The patient was operated by me 25-Novemeber-2015 for PLD L4-5. The patient then came to the clinic 07-July-2018 complaining of LBP with left sciatica for 15 days. He is using crutches for 10 days. MRI lumbar spine performed 11-June-2017 ruled out recurrence of the disc.

On examination, the patient is in agonizing pain, was limping with scoliotic stance. Difficult micturition, SLRS was 70 degrees right side with pain and 70 degrees left side without pain. There was weak dorsiflexion left foot -3/5 and planterflexion 4/5. There is hypalgesia left L5 root territory.

The patient was sent for investigations and MRI lumbar spine performed 07-July-2018 showing huge recurrence of L4-5 more to the left with no signs of overmobility.

Neurolysis left L5 root  with removal of the extrusion and left sided cleaning L4-5 disc space. During inspection, there is CSF leak coming from the anterior wall of the dura, not reachable to visual control. A piece of muscle was applied to the suspected area and Surgicele was applied to the disc defect and lateral to the root. Using MultiGen, bipolar motor stimulation of the left L5 root was achieved with 3.0 V. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to the left L5 root was achieved using 2 bended catheters 10 mm exposed length. Further bipolar motor stimulation of the left L5 root was achieved with 2.5 V. Routine water-tight closure of the wound.

Smooth postoperative recovery. The power of the left foot became normal. He was sciatica free. He was sent to the ward.

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

The dural tear cannot be judged, that it was before the attack or during removal of the fragments. The presence of scars make it very difficult to manipulate properly during this situation.

This is the 158th 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 stimulation power of motor stimulation of the affected root after application improved.

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.

The presence of scar increase the threshold of motor stimulation.