The patient came to the clinic 17-December-2023 complaining of agonizing left sciatica with inability to walk for 2 weeks and LBP for 1 month with numbness and pain down to the left foot. MRI lumbar spine done 16-December-2023 showing huge extruded disc L405 with downward migration. The patient is diabetic for 1 year and hypertensive  for 19 years in Methyldopa 250 mg three times daily. The patient stopped Baby aspirin 1 day ago. She is pregnant 3 months and she underwent epidural injection one day ago without effect. She underwent discectomy L5-S1 2014 for right sciatica.

On examination, the patient examined in bed: SLRS was 30 degrees with pain right side and 0 degrees with more pain in the left. There is severe weak dorsi and planterflexion left foot 2/5. There is hypalgesia left L5 and S1 territories. The left quadriceps muscle weak 4/5 which is could be due to pain.

The patient was admitted to the hospital and ESR was 40 mm/h and CRP 25 mg/DL, for what antibiotic was started the day of admission and diabetic chart started and to be seen by gynecologist. The gynecologist telling that the fetus has trisomy and needs abortion. We agreed to perform discectomy and after 2-3 weeks to be followed by gynecologist.

Foraminotomy left L5 root with subaxillary removal of disc in one big piece. Left sided cleaning L4-5 disc space, Using MultiGen, bipolar stimulation of the left L5 root was not responding even to 4 Volts. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to left L5 roots  was achieved using 2 bended catheters 10 mm exposed length. Further bipolar stimulation of the left L5 root was not responding even to 4 Volts. The patient was put in Reverse Trendelenburg position with Valsalva maneuver and hyperventilation. No CSF leak. The power of the left foot improved dramatically and the fetus heart rate is acceptable and she was sent to the ward.

Too early now.

The patient has almost drop left foot and the maximum mass effect due to huge extrusion.

This is the 266th 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, 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 remove the tourniquet before performing motor stimulation.