The patient was operated twice for PLD L5-S1  16 years ago elsewhere then was operated by me 19-January-2008 for PLD L4-5. The patient then came to the clinic 23-July-2011 complaining of weak right leg during walking for one month, then agonizing right sciatica for the last 12 days.

MRI lumbar spine done 20-July-2011 showing huge extruded disc L3-4 with right downward migration. There is no recurrence of L4-5 with assimilation of L5-S1.

On examination: the patient was limping walking with widened gait with scoliotic stance and weak dorsiflexion left foot 3/5  which was an old one and recently weak dorsiflexion right foot 4/5. SLRS was 15 degrees in the right.

Using C-arm the L3-4 level was identified and right L4 root foraminotomy was done with extended subaxillary exposure. Partial flavotomy of L3-4 was achieved. The huge far downward migrating disc was removed from under the axilla. It was removed in several pieces. The disc space of L3-4 was violated and meticulous cleaning was done from the right. Further inspection of the axilla lateral, revealed other fragments, which were removed. The root became free. There was no epidural fat at the severely compressed area.

Routine closure of the wound.  Smooth postoperative recovery with normalization of the power of the right  foot with disappearance of right sciatica.

The estimated postoperative recurrence rate is around 7% because the disc space of L3-4 is still not shallow.

Due to assimilation of L5-S1 and very narrow space of L4-5 the stress at L3-4 unit became high, which was the triggering factor for this extrusion.

The extruded disc was very far from the disc level. It was necessary to go down for 20 mm below the disc level to remove the extruded disc.