The patient was operated by me 20-May-2014 for right far-lateral disc L4-5 with stenosis. The patient came 05-June-2014 with slight improvement with SLRS 10 degrees in the right with normalization of the power of the right foot. She still complaining of right sciatica with hypalgesia right L5 and S1 roots. MRI lumbar spine done 07-June-2014 showing no recurrence of L4-5 with swollen right L5 root. The patient then was admitted to Shmaisani hospital 15-June-2014 for fainting attack and MRI of the brain showed mastoiditis right side. Cardio consultation revealed regurgitation of the aortic valve. The patient then came 28-June-2014 telling that the LBP with bilateral sciatica more the right increased the last week.

On examination; the patient is not limping. SLRS was 85 degrees without pain in the right. Hypalgesia right L5 and S1 roots territories.

The patient was sent for new investigations: MRI lumbar spine with contrast done 28-June-2014 showing severe stenosis at L4-5 with ganglion? arising from the right L4-5 facet, or huge recurrence causing severe foraminal compression.

The old wound refreshed. During superficial dissection, clusters of the inserted at first surgery was seen with reactionary changes around it in the subfascial layers. These reactions were seen at all sites of dissection, denoting that the bone graft never became solid and it gradually completely escaped from the disc space to the surrounding tissues. Refreshment of the right upper corner of L5 lamina to follow the dura up. A huge material of bone graft was seen intermingled with the ligamentum flavum. The right L4-5 facet was exposed and all the reactionary masses were removed. There is no proper ganglion in the area. Instead there is the bone graft and a huge recurrence of the disc material with up and downward migration. The huge recurrence was removed in several pieces. The disc space was empty and further cleaning of disc space was performed to see if any bone graft was left there. There is no remnants of bone graft in the disc space. Wide foraminotomy of the right L5 root was achieved. Routine closure of the wound.

Smooth postoperative recovery.

The estimated postoperative recurrence is still was around 7%, but here 2 ml of bone graft was inserted to the disc space to prevent future collapse of the area and promote fusion of L4 and L5. That was what supposed to be in the first surgery.

During this revision, the bone graft will not ossify within 30-40 min as it was told to us. It   gradually and completely escaped the intradiscal space , causing during that reactionary changes around the root, which was swollen at certain stage, and reactionary changes around the facet mimicking ganglion and intradiscally triggering the recurrence.

Do not ever put Hydr'Os inside the disc space. It will never ossify, instead it will slip out causing several reactionary changes with trigger to high recurrence rate.