The patient was operated by me 16-January-2016 for huge extruded disc L5-S1 with left downward migration and left sciatica. The patient then came to the clinic 22-September-2024 complaining of agonizing left sciatica with inability to walk for 3 days.

On examination, the patient is limping with exaggerated scoliotic stance. SLRS was 60 degrees right side with pain and 0 degrees left side with more pain. There is weak dorsi and planterflexion left foot 3/5. There is hypalgesia left L5 root.

The patient was sent to investigations and MRI lumbar done the same day showing recurrence of L5-S1 with left foraminal occlusion, less than before the first surgery. Dynamic studies ruled out overmobility. The patient was treated conservatively. The patient did not improve and cannot sleep due to pain despite receiving heavy pain-killers.

Left S1 foraminotomy was performed. During dissection at the left lower part a CSF leak came from under the scar, for what the patent was positioned with head down the cardiac level. The extruded disc was removed lateral to the axilla and left sided intradiscal cleaning of L5-S1 was performed. Using MultiGen, bipolar stimulation of the left S1 root responded to 1.3 Volts. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to right S1 root  was achieved using 2 bended catheters 10 mm exposed length. Further bipolar stimulation of the left S1 root responded 1.0 Volts. The patient was put in Reverse Trendelenburg position with Valsalva maneuver and hyperventilation. CSF leak was noted from the previous mentioned point, it was covered with fat. The power of the left foot improved dramatically and she was sent to the ward.

Too early now.

The patient has almost drop right foot and the maximum mass effect due to severe root compression.

This is the 275th 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.