The patient came to the clinic 18-June-2013 complaining of LBP with left sciatica for 15 years. The last week got exacerbation of LBP with bilateral sciatica more the right with numbness all toes right foot and positive cough sign.

MRI lumbar spine done 16-June-2013 showing huge extruded disc L4-5 with upward migration bilateral more to the right. There is old bulge L5-S1.

On examination: The patient is limping with exaggerated scoliotic stance. SLRS was 75 degrees with more pain in the right. Weak dorsiflexion right foot -4/5 and left foot 4/5. Weak planterflexion right foot 3/5. There is hypalgesia both L5 roots and right S1 territories.

Bilateral L4-5 flavotomy and foraminotomy both L5 roots. The extruded disc had 2 components, the soft part in the right side and hard part in the left side, and they were attacked first from the right side and the upward migrating disc was removed. Inspection of the left side showed more severe extrusion, which was removed lateral to the left L5 axilla. After removal of the huge extrusion from the left side a pin point CSF leak took place. The pin point dural defect located at the upper border of the left L5 axilla was closed by nylon 6 Zero applying one stitch. Check for CSF with Valsalva maneuver and elevation of the head was negative. Bilateral cleaning of L4-5 disc space was carried on.

Routine closure of the wound. Smooth postoperative recovery. The power of both feet dorsiflexion became normal and slight improvement of the planterflexion right foot.

The patient still has an estimated postoperative recurrence around 7%, because the disc space is still not shallow, even with bilateral cleaning.