The patient was operated by me 18-December-2023 for huge extruded disc L4-5 with left sciatica. She was pregnant at that time and the daughter was born in good condition. The patient then came to the clinic 04-September-2024 complaining of agonizing right sciatica with inability to walk for 3 days.

On examination, the patient is limping with exaggerated scoliotic stance. SLRS was 03 degrees right side with pain and 70 degrees left side without pain. There is weak dorsi and planterflexion right foot 3/5. There is hypalgesia below right L3 root.

The patient was sent to investigations and MRI lumbar done the same day showing scar at the previous L4-5 and L5-S1 levels. No data supporting recurrence in the right side. Dynamic studies ruled out overmobility. ESR was 40 mm/h. The patient was treated conservatively. The patient did not improve and cannot sleep due to pain despite receiving heavy pain-killers. The patient performed MRI dorsal spine and the pelvis 17-September-2024 to rule out other pathological sites. ESR and CRP were normal 

After studying the data it was noticed that the right facet of L5-S1 was the cause of her sciatica and surgical exploration of the right L5 and S1 root was suggested.

Right L5 hemilaminectomy. Foraminotomy right L5 and S1 roots was performed. Using the high speed drill the right L5-S1 facet was drilled medially to decompress the right S1 root. Using MultiGen, bipolar stimulation of the right L5 root was not responding even to 4 Volts, bipolar stimulation of the right S1 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 right L5 and S1 roots  was achieved using 4 bended catheters 10 mm exposed length. Further bipolar stimulation of the right L5 root responded to 3.0 Volts, bipolar stimulation of the right S1 root responded 2.0 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 she was sent to the ward.

Too early now.

The patient has almost drop right foot and the maximum mass effect due to severe root compression.

This is the 273d 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 release the tourniquet before performing motor stimulation.