23-DECEMBER-2025  FATHIYE QATHAFI MUHAMED QATHAFI  49 YEARS  EXTRUDED DISC L3-4 WITH RIGHT FAR DOWNWARD MIGRATION AND ELEMENTS OF CAUDA EQUINA.

The patient came 17-December-2025 complaining of agonizing right sciatica down to the heel left foot for 10 months with LBP with disturbed micturition. MRI lumbar spine done the same with contrast showing huge extruded disc L3-4 with right far downward migration.

On examination, the patient is limping with scoliotic stance. SLRS right side was 40 degrees with pain and 90 degrees in the left without pain. There is  almost drop right foot. There is hypalgesia right L5,S1-2-3 and 4.

The patient was sent for investigations which confirmed the presence of the extrusion of L3-4 disc with far downward migration. Dynamic studies ruled out overmobility. Lab investigations showed CRP 13, ESR 35 mm/h for what Zinnat was started several days before surgery.

The level of L3-4 was identified and foraminotomy right L4 root was done.  Right sided L3-4 disc cleaning was done with removal of the right far down migrating extrusion in one piece. Using MultiGen, bipolar stimulation of the right L4 root responded to 1.5 Volts. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to the right L4 root  was achieved using 2 bended catheters 10 mm exposed length. Further bipolar stimulation of right L4 root responded to 1.1 Volts. The patient was put in Reverse Trendelenburg position with Valsalva maneuver and hyperventilation. No CSF leak. Routine closure of the wound. The patient showed dramatic recovery. She was sent to the ward.

Too early now.

The extruded disc was occluding right L3-4 foramen with far downward migration.

This is the 296th 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 despite that the root was severely damaged, and the sciatic pain disappeared and regained almost normal power of the right 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.