The patient came to the clinic 01-January-2014 complaining of LBP with right sciatica for 5 months. MRI lumbar spine done 19-August-2013 showed extruded disc L4-5 with right foraminal occlusion and mild spondylolisthesis  L5-S1. On examination at that time, he was limping with exaggerated scoliotic stance. SLRS was 40 degrees with pain in the right with weak dorsiflexion right foot 4/5. The patient was sent for investigations and done 06-January-2014 and MRI lumbar spine showing extruded disc L4-5 with right foraminal occlusion. The patient telling that he is improving, for what conservative treatment was advised.

The patient then came 06-July-2014 complaining of exacerbation of the LBP and right sciatica the last 10 days.

On examination; the patient in agonizing pain, using crutches for 10 days, was limping with more exaggerated scoliotic stance. Positive cough sign, SLRS was 15 degrees with pain in the right and 80 degrees in the left. Weak dorsiflexion right foot -4/5.

The patient was sent for new investigations and the MRI lumbar spine performed the same day, showing the extruded disc of L4-5 with more right foraminal occlusion with stenosis  and mild spondylolisthesis L5-S1 less then 2 mm. Dynamic studies showed ossification of the anterior part of all disci including the L5-S1 with no signs of instability ruling out the importance of the mild spondylolisthesis of L5-S1.

There is some discoloration of the skin in the proposed surgical wound. Skin incision done. A huge amount around 20 ml of seroma came out from under the skin. The relatives explained that this was the result of prolotherapy, performed 6 months ago. It was taken for CXS. The patient was given triple antibiotics during surgery. Right L5 foraminotomy was done. The ligamentum flavum was reflected to the left to preserve it. Check for instability of L5-S1 and L4-5 was negative. The extruded disc was removed lateral to the axilla. The root became free at the disc level, but further foraminotomy was done to achieve good decompression of the root and to inspect the subaxillary area. The ligamentum flavum reflected back and routine closure of the wound.

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

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

Preservation of the ligamentum flavum is the best way to decrease the scar formation after disc surgery.

Prolotherapy is not effective in this case and causing accumulation of serous fluid under the skin, which is an alerting sign for cellulitis.