The patient came to the clinic 21-October-2024 complaining of LBP for 8 months with left sciatica down to the heel left foot. MRI lumbar spine done 19-October-2024 showing extruded disc L4-5 with left foraminal occlusion.

On examination, the patient is limping with exaggerated scoliotic stance. SLRS was 80 degrees right side without pain and 50 degrees left side with pain. There is weak dorsiflexion left foot 3/5. There is hypalgesia left L5 and S1 roots territories.

The patient was sent to lab investigations  which was normal.

Left L5 foraminotomy was performed. The extruded disc was removed lateral to the axilla and left sided intradiscal cleaning of L4-5 was performed. Using MultiGen, bipolar stimulation of the left L5 root responded to 2.8 Volts. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to left L5 root  was achieved using 2 bended catheters 10 mm exposed length. Further bipolar stimulation of the left L5 root responded 2.2 Volts. The patient was put in Reverse Trendelenburg position with Valsalva maneuver and hyperventilation. No CSF leak. Routine closure of the wound. The power of the left foot improved dramatically and he was sent to the ward.

Too early now.

The patient has persistent left sciatica, not responding to medications due to severe root compression.

This is the 276th case using the MultiGen. This procedure regained routine acceptance.  It became a usual part of the spine and peripheral nerves surgery. Click here for reference. The patient showed improvement of the motor stimulation after BPRF, the sciatic pain disappeared and dramatic improvement of the power of the foot.

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.

It is unclear why the roots have several motor response with different patients, despite the fact that the neurological status was the same and the anesthesia protocol also the same.

It could be that the nerve is recovering minute by minute after decompression and this can explain why the motor conductivity is improving after the BPRF application, which require 5 minute session in most cases.

After the 172d case, the elevation of motor stimulation above 5 V was abandoned to avoid delayed dural tear with subsequent CSF leak, which take place at the contact at the lower electrode shaft with the dura below or above the level of the axilla.

Before doing motor stimulation in peripheral nerve surgery with tourniquet. always release the tourniquet before performing motor stimulation.