A 31 year old lady after trivial trauma one year ago, got LBP.  The last 4 months started to complain of severe LBP with left sciatica with inability to walk. Conservative measures failed, then MRI performed and showed very huge extrusion of L5-S1.

On examination: The patient had drop left foot with severe weak planterflexion of the same foot. Anesthesia of the left L5, S1 territories.

She was operated 25-02-2005. Using the high-speed drill and micro instrumentation, left hemiflavotomy with foraminotomy of left S1 were performed.  The left S1 root was shifted up and lateral. The extruded mass was attacked below the axilla and piecemeal resection was done to avoid any distraction injury to the surrounding neural structures, because the mass boundaries were adherent to the nerve and veins and the swollen compressed epidural fat. Here a good demonstration for 2 points:
1. To minimize recurrence, the cleaning of the intradiscal space was done with minimal quantity, using very tiny pituitaries. The hole of the attack was the same of the slipped material, so as not to increase the defect in the annulus fibrosis. After that the hole was coagulated to shrink the hole in dimensions.
2. Due to severe compression, the epidural fat was missing in many places, despite careful attention not to violate it. Epidural fat transfer was done from less important areas to the mobile root. After that, transfer of the most  near fat was done with pedicle. It is becoming evident that,  the most near fat is morphologically similar to epidural fat. The farther away you go, the less resemblance of the fat structure. For several months , I stopped using the subcutaneous fat in pedicle to fill the epidural space for several reasons, mentioned elsewhere.

The patient  came to the clinic 09-March-2005 with clean wound. SLRS was 75 degrees both sides with minimal pain with mild weak dorsiflexion left foot.

The estimated postoperative recurrence is around 7%, because the disc space is not completely collapsed.