The patient from Palestinian Authority came to the clinic 06-November-2021 complaining of choric LBP with exacerbation last 3 months with right sciatica with feeling of weak both lower limbs and inability to walk more than 50 meters. The patient is a known hypertensive for 10 years under treatment. She underwent lumbar disc surgery 1994, 1997 in Palestine and 2007 in USA. Total left knee replacement 2015.

On examination, the patient in agonizing pain, limping with exaggerated scoliotic stance. SLRS 80 degrees both side with pain. There is weak dorsiflexion both feet 4/5 with hypalgesia right L5 root territory.

The patient was sent for investigations and MRI lumbar spine showed assimilation of L4 and 5. There is spondylolisthesis L2-3 and L3-4 with segmental stenosis.

The level of L2-3 was identified by the C-arm. Skeletonization of L2,3,4 down until the lateral processes were seen. Using ERISMA-LP EVOLUTION system, transpedicular screws, polyaxial to L3 and monoaxial to L2 and L4 body were inserted 6.5x45 dimensions. Cross connector large size was inserted. Foraminotomy right L3 root with removal of compressing elements. Using MultiGen, bipolar stimulation of the right L3 root was achieved with 2.5 Volts. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to the right L3 root  was achieved using 2 bended catheters 10 mm exposed length. Further bipolar stimulation of the right L3 root was achieved with 2.2 Volts. The patient was put in Reverse Trendelenburg position with Valsalva maneuver and hyperventilation. No CSF leak. The harvested bone was put lateral to the rods. A fat tissue with pedicle was used to cover the dura to minimize the postoperative scar formation and prevent postoperative CSF leak. Routine closure of the wound. Smooth postoperative recovery. The power of the feet improved. She was sent to the ward.

Too early now.

This is the 229th 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.