The patient an Iraqi citizen, came to the clinic 27-April-2024 complaining of LBP with bilateral sciatica for 8 years with burning sensation with pareasthesia both feet, more the left. The patient is a known diabetic and hypertensive for more than 20 years.

On examination: The patient is limping with exaggerated scoliotic stance. SLRS was 70 degrees with pain both sides and walking with stick.

The patient was sent for investigations and MRI lumbar spine showed degenerative spine with multiple bulges. EMG showed severe mixed axonal polyneuropathy with severe CTS more the left and severe TTS more the left.

Under G.A, with tourniquet to the left foreleg, 2 separate incisions were done over the projection of the left posterior tibial nerve. In the above incision the posterior tibial nerve was found and neurolysis was achieved, releasing during that the edge of the tarsal tunnel was bisected and through the lower incision the three major divisions of the nerve including the Baxter nerve were identified, released. Using MultiGen, the posterior tibial nerve was not responding even to 4 Volt. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to the posterior tibial nerve  was achieved using 2 bended catheters 10 mm exposed length. Further bipolar stimulation of the nerve was responding to 3.8 Volts and the medial planter branch to 2.7 Volts. Routine closure of the wounds after strict hemostasis. She was sent to the ward.

Too early now.

The patient has multiple problems and the expectation for partial improvement of such surgery is highly expected.

This is the 270th 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 disappeared and dramatic improvement of the power of the 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 at least 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 remove the tourniquet before performing motor stimulation.