The patient came to the clinic 19-November-2009 complaining of LBP for 10 years with right sciatica for 1 year. MRI lumbar spine done 08-November-2009 showing PLD L4-5 more to the left. The patient was sent for another investigations and the new MRI done 19-November-2009 showing extruded disc L3-4 and D11-12. The patient was treated conservatively.

The patient then came 23-February-2013 claiming that he was operated at Saudi Arabia 8 months ago after what he improved for a while to deteriorate with exacerbation of LBP and bilateral sciatica, more the left. The patient underwent total left knee replacement 2 years ago. He has urgency for 2 years.

MRI lumbar spine done 18-February-2013 showing huge recurrent extruded disc L3-4 causing complete stenosis.

On examination: The patient using crutches, walking bended anterior, limping with exaggerated scoliotic stance. SLRS was 45 degrees with pain in the right  and 70 degrees with less pain in the left side. There is weak dorsiflexion both feet 4/5.

Refreshing the old incision. All the area is full of scars and there is bony defect at the lower edge in the right side, through which CSF is coming with tortuous roots coming out. Using C-arm the L3-4 level was identified and the CSF leaking defect is at the lower edge of L4 lamina. Laminectomy of L3 was done with foraminotomy of the left L4 root. The huge extruded disc was removed in several pieces with one huge piece came from the outside of the disc space. Meticulous cleaning of the L3-4 disc space. The root became lax. Considering that the tiny bony defect with CSF leak is away from the operative field it was considered wise to use several muscle pieces aided with Glubran 2  3Y0091912 05/14 in stepwise fashion to achieve prompt sealing of the defect. The head of the patient was elevated up and Valsalva maneuver was done to check for any CSF leak.

Water-tight closure of the wound. Smooth postoperative recovery. The power of both feet became normal.

The patient had huge recurrent extrusion of L3-4 and the disc space is still not shallow, for what the expected postoperative rerecurrence is around 7%.

The first surgery was done at several levels and there could be a problem at the right side of L4-5. These data are not seen at the MRI so as to be ready to predict them. The CSF leak came from bone and the tortuous roots also. The best solution was to push a small piece of muscle with other bigger muscles aided with glue to eliminate the defect.