The patient came to the emergency of Shmaisani hospital 01-August-2023 complaining of agonizing left sciatica with inability to walk for 1 day and LBP for 20 days. MRI lumbar spine done24-July-2023 showing severe LCS L3-4 with huge right extruded disc L3-4 with upward migration. EMG done 26-July-2023 suggesting Guillain-Barre syndrome?. The patient is diabetic insulin dependent  for 7 years and hypertensive  in Co-Diovan 160/25 and Concor 5 mg once daily. The patient stopped Baby aspirin 2 days ago.

On examination, the patient examined in bed: SLRS was 60 degrees with pain and 20 degrees with more pain. There is drop left foot with weak dorsiflexion right foot and planterflexion left foot 3/5. There is analgesia both L5 territories. The left quadriceps muscle weak 4/5.

The patient was sent for investigations and MRI lumbar spine done 01-August-2023 showing severe LCS L3-4 with wide based extrusion more to the right and compressing both L4  roots. Dynamic studies ruled out overmobility. ESR was 70 mm/h and CRP 10.9 mg/DL, for what 2 antibiotics were started the day of admission.

Decompressive laminectomy L3 and upper third of L4 with foraminotomy both L4 roots with removal of disc starting from the right, then the left. There was a tiny dural defect at the right lower corner of the field, which was shrunken by bipolar coagulation. Using MultiGen, bipolar stimulation of the right L4 root was responding 2.4 Volts, bipolar stimulation of the left L4 root was not responding even to 4.0 Volts. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to both L4 roots  was achieved using 4 bended catheters 10 mm exposed length. Further bipolar stimulation of the right L4 root was responding to 1.6 Volts, bipolar stimulation of the left L4 root was responding to 3.5 Volts. The patient was put in Reverse Trendelenburg position with Valsalva maneuver and hyperventilation. No CSF leak. The power of the feet improved and he could elevate the left foot big toe with weakness. He was sent to the ward.

Too early now.

The patient has drop left foot and the maximum mass effect due to extrusion was in the right side?

This is the 262d 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 considerable improvement of the motor stimulation after 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.

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 remove the tourniquet before performing motor stimulation.