The patient came to the clinic 10-October-2016 complaining of LBP without sciatica for 5 years. The last 45 days bilateral sciatica more the right down with numbness all toes right foot with signs of coccydenia. MRI lumbar spine performed 15-December-2015 showing bulge L3-4, L4-5 and L5-S1.

On examination, the patient is not limping now. She has scoliotic stance. SLRS was 70 degrees with pain right side and 75 degrees with pain left side. There is weak dorsiflexion both feet -4/5.

The patient was sent for investigation and MRI of the lumbar spine performed 10-October-2016 showing the same bulges of L3-4, 4-5 and L5-S1. MRI of the pelvis showing multiple fibroids with large Bartholin cyst. Dynamic studies showed spondylolisthesis of L4-5. The patient was sent for gynecologic evaluation and medication prescribed.

Skeletonization of L3-4-5. Check of overmobility was positive for L4-5. Transpedicular fixation of L4-5 using XIA 3 system with 4 monoaxial screws 6.5x45 to L5 and L4. The screws were not responding even to 8 V. Using MultiGen, bipolar motor stimulation of left L4 was achieved with 0.4 V. The left L5 root with 0.7 V. The right L4 root was responding to 0.3 V and the right L5 root to 1.0 V. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to both L4 and L5 roots was achieved using 4 bended catheters 10 mm exposed length lateral to the isthmi . Further motor stimulation done to the same roots and the response was 0.2 V to the left L4 root, 0.6 V in the left L5 with more brisk response and 0.3 V to the right L4 root, and 1.0 V to the right L5 root. Cross connector was applied 42 mm Slight distraction reduction was applied. Routine closure of the wound.

Smooth postoperative recovery. The power of both feet normalized. She was sent to the ward.

The patient has bulge diski several levels, that cannot explain the agonizing pain. The segmental overmobility is the determinant factor for pain generation, which needs correction.

This is the 86th case using the BPRF mode with MultiGen. This procedure regained routine acceptance.  It became a usual part of the spine surgery. Click here for reference.

It still unclear to evaluate the differences of pre and post application motor responses. The only sure thing that it tell that the electrodes did not migrate during the procedure and the nerve is functioning properly. Here there was no change of the threshold of stimulation power of motor stimulation after the BPRF.

With accumulation of data, it became clear that the irritated nerve with aberrant currents running in the C fibers up, not only causing no change or elevation of the required voltage to achieve motor response, but they could cause the preoperative weakness. Ablation of such currents results in facilitation of the motor response and improvement of function with disappearance of pain.

In this case the roots were reached externally, lateral to the isthmi.