The patient came to the clinic 10-July-2010 complaining of LBP for 2 years with right sciatica. Exacerbation of the right sciatica the last 5 months. MRI lumbar spine performed 26-August-2008 extruded disc L4-5 and L5-S1 (bad quality).

On examination: the patient start to limp after a while with scoliotic stance. SLRS was 75 degrees in the right with pain.

MRI of the lumbar spine performed 11-July-2010 showing very huge extruded disc L4-5 with right downward migration and bulge L5-S1

Using image-intensifier the L4-5 level was identified and dissection is carried out.  Another check of the level was carried out and it was the L3-4 level, for what the dissection was redirected to L4-5 level. Right side partial flavotomy of L4-5 was done and foraminotomy of the right L5 root was performed. There is no epidural fat at the root territory due to severe compression. The extruded disc was removed in several pieces intentionally to avoid trauma to the severely compressed and stretched root. After removal of all the extrusion, meticulous cleaning of L4-5 disc space was performed from the right.

Smooth postoperative recovery and improvement of the power of right foot.

This estimated postoperative recurrence in this case is more than 7% because the defect in the annulus fibrosis is wide and the disc space is still not shallow.

When you suspect your level, all the time use image-intensifier, to avoid wasting time and prevent unnecessary dissection and skeletonization. We are trying not to use methylene blue, because it could trigger possible postoperative infection or reactionary changes.