The patient came to the clinic 26-January-2022 complaining of LBP with left sciatica for 2 years. MRI lumbar spine done in Yemen, bad quality but showing huge extruded disc L5-S1 with compression of the left S1 root. MRI repeated 24-January-2022 showing the same data with slight regression of the extrusion. The patient is claiming that all conservative measures failed to relieve his pain and even local injections performed by others did not help him.

On examination, the patient now is not limping with no scoliotic stance. SLRS was 90 degree left side with pain. There is weak dorsiflexion left foot. It was explained to the patient that if he is Jordanian citizen, I will not operate him, but he urged for it, because as he claims that with difficulty of wars and travels he insisted for surgery.

Foraminotomy left S1 root with removal of the extrusion. Intradiscal cleaning L5-S1 left side lateral to the root. Using MultiGen, bipolar stimulation of the left S1 root was achieved with 0.4 Volts. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to the left S1 root  was achieved using 2 bended catheters 10 mm exposed length. Further bipolar stimulation of the left S1 root was achieved with 0.4 Volts. The patient was put in Reverse Trendelenburg position with Valsalva maneuver and hyperventilation. No CSF leak. Smooth postoperative recovery. The power of the left foot normalized. He was sent to the ward.

Too early now.

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

This is the 231st 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 tells that the electrodes did not migrate during the procedure and the nerve is functioning properly. Here the threshold of motor stimulation of the affected nerve showed improvement after BPRF.

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 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 4 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 the level of the axilla.

In this case the aim of the surgery was not to decompress the nerve, but to alleviate his pain.

The nerve was severely irritated, that it responded to very low current, which explain his agonizing sciatica.