The patient came to the clinic 20-May-2015 complaining of LBP for 1 year with bilateral sciatica and neck pain and both shoulders pain. MRI  lumbar spine performed 29-April-2015 showing bulge L5-S1. On examination at that time, she was not limping with scoliotic stance with weak flexion, extension right hand 4/5 and the right triceps muscle. The power and sensation of both feet were normal. The patient was sent for MRI of the cervical spine and the pelvis. Dynamic studies of the lumbar spine with lab investigations were also requested. MRI of the cervical spine performed 20-May-2015 showed bulge disci C4-5, 5-6 and C6-7 with the last more to the right. Other investigations were normal. The patient then came 30-August-2017 still complaining of LBP with bilateral sciatica more the right side. She underwent hysterectomy 1 year ago for the LBP, but the pain persisted. She cannot tolerate anti-steroidal drugs.  

On examination, the patient is not limping with scoliotic stance. SLRS was 80 degrees with pain both sides more the right. There is weak dorsiflexion right foot 4/5 with hypalgesia right L5 territory.

The patient was sent for investigations and MRI lumbar spine performed 30-August-2017 showing bulge disci L4-5, L5-S1, dynamic studies ruled out overmobility. Lab investigations were all normal.

The patient put in supine position. With local anesthetic, the electrodes were targeted to both L5 and S1 roots both sides using the C-arm.  Using MultiGen, bipolar motor stimulation of the right L5 was achieved with 2.5 V, bipolar motor stimulation of the left L5 was achieved with 2.6 V, bipolar motor stimulation of the right S1 was achieved with 2.8 V, bipolar motor stimulation of the left S1 was achieved with 2.5 V. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to the both L5 and S1 roots was achieved using 4 bended catheters 10 mm exposed length. Further bipolar motor stimulation of the right L5 was achieved with 2.3 V, bipolar motor stimulation of the left L5 was achieved with 2.6 V, bipolar motor stimulation of the right S1 was achieved with 2.8 V, bipolar motor stimulation of the left S1 was achieved with 2.2 V.

The power of the right foot normalized and she was sciatica free. She complained of the pain of the catheters insertion and could walk in the operating room. She was sent to the ward.

The patient came to the clinic 14-September-2017 telling that there no improvement at all. The power of the right foot normalized, but the patient worry of morning LBP still the same.

I was hesitating to perform to the patient the BPRF, but according to the fact that she underwent hysterectomy of normal uterine one year ago, shifted me to perform the procedure.

If the patient during performance of BPRF is not complaining, in the future, stop it. The patient must be in agonizing radicular pain to meet the requirement of best results of BPRF.

The patient performed hysterectomy for LBP without improvement and she cannot tolerate the non-steroidal medication. The only solution was suggested to undergo BPRF. It is functionally harmless and nondestructive.

This is the 134th case using the BPRF mode with MultiGen and the second case in awaken patient. This procedure regained routine acceptance.  It became a usual part of the spine and peripheral nerves surgery. Click here for reference.

It 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. Here the threshold of stimulation power of motor stimulation of the root after application was better in some roots and the same with others.

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 is 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 4 minute session in most cases.

In this case the required voltage for motor response was relatively high, because the tips were relatively wide apart.