The patient came to the clinic 14-December-2005  complaining of LBP with right sciatica after performing 2 surgeries to his extruded disc L4-5 03-July-2005 and 04-October-2005 elsewhere. MRI lumbar spine performed 06-December-2005 showing recurrence of L4-5 with decreased height of the L4-5 disc space. The patient is a known hypertensive for 5 years. On examination at that time, he had exaggerated scoliotic stance with SLRS 45 degrees with pain both sides. There was weak dorsi and planterflexion right foot -4/5 with hypalgesia right L5 and S1 root territories. The patient was treated conservatively.

The patient then came 24-December-2012 complaining of LBP with left agonizing sciatica for one week. The old right sciatica persisted as before. MRI lumbar spine done 24-December-2012 showing huge extruded disc L3-4 and still persisting foraminal occlusion L4-5 both sides. The patient underwent stinting 10 days ago and he is now in clexane 80 mg  twice a day.

On examination: the patient is limping with exaggerated scoliotic stance. SLRS was 80 degrees degree in the left side with pain and there is drop left foot with weak dorsi and planterflexion right foot -4/5.

Refreshment of the old incision. Complete laminectomy of L4 was done in the first surgeries. There is also scar reaching the L2-3 level and down to the L5, S1 level. Partial laminectomy of L3 with scarolysis down from the left to perform foraminotomy of the left L4, L5 roots. Left sided discectomy of L3-4 and L4-5. It was noticed that the left lateral masses of L3-4 and L4-5 were flail. They were removed. TLIF cages Novel TTL 10x20  were inserted to L3-4 disc space and 6x25 mm to the L4-5 disc spaces. The bone graft was inserted to both sides of the cages.  Using Scientex Alphatec Spine system 4 polyaxial 6.2x40 mm were inserted to the L3 and L5 levels. 2 monoaxial 6.2x40 mm screws were inserted to L4 body. All stages of surgery were done using the C-arm. Rods 70 mm length bended to adopt the normal local curve of the spine with cross connector were used with slight compression to fuse L3.4 and L5 bodies. Bone graft was used parallel to the rods.

Routine closure of the wound. The power of the left foot remained the same.

The patient has an estimated postoperative recurrence rate around 7-15%, because the disc space height is still not shallow at L3-4.

The patient still suffering from L4-5 disc space and it could participating in his recent problem, for what it was included in the surgical management.

When drop foot take several weeks, recovery will take long time.

The patient progressed acute MI with cardiac arrest 2 hours after recovery, for what he was intubated and AF was corrected by DC shock and coronary angiography performed 2 hours later and the thrombosis was dealt and the patient was extubated the next day 30-December-2012 with stable vital signs. The patient is alert and responding well with slight improvement of his drop left foot with mild right VI nerve paresis.