The patient came to the clinic 29-September-2024 complaining of agonizing right sciatica for 7 months with shooting pain to the right ankle. MRI lumbar done 28-July-2024 bad quality showing extruded disc L5-S1.

On examination, the patient is limping with exaggerated scoliotic stance. SLRS was 60 degrees right side with pain and 75 degrees left side without pain. There is weak dorsi and planterflexion right foot 3/5. There is hypalgesia right right L5 root territory.

The patient was sent to investigations and MRI lumbar done the same day showing extruded disc L5-S1 pin-point compressing the right S1 root.

Right S1 foraminotomy was performed. The extruded disc was removed and the right S1 root became relaxed and right sided cleaning L5-S1 disc space was achieved. The root was swollen at its ganglionic part. Using MultiGen, bipolar stimulation of the right S1 root responded to 1.4 Volts. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to right S1 root  was achieved using 2 bended catheters 10 mm exposed length. Further bipolar stimulation of the right S1 root responded 1.1 Volts. The patient was put in Reverse Trendelenburg position with Valsalva maneuver and hyperventilation. No CSF leak. The power of the right foot improved dramatically and he was sent to the ward.

Too early now.

The patient has small extrusion, but piercing the right S1 root, causing right foot weak dorsi and planterflexion and agonizing sciatica.

This is the 274th 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, but 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.