The patient was operated by me 03-December-2011 for extruded disc L4-5 with left far downward migration. The patient was doing well until 3 weeks ago got agonizing LBP with left sciatica. The patient is living in UAE and she is pregnant and still having 3 months until full term delivery. MRI lumbar spine performed 07-December-2016 showing huge recurrence of L4-5 disc with left foraminal occlusion and downward migration. For unknown reasons the patient was operated in UAE in the German Saudi Center with epidural anaesthesia in right sided position and the patient did not tolerate the procedure and was put under G.A., but the neurosurgeon for  difficult circumstances could not perform the removal of the recurrence, MRI performed 12-December-2016 showing the same extrusion as before the surgery. The patient after surgery still in agonizing pain and they came to Jordan urging for surgery.

On examination, the patient is bedridden now. SLRS was 20 degrees with pain in the left. There is weak left foot dorsiflexion 2/5 with hypalgesia left L5, S1 territories. The wound clean and the stitches removed. She was seen by gynecologist and pediatrician and she was given 1 unit blood and 2 units FFP

The patient was put in prone position with Wilson frame, so that the abdomen is hanging free with monitoring both the patient and the fetus with recommendation of the gynecologist. Neurolysis of the left L5 root was achieved. The extruded disk was removed lateral to the axilla under the L5 root. Left sided cleaning of L4-5 was performed. Using MultiGen, bipolar motor stimulation of left L5 was achieved with 4.5 V. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to left L5 root was achieved using 2 bended catheters 10 mm exposed length. Further motor stimulation done to the same root and the response was 4.0 V in the left L5 with more brisk response. Routine closure of the wound.

Smooth postoperative recovery. The power of left foot improved slightly and she was sciatica free. She was sent to the ward.

The patient still having an estimated postoperative recurrence around 7%, because the disc space is still not shallow.

This is the 97th 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 tell that the electrodes did not migrate during the procedure and the nerve is functioning properly. Here there was considerable improvement of the threshold of stimulation power of motor stimulation after the BPRF. The high voltage needed to the motor response was a sign of dissection injury due to previous surgery performed 2 weeks ago.

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 anaesthesia protocol also the same.