25-SEPTEMBER-2025  MAHER TAHA JUMAA  25 YEARS  HUGE EXTRUDED DISC L5-S1 WITH RIGHT FAR DOWNWARD MIGRATION AND RECURRENT DISC L4-5 RIGHT SIDE.

The patient came, an Iraqi citizen came to Dr. Ali Al-Bayyati 22-September-2025 complaining of agonizing LBP with right sciatica down to the heel right foot for 2 months. The patient was operated 2021 in Iraq for left sciatica and discectomy L4-5 was performed. After that surgery he suffered drop right foot, which slightly recovered over 4-5 months.

On examination, the patient limping with scoliotic stance. SLRS right side was 30 degrees with pain and 85 degrees in the left with no pain. There is  weak dorsiflexion both feet 4/5 with hypalgesia right S1 territory.

MRI lumbar spine done 23-September-2025 showing huge extruded disc L5-S1 with right far downward migration and recurrent disc L4-5 right side. Dynamic studies ruled out overmobility. Lab investigations were uneventful.

The level of L4-5 was identified and foraminotomy right L5 root was done.  Right sided L4-5 disc cleaning was done with removal of the extrusion. Foraminotomy right S1 root was done and removal of the right far downward migrating piece was achieved and right sided intradiscal cleaning of L5-S1 was done. Using MultiGen, bipolar stimulation of the right L5 root did not respond even to 3.5 Volts. The right S1 root did mot respond even to 3.5 Volts. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to the 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 3.5 Volts. The right S1 root did not respond eve  to 3.5 Volts. The patient was put in Reverse Trendelenburg position with Valsalva maneuver and hyperventilation. No CSF leak. Routine closure of the wound. The patient showed normal recovery. He was sent to the ward.

Too early now.

The extruded disc L5-S1 was right far downward migrating with the L4-5 had recurrence right side.

This is the 291st 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 mild improvement of the motor stimulation after BPRF at the right L5 root, and the sciatic pain disappeared and regained normal power of the both feet.

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.

Since I am living in Jordan with all factors directed against doing science and complete absence of industrial infrastructure, all these data must be considered with caution.