The patient came to the clinic to Dr, Ali Al-Bayyati 27-March-2020 complaining of chronic LBP with bilateral, more the right heel pain exacerbating during standing and walking. The patient is diabetic, hypertensive and receiving L-Thyroxin for several years. 

On examination, the patient is limping due to right foot pain. Tinel's sign positive over both more, the right posterior tibial nerve.

The patient was sent for investigations and MRI lumbar spine showed degenerative spine of no significance. The patient was treated conservatively.

The patient came several times and local steroids was applied. The patient then came 17-May-2023 complaining of both feet pain, more the right with exacerbation last month, associated with burning sensation of the planter aspect right foot. Tinel's sign was positive for tarsal tunnel syndrome and provocative signs was positive. EMG confirming presence of severe right tarsal tunnel syndrome.

Under G.A, with tourniquet to the right foreleg, 2 separate incisions were done over the projection of the right posterior tibial nerve. In the above incision the posterior tibial nerve was found and neurolysis was achieved, releasing during that the edge of the tarsal tunnel was bisected and through the lower incision the three major divisions of the nerve including the Baxter nerve were identified, released. Using MultiGen, the posterior tibial nerve did not respond even to 5 Volts. The tourniquet was the cause, for what it was released and proper hemostasis was achieved. The the nerve responded to 1.8 Volt. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to the posterior tibial nerve  was achieved using 2 bended catheters 10 mm exposed length. Further bipolar stimulation of the nerve was responding to 0.8 Volts. Routine closure of the wounds after strict hemostasis. She was sent to the ward.

Too early now.

The tarsal tunnel syndrome here manifest itself as late sequence of mixed degenerative factors.

This is the 257th case using the BPRF mode with MultiGen. This procedure regained routine acceptance.  It became a usual part of the spine and peripheral nerves surgery. Click here for reference.

It is still unclear to evaluate the differences of pre and post application motor responses. The only sure thing that it tells that the electrodes did not migrate during the procedure and the nerve is functioning properly. The nerve improved to motor stimulation after performed 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.