The patient came to the clinic 19-February-2007 complaining of LBP for 15 years with right sciatica. Exacerbation of the LBP with left sciatica the last 7 months without numbness.

MRI lumbar spine done 17-July-2006 showing assimilation of L4 and L5 and D11 and D12 with bulge L5-S1.

On examination: The patient had scoliotic stance. SLRS was 90 degrees in both sides with pain in the right. There was no sensory or motor deficit.

The patient then progressed severe agonizing right sided sciatica the last 10 days , for what MRI was repeated and showed extrusion of the L5-S1 disc with migration to the right S1 root foramen with severe compression.

The patient came to the emergency of Al-Shmaisani hospital 04-April-2007 with agonizing pain and drop right foot with severe weak planterflexion right foot.

Right L5-S1 hemiflavotomy with left S1 and L5 roots foraminotomy was performed. The extruded disc was was migrating upward and compressing the right L5 root, which was unusual, because she had several abnormalities, making image intensifier a must, so as to understand the presence and location of the foramina.  The far-lateral extrusion was removed in piece-meal fashion and the right L5 root was inspected and all the compressing elements were eliminated.

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

The patient had an abnormal anatomy, making the use of image-intensifier a needed procedure to know exactly what to do. Using the bony guides, were useless in this case.

The extruded disc was migrating upward and the compression was directed to the right L5 root, which is unusual. The distance between the L5-S1 annulus fibrosis and the running L5 root was minimal, causing misunderstanding of the anatomical relationships.

Presence of such extrusion with complete occlusion of the foramen caused severe compression of the right L5 root, which made it necessary to undergo surgery.