17-NOVEMBER-2025  FATMEH MUSTAFA HUSSEIN  43 YEARS  HUGE EXTRUDED DISC L4-5 WITH LEFT FAR DOWNWARD MIGRATION.

The patient came 13-November-2025 complaining of agonizing left sciatica down to the heel left foot for 20 days with LBP. MRI lumbar spine done 12-November-2025 showing huge extruded disc L4-5 with left far downward migration.

On examination, the patient is limping with scoliotic stance. SLRS right side was 90 degrees with tightness and 70 degrees in the left with agonizing pain. There is  almost drop left foot and weak planterflexion 1/5 same foot. No sensory deficit, but numb left foot.

Lab investigations were uneventful. CRP was negative, ESR 19 mm/h.

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 left far down migrating extrusion in one piece. Using MultiGen, bipolar stimulation of the left L5 root did not responded even to 3.5 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 left L5 root did not responded to 3.5 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 bilateral L3-4 foramen with extension extraforaminal.

This is the 292d 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 because the root was severely damaged, and the sciatic pain disappeared and regained almost normal 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.