Surgical Standards:

1. Skeletonization of L4, L5 laminae and the upper border of the sacrum, performed, trying during that , to check for movable segments, for further intraoperative confirmation. It happened several times, that the patient was planned for such a procedure, and this trick , changed the plan of surgery, before attempting to go far, to such areas as the transverse processes. Using towel clips is a useful tool for such task.

2. Check for recent fractures at the isthmus, since malpractice of others especially in the third world, by using a baton for LBP patients, which causing fractures of the spinous process, lamina and isthmus. To these special cases, which the patient try to escape these events before surgery, I modified a new technique by using miniscrews, after drilling the surface of the bone , to accept three or four screws from the orthopedic hand set screws. It usually works excellent and the construct becoming stable.

3. Remove the whole lamina of L5 with all the cartilage, performing during that foraminotomy of both S1 roots for not less than 10 mm distance. Expose both L5 roots and remove all the compressing elements. By doing this, you avoid any injury to these roots , and nibbling with drilling down to the pedicle, you actually not in need for fluoroscopy. This also facilitate later the process of reduction. Don't forget to gather the bone for subsequent grafting.

4. Try all the time to preserve the epidural fat, since it prevents subsequent fibrosis and in case, of its poverty, you can transfer the most near local fat tissue. These fatty tissues are more similar to the epidural fat , than the subcutaneous or the fat over the dorsal sheet, or other artificial materials, with which I had in the past a bad experience, such as the adcon-gel, which to my knowledge is out of production.

5. Perform bilateral discectomy L5-S1, trying to make the holes very small, to preserve the PLL and the posterior aspect of the annulus fibrosis, to prevent recurrent disc . Try meticulously clean the disc space and try during that to reduce the slippage by curved blunt metallic devices, they are many. Observe the adjacent vertebral edges to notice the difference in the level. Some times, you need to perform tiny drilling at the level of the disc space to insert the reducing device, as seen in the present video.

6. Using the polyaxial transpedicular screws, facilitate the easiness of rods placement and check fluoroscopy must be done, in spite of the previously mentioned exposed pedicles. Do not be confident, all the time double check your actions. After inserting the four screws, the rods must be a little bit longer, to perform distraction and subsequent reduction.

7. After your device in place and the reduction is acceptable, and you are satisfied with the images, check the roots and the pedicles, which could have small cracks at the insertion canal and remove them, to prevent any unnecessary malformed structures in the roads. Check the disc space from both sides and perform further discectomy, if needed.

8. The gathered bone, at the start of the operation is chipped in small pieces and realigned lateral to the rods with refreshment of the transverse processes for future bony fusion. You must take in consideration, that in some cases the construct becoming loose and this graft can help in this situation, in case of removing the device after several months, so whatever the reason was.

9. During closure and fat tissue transfer, observe the chips of bone so as to prevent them from slipping to the neural elements. Water-tight closure with subcuticular stitching, avoid Ready-vac drains.

10. Use intraoperative monitoring with triggered myogenic stimulation to avoid root irritation or damage during the insertion of the pedicular screws.