The patient came to the clinic 26-March-2007 complaining of difficult gait for 3 years with numbness four limbs. Exacerbation of LBP with left sciatica the last month.

MRI of bad quality done 13-March-2007 done showing extruded disc L4-5 with upward migration. MRI of the cervical spine performed later showing spondylolisthesis C5-6 with stenosis and malacia of the spinal cord at that level.

On examination: the patient walking with aid and crutches. The patient is left handed using the right. The power of the right upper limb is diminished 4/5 with weak dorsi and planterflexion left foot and severe weak left quadriceps muscle 3/5. SLRS was 50 degrees in the right and 5 degrees in the left with agonizing pain. Babinski was positive in both sides.

The patient was sent for new MRI of the lumbar spine, which was performed and more clearly demonstrated the extrusion and the left side upward migration of the piece. Considering that the extrusion is causing an agonizing pain it was decide to operate first the lumbar spine and later to manage the cervical problem.

During positioning of the patient in the operating table, great care was directed to the cervical spine to avoid possible complications of the cervical spine. Left L4 hemilaminectomy with left L5 foraminotomy was done and the extrusion was removed and the disc space of L4-5 was cleaned from the left side.

Routine closure of the wound and smooth postoperative recovery with improvement of the motor power left foot.
Another time great care was paid for the cervical spine during transfer from the operating table to the ward.
 

Considering that the extruded disc was an agonizing one, exception was made to operate the patient in the lumbar spine. Usually precedence is directed to the cervical spine, but in this case it was an exception.

The patient must be operated later for his cervical problem and an interval of 3-4 months must be waited until the patient recover from his first problem.