The patient was operated by me 01-March-2018 for extruded disc L4-5 with right downward migration and discharged in good condition with recovering the right drop foot. 5 days later, she progressed CSF leak and she was advised to keep in bed rest with Lasix 40 mg tab once daily. The wound was dry for 3 days, then the CSF leak took place. The patient cannot tolerate the proposed to her plan of treatment, for what she came to the Emergency of Shmaisani hospital 20-March-2018 complaining of severe headache after dressing of the leaking wound and taking her antihypertensive medication. The patient was hospitalized and MRI of the lumbar spine with contrast with myelography showing the CSF leak from the dura. ESR and CRP were very high, for what Vancomycin 500 mg I/V twice daily was started. 

On examination, the patient is complaining of headache and fainting attacks, but no fever nor rigidity. The power of both feet are normal and no sciatica.

The wound was opened and exploration for the dural defect was proceeded. There no dural defect, nor CSF leak. The intradiscal space was inspected to rule out anterior defect. No CSF leak. The right L5 root foraminotomy was extended and the root inspected. No dural defect, not CSF leak. It seems that a tiny clot during approach occluded the tiny defect. All the suspected areas were bipolar coagulated in case if there is dural tiny defect. 18 ml sterile water were injected intradurally and the patient was brought head up position, and Valsalva maneuver were applied. No CSF leak. Surgicele was used to cover all seen dural structures in the field and muscle flap transferred over it. Water-tight closure of the wound. The skin was refreshed and subcuticular stitches were applied. Routine closure of the wound.

Smooth postoperative recovery. She was sent to the ward.

The patient during the first surgery did not show any dural defect, nor CSF leak. The far right migrating huge extrusion was removed subaxillary. The CSF leak took place 5 days after surgery. Exploration of the wound could give a clue about what was the cause of the CSF leak.

During the surgery there was no identifiable dural defect and all these mentioned above procedures were performed.