The patient came to the Shmaisani hospital 24-March-2013 transferred from Palestine, claiming that he underwent discectomy for for  right far-lateral extrusion L3-4. After the surgery he immediately deteriorated with more agonizing sciatica and numbness left leg and drop left foot and oozing from the wound resembling CSF leak. The patient underwent three surgeries for PLD L5-S1 in 1990 and 2 surgeries for L4-5  last 2 were done by me 05-June-2002 and 01-April-2005. The patient underwent CABG 2009 and he stopped anticoagulants 2 weeks ago.

MRI lumbar spine done 24-March-2013 showing huge extruded disc L3-4 with up and downward migration, causing complete occlusion of the canal. ESR was 65 mm/h and CRP 76 mg/L. Dynamic X-rays showing slight lateral shift of L3 upon L4 with mild spondylolisthesis L4-5.

On examination: The patient is unable to stand to evaluate limping or the scoliotic stance. SLRS was 45 degrees in the right with pain and 75 degrees in the left with more pain. There is complete drop left foot and severe weak planterflexion 4/5 same foot with weak dorsiflexion right foot 3/5 and planterflexion 4/5. There is hypalgesia right L5, S1 and left S1 and analgesia left L5 roots.

The infected wound reopened. Laminectomy of L3 was done. Inspection for CSF leak from all the corners of the wound were sought, but failed. Only several bloody collections with puss components were found and remnants of surgicele was seen among the scars. Exploration of the right side revealed infected fragments of the upward extrusion, which were removed. Right sided cleaning of the L3-4 disc space. The downward migrating pieces were also removed. Left sided cleaning of the L3-4  disc was done and further removal of the upward and downward migrating infected disc material was removed. Meticulous bilateral cleaning of L3-4 disc space was achieved. The patient was put with head up the horizontal with Valsalva maneuver to detect possible CSF leak. It was negative. Debridement of the infected wound and water-tight closure of the wound was performed.

Routine closure of the wound. Smooth postoperative recovery. The power of the right foot became normal and the power of planterflexion left foot became normal and slight improvement of the left drop foot with recovery of sensation to the analgesic portion with disappearance of the sciatic pain.

There is still an estimated postoperative recurrence below 7%, because the disc space is still not shallow but infected.

There was speculation that CSF leak having place before surgery, which was ruled out during surgery.