The patient came to the clinic 30-March-2024 complaining of agonizing right sciatica with difficulty to walk for 20 days and LBP with numbness and pain down to the right foot. He is using crutch and diabetic for 3 months.

On examination: The patient is limping with exaggerated scoliotic stance. SLRS was 20 degrees with pain right side and 90 degrees without pain in the left. There is drop right foot. There is analgesia right S1 territories.

The patient was sent for investigations and MRI lumbar spine showed huge extruded disc L4-5 with right downward migration.

The patient before surgery showed slight improvement of his drop foot. Foraminotomy right L5 root. The right L5 root is swollen and compressed. Right sided cleaning L4-5 disc space, Subaxillary inspection was negative and the swollen L5 root is free of any compression. Using MultiGen, bipolar stimulation of the right L5 root was not responding to 4 Volts. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to right L5 roots  was achieved using 2 bended catheters 10 mm exposed length. Further bipolar stimulation of the right L5 root still not responding to 4.0 Volts. The patient was put in Reverse Trendelenburg position with Valsalva maneuver and hyperventilation. No CSF leak. The power of the right foot improved dramatically and he was sent to the ward.

Too early now.

The patient has huge extruded disc mandating surgery.

This is the 269th 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.