The patient a Yemeni citizen came to the clinic 20-March-2004 complaining of LBP with right sciatica for 6 months with numbness of the right S1 root territory and positive cough sign. MRI lumbar spine performed 16-March-2004 showing huge extruded disc L5-S1 with right foraminal occlusion. The patient has left abducens paresis for 45 days with headache and left temporal area.

On examination: the patient is limping with exaggerated scoliotic stance. SLRS was 80 degrees right side with pain. There is weak dorsi and planterflexion right foot 4/5.

The patient was sent for thorough investigations and MRI of the brain was normal and the abducens paresis was considered to be diabetic mononeuritis.

Foraminotomy right S1 root with preservation of the ligamentum flavum and reflection to the left. Removal of the extrusion lateral to the axilla. After that, the root became lax and right sided intradiscal cleaning L5-S1 disc space was done. The patient was put in Reverse Trendelenburg position with Valsalva maneuver and hyperventilation. No CSF leak. A free fat was harvested from the subcutaneous layer and covered the exposed parts of the root, to minimize postoperative scarring. The preserved ligamentum flavum was returned back in place. Routine closure of the wound. Smooth postoperative recovery. The power of the right foot normalized.

The patient came to the clinic 29-March-2004 with clean wound and SLRS 80 degrees both sides without pain and normal power right foot and sensation. The mononeuritis also resolved.

The estimated postoperative recurrence is still ranking around 7%, because the disc space is still relatively not shallow.

This is the first operation that the ligamentum flavum was preserved and reflected to the contralateral side and returned back after at the end of the surgery.