10-SEPRTEMBER-2026  AYA ABEDL-RAZAQ AL-QAWASMEH  28 YEARS  EXTRUDED DISC L4-5 WITH BILATERAL EXTRUSION, MORE TO THE LEFT.

The patient came to the clinic 07-September-2026 complaining of agonizing LBP for 5 months with left sciatica last week.

On examination, the patient is limping with exaggerated scoliotic stances. SLRS right side was 70 degrees with pain and 70 degrees in the left with more pain. There is weak dorsi and planterflexion left foot -4/5. There is no sensory deficit. There are no signs of cauda equina syndrome.

The patient was sent for MRI lumbar spine which was done the same day showing huge extruded disc L4-5 with bilateral more to the left foraminal and downward migration. Dynamic studies ruled out overmobility. Lab investigation were normal.

Prone position. The level of L4-5 was identified and foraminotomy left L5 root was done.  Left sided L4-5 disc cleaning was done with removal of the extrusion. It was noted that there is very tiny CSF leak without apparent tear due to severe compression of the nerve. Inspection of the right side. Using MultiGen, bipolar stimulation of the left L5 root responded to 1.9 Volts. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to the left L5 root  was achieved using 2 bended catheters 10 mm exposed length. Further bipolar stimulation of the left L5 root responded to 1.4 Volts. To avoid postoperative CSF leak, a muscle in pedicle was transferred to the suspected area. Valsalva maneuver was negative. Water-tight closure of the wound. The patient showed improvement of the power and decrease of the sciatica. She was sent to the ward.

Still early now.

The extruded disc was occluding the left L5 root and surgery will improve the related to the extrusion problems.

This is the 306th 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 and the sciatic pain decreased and regained improvement of power of the left 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.