The patient came to the clinic 04-August-2010 complaining of left sciatica for 7 months and LBP for 4 months. Exacerbation of sciatica the last week.

MRI lumbar spine done 22-July-2010 showing huge extruded disc L4-5 with left downward migration with secondary canal stenosis.

On examination: the patient was not limping with mild scoliotic stance. SLRS was 40 degrees in the right with pain and 20 degrees in the left with more pain. He had weak dorsiflexion right foot 4/5 and left foot -4/5 with weak planterflexion left foot 4/5. He had hypalgesia left L5 and S1 territories.

The patient then came 29-June-2011 claiming that he got deterioration the last 4 days with new MRI done 26-June-2011 showing the same picture as before.

On examination: the patient was limping with exaggerated scoliotic stance with the same SLRS with weak dorsiflexion left foot -4/5.

Bilateral L4-5 flavotomy. CSF came before reaching the dura, which was lacking the epidural fat. Bilateral foraminotomy of L5 roots. The head position was lowered to decrease the CSF flow. There were 2 tiny dural defects which were repaired by 6 zero nylon. The huge extrusion was attacked from the right, then from the left to avoid damage to the left severely stretched and compressed left L5 root. Bilateral removal of the extrusion and bilateral cleaning of L4-5 disc space.

Routine closure of the wound.  Smooth postoperative recovery with normalization of the power of the left  foot with disappearance of left sciatica.

The estimated postoperative recurrence rate is below 7% because the disc space of L4-5 is shallow in its anterior part.

The huge disc causing stenosis, both together must be corrected during surgery. Bilateral cleaning must be performed.

The CSF leak took place before approaching the dura. This means that the dural defects were present before approaching then and after relieving the ligamentous structures the CSF start to flow.