The patient came to the clinic 27-November-2014 complaining of LBP with left sciatica down to the left big toe with numbness for 2 months. MRI lumbar spine done 27-October-2014 showing lumbar canal stenosis L4-5 with left foraminal occlusion with huge Tarlov cysts extending from S2-4. The patient is a known diabetic insulin dependent for 25 years with arterial hypertension for 6 years and underwent stinting.

On examination, the patient is limping with exaggerated scoliotic stance. SLRS was 80 degrees with pain in the left. There is weak dorsiflexion left foot -4/5 and planterflexion same foot 4/5.

The patient was sent for cardiac evaluation and MRI lumbar spine repeated showing extruded disc L4-5 with left foraminal occlusion with Tarlov cysts in the sacral area.

Left L4-5 hemiflavotomy with foraminotomy left L5 root. There is mild CSF leak from the axilla, but seen only one dural defect 0.1 mm. Removal of the extrusion lateral to the axilla and left sided cleaning L4-5 disc space. The root became lax and the CSF leak still having place. Coagulation of the defect failed to stop the leak. 6 zero nylon applied to the visible defect, but with Valsalva procedure still having leak, but less intensity. Another 2 stitches applied above and below the stitch, but still minimally oozing without seeing the source of the leak. A piece of muscle was applied to the area and fat over it to cover the leaked unknown source. Routine closure of the wound.

Smooth postoperative recovery. The power of the left foot became normal.

The pressure upon the dural layer of the axilla can caused dural defects and they become evident after removing the compressing elements. They must be closed immediately or at the end of surgery if the oozing is minimal.

The patient still have an estimated postoperative recurrence around 7%.