31-AUGUST-2026  MUWAFAQ MARWAN AL-SHISHANI  31 YEARS  EXTRUDED DISC L4-5 WITH RIGHT FORAMINAL AND DOWNWARD MIGRATION.

The patient came to the clinic 26-August-2026 complaining of agonizing LBP with right sciatica for 2 months.

On examination, the patient is limping with exaggerated scoliotic stances. SLRS right side was 40 degrees with pain and 85 degrees in the left without pain. There is weak dorsi and planterflexion right foot -4/5. There is no sensory deficit. There are no signs of cauda equina syndrome.

The patient was sent for MRI lumbar spine which was done the same day showing huge extruded disc L4-5 with right foraminal and downward migration. There is lumbarization of S1. Dynamic studies ruled out overmobility. Lab investigation were normal.

Prone position. 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. Using MultiGen, bipolar stimulation of the right L5 root responded to 2.9 Volts. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to the right L5 root  was achieved using 2 bended catheters 10 mm exposed length. Further bipolar stimulation of the right L5 root responded to 2.3 Volts. Valsalva maneuver was negative. Water-tight closure of the wound. The patient showed improvement of the power and decrease of the sciatica. He was sent to the ward.

Still early now.

The extruded disc was occluding the right L5 root and surgery will improve the related to the extrusion problems.

This is the 305th 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 improvement of the motor stimulation after BPRF and the sciatic pain decreased and regained improvement of power of the left 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.