The patient was operated by me the second time 24-Novmber-2008 for the third recurrence at L4-5 level right side. The patient was doing well until he came 27-April-2009 complaining of LBP with right sciatica for one week.

On examination: the patient is limping with exaggerated scoliotic stance with SLRS 30 degrees in the right and 45 degrees in the left. There was no weakness or hypalgesia.

The patient sent for new MRI lumbar spine, which was done 28-April-2009 which showed another recurrence in the right with soft consistency component. The patient was given two options: either to wait for 30-45 days until the piece start to shrink or to undergo another surgery. The patient could not tolerate the pain and was admitted for surgery.

The wound was refreshed and the most upper right corner was skeletonized. Sharp dissection was proceeded medial to the facet joint without violating the bony structures. The extruded disc came under vision and removed in several big pieces. Meticulous cleaning of the intradiscal space of L4-5 from the right until the disc space became empty. Routine closure of the wound.

Smooth postoperative recovery with disappearance of right sciatica.

The estimated recurrence rate in this case is now must be zero, because the disc space almost collapsed.

The patient got the 4th recurrence which is rare, and the amount of the disc material removed in this surgery hold the possibility, that the disc material could regenerate, because during every surgery a huge amount was removed

It was not necessary to expose all the neural structures. It was only needed to reach the extrusion and remove it. From that point of entry, further cleaning of the disc space was performed.