The patient came to the clinic 06-March-2021 complaining of LBP with right sciatica for 45 days. MRI lumbar spine performed 06-February-2021 showing extruded disc L4-5 with right downward migration. The patient is a known diabetic for 20 years, underwent stinting 4 times and receiving Plavix and aspirin. He underwent arthroscopy left knee 10-November-2021.

On examination: The patient is in agonizing pain, limping with exaggerated scoliotic stance. There is weak dorsiflexion both feet -4/5. SLRS was 30 degrees with pain right side.

The patient was sent for investigations and to be seen by cardiologist and stop anticoagulants for 10 days.

Extended right L5 foraminotomy with subaxillary removal of the right downward migrating extrusion and right sided intradiscal cleaning of L4-5.  After the root became relax, inspection showed lateral tear of the dura above the axilla. 2 stitches using 6 zero nylon were applied and muscle was covered. Using MultiGen, bipolar motor stimulation of the right L5 root was achieved with 4 Volts. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to the right L5 root  was achieved using 2 bended catheters 10 mm exposed length. Further bipolar motor stimulation of the right L5 root was achieved with 2 Volts. The patient was put in Reverse Trendelenburg position with Valsalva maneuver and hyperventilation. No CSF leak. Routine closure of the wound.

Smooth postoperative recovery. The power of the feet improved. He was sent to the ward.

The patient came to the clinic 27-March-2021 telling that the sciatica disappeared, but still having mild pain in the right hip joint. SLRS was 70 degrees without pain in the right. There is still weak dorsiflexion right foot 4/5 with gross hypalgesia right L5 territory. Advised to have Nucleo-CMP twice daily for 5-6 months.

There is still an estimated postoperative disc recurrence around 7%, since the disc space is not completely shallow.

This is the 209th 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 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 motor stimulation of the affected nerve did not change.

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.

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 the level of the axilla.