The patient came to the clinic 31-August-2008 complaining of LBP with left sciatica for 1 year after lifting heavy object with exacerbation last month. MRI lumbar spine done 03-August-2008 showed dehydration L4-5, L5-S1 with small extrusion L4-5 left side. SLRS at that time was 70 degrees with pain in the left with weak dorsiflexion left foot 3/5. The patient is a known diabetic with arterial hypertension for 4 years. The patient was treated conservatively. The patient then came 15-January-2009 complaining of exacerbation of LBP with left sciatica for 3 weeks with agonizing left sciatica with weak dorsiflexion left foot 2/5, and planterflexion same foot 3/5. SLRS was 10 degrees with pain in the left. MRI lumbar spine repeated 16-January-2009 showing extruded disc L4-5 with left downward migration. It was agreed with the patient to try conservative treatment and in case of not improving, then to consider surgery.

The patient then came 06-April-2014, telling that after falling down in the elevator 2 years ago the left sciatica became right with exacerbation of the right sciatica the last 20 days.

On examination; The patient is limping without scoliotic stance. SLRS was 30 degrees in the right with pain. There is weak dorsiflexion right foot 3/5 and left foot 4/5. The right AJ was absent. The patient sent for new investigations, which were done 19-May-2014 showing extruded disc L4-5 with right foraminal occlusion  with severe stenosis at this level. Dynamic studies were not informative.

Using image-intensifier, the L4-5 level was identified. Check for instability was negative. Laminectomy of L4 and upper third of L5 was done. Flavotomy of L3-4 was done. Foraminotomy L5 roots both sides. The extruded disc in the right side was removed and right sided intradiscal cleaning of L5-S1 was done. Inspection of the right L5 root revealed that there is still a mass under the root , which is compressing the nerve. Trail to reach the lesion from under the axilla and lateral to the axilla failed to decompress the compression. The dura was opened parallel to the incision and the right L5 root was inspected. The extradural compression was squeezed out lateral to the axilla and removed. The root was calcified. The dura was very thin and many stitches of nylon 6 zero was needed to obtain water-tight closure of the dura. The dural closed defect was aided with pieces of muscle. Routine closure of the wound.

Smooth postoperative recovery. The power of both feet became normal.

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

Think thousand of times before opening the dura at the compressed level. It is very thin and liable to additional tears during closure.

It is rare, but have place, that the patient could have intradural fragments, which if missed, the patient will suffer for a long time until these intradural fragments are removed.