05-APRIL-2026  RABAA BADER AL-HNEYTI  59 YEARS  EXTRUDED DISC L3-4 WITH LEFT FORAMINAL AND EXTRAFORAMINAL OCCLUSION.

The patient came to the clinic 08-September-2025 complaining of agonizing left sciatica down to the heel left foot for 1 month with LBP. MRI lumbar spine done 27-August-2025 showing extruded disc L3-4 with left up and extraforaminal migration.

On examination, the patient is not limping with no scoliotic stances. SLRS right side was 80 degrees with tightness and 60 degrees in the left with pain. There is weak dorsiflexion left foot 4/5. There is sensory deficit left S1 root territory. Weak left iliopsoas and left quadriceps 4/5. The patient was given medication and advised for surgery, but she disappeared. She is a known diabetic and have arterial hypertension.

The patient then came urgently to the hospital with agonizing pain for 2 days urging for surgery 04-April-2026. MRI repeated showing the same extrusion with more extraforaminal extrusion and regression of the upward piece and cardio consultation was asked.

Prone position. The level of L3-4 was identified and foraminotomy left L4 root was done.  Left sided L3-4 disc cleaning was done with removal of the left far lateral migrating extrusion. Using MultiGen, bipolar stimulation of the left L4 root responded to 1.7 Volts. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to the left L4 root  was achieved using 2 bended catheters 10 mm exposed length. Further bipolar stimulation of left L4 root responded to 1.2 Volts. The patient was put in Reverse Trendelenburg position with Valsalva maneuver and hyperventilation. No CSF leak. Routine closure of the wound. The patient showed dramatic recovery. She was sent to the ward.

The patient then came 11-April-2026 with agonizing left sciatica and MRI done urgently showing huge recurrence of the extrusion of L3-4 left side. The patient then urgently was transferred to the operative room and the wound was opened. There was still leaking fluid in the area of the wound due to diabetic mellitus with the extrusion was compressing the left L4 root. Further drilling lateral left side and more foraminotomy of the left L4 root. The extruded swollen piece was removed and further cleaning of the disc space was achieved. Routine closure of the wound and intraoperative MRI was done before weaning to the patient was done, confirming disappearance of the extrusion.  There was no video recording because all measures were taken urgently. Routine closure and the sciatic a disappeared.

The patient was discharged 13-April-2026.

The extruded disc was occluding the left L4 root and surgery will improve the related to the extrusion problems.

This is the 297th 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 regained almost normal 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.

In this particular case the recurrence was related to her diabetes mellitus which caused swelling of the annulus fibrosis.