.

MRI lumbar spine done 07-January-2014 showing spondylolisthesis L4-5 with bulge L3-4 and L4-5 with segmental stenosis. Dynamic studies showed 10 mm mobility of the L4-5 spondylolisthesis. MRI brain showed scattered small old lacunar infarctions of no clinical significance. MRA of the left CA showed complete occlusion above the bifurcation of CCA-ICA with good contralateral circulation.

Using C-arm, the L4-5 level was identified. Decompressive laminectomy L4, upper third of L5 and lower third of L3. Foraminotomy L4 and L5 roots was achieved at both sides. Using ISIS Inomed IOM, with transpedicular set, the roots were responding to 2mA DNS except the left L5 root was responding to 4 mA. Discectomy of L4-5 from the right with insertion of TLIF cage Novel TL 9x5x28 mm dimension. 2 polyaxial screws Isobar TTL module in 6.2x50 mm inserted to L4 body. 4 monoaxial screws 6.2x45 mm inserted to L3 and L5 bodies. 2 rods 100x5.5 mm were bended to accept the natural curve of the spine and cross connector, transpedicular fixation of L3,4 and L5 was done with slight compression between L4-5 level. Bone graft was applied where necessary. At all stages of surgery the roots were responding to 2 mA DNS and screws showed no response even to 15 mA DNS. Routine closure of the wound.

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

The patient has severe canal stenosis with spondylolisthesis at L4-5. All presenting problems must be taken to consideration and surgically corrected.

Using Inomed ISIS at all stages of surgery, permit to catch the moment when any neurologic deterioration took place and why.