The patient was transferred from Al-Salt hospital to Al-Shmaisani hospital 17-November-2024 complaining of agonizing LBP for 4 days with left sciatica down to the heel left foot. MRI lumbar spine done 17-November-2024 showing extruded disc L4-5 with left foraminal occlusion and huge upward migration. The patient has chronic anemia and she received 2 units blood at the referring hospital.

On examination, the patient is bedridden and unable to walk. SLRS was 10 degrees right side with pain and 0 degrees left side with more pain. There is weak dorsiflexion left foot 3/5 and planterflexion 4/5. There is analgesia left L5 and hypalgesia left S1 roots territories.

The patient lab investigations  where normal.

Left L5 foraminotomy was performed. The extruded disc was removed lateral to the axilla and left sided intradiscal cleaning of L4-5 was performed. Using MultiGen, bipolar stimulation of the left L5 root responded to 1.7 Volts. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to left L5 root  was achieved using 2 bended catheters 10 mm exposed length. Further bipolar stimulation of the left L5 root responded 1.2 Volts. The patient was put in Reverse Trendelenburg position with Valsalva maneuver and hyperventilation. No CSF leak. Routine closure of the wound. The power of the left foot improved dramatically and he was sent to the ward.

Too early now.

The patient has persistent left sciatica, not responding to medications due to severe root compression.

This is the 277th 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.