The patient came to the clinic 23-September-2012 complaining of  left sciatica for 6 months down to all toes left foot with LBP for 2 months.

MRI lumbar spine done 17-September-2012 showing extruded disc L4-5 with left downward migration.

On examination, the patient is limping with exaggerated scoliotic stance with SLRS was 20 degrees left side with weak dorsiflexion left foot 3/5 and hypalgesia below the left knee with preservation of sensation of the left S1 territory.

Initial approach was intended for left L4-5 hemilaminectomy, but the spinous process was flail with isthmolysis, for what skeletonization of L4 and L5 was done. The fracture of both isthmi were not old, but not recent. Left L4-5 partial flavotomy with foraminotomy left L5 root. The extruded disc was removed lateral to the axilla. and meticulous cleaning of L4-5 disc space was done from the left. Using image-intensifier, check for spondylolisthesis revealed micromotion around 2-3 mm. It was decided to refresh the isthmolytic parts and fill the disc space and the isthmolytic gaps with NovaBone powder.

Routine closure of the wound. Dramatic improvement of the left foot.

The patient did not perform dynamic studies before surgery and the isthmolytic changes were found during surgery. It happens that the Arabic methods by using thick woody stick over the spinous process could cause such as this picture, but the family deny this event. It could be that the patient suffered minor injury with subsequent extrusion. For this reason, it is preferable to perform dynamic studies to all patients undergoing disc surgery.

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