The patient came to the clinic 15-February-2024 complaining of agonizing right sciatica with difficulty to walk for 2 months and LBP with numbness and pain down to the right foot. MRI lumbar spine done 14-February-2024 showing huge extruded disc L5-S1 with right downward migration. Dynamic studies - no overmobility.

On examination: The patient is limping with exaggerated scoliotic stance. SLRS was 20 degrees with pain right side and 70 degrees without pain in the left. There is severe weak dorsiflexion right foot 1/5 and planterflexion 3/5. There is hypalgesia right L5 and S1 territories.

The patient was admitted to the hospital and ESR was 10 mm/h and CRP 4.2 mg/DL.

Foraminotomy right S1 root. The right S1 root is compressed. Right sided cleaning L5-S1 disc space, Subaxillary inspection was negative and the right S1 root is free of any compression. Despite drilling of the upper edge of S1 lamina and leaving 2-3 mm thickness of bone a twig of root let came from the inside of the bone, causing slight CSF leak. It was closed by tiny piece of muscle. Using MultiGen, bipolar stimulation of the right S1 root was responding to 3.9 Volts. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to left L5 roots  was achieved using 2 bended catheters 10 mm exposed length. Further bipolar stimulation of the right S1 root responding to 3.9 Volts. Fat transfer was applied to fill the dura and prevent possible CSF leak. The patient was put in Reverse Trendelenburg position with Valsalva maneuver and hyperventilation. No CSF leak. The power of the right foot improved dramatically and he was sent to the ward.

Too early now.

The patient has huge extruded disc mandating surgery.

This is the 268th 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 no improvement of the motor stimulation after BPRF and 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 at least 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 remove the tourniquet before performing motor stimulation.