19-JANUARY-2025  RANA ADEL KHALED 35 YEARS  SMALL EXTRUDED DISC L5-S1 PENETRATING THE RIGHT S1 ROOT.

The patient was operated by our team 19-March-2023 for huge disc L4-5 with left downward migration. The patient then came 18-January-2025 telling that she started yesterday complain of agonizing right sciatica with pain in the right gluteal area. 

On examination, the patient is in agonizing pain, limping with exaggerated scoliotic stance. SLRS was 35 degrees right side with pain and 70 degrees left side with less pain. There is no motor, nor sensory deficit.

The patient was sent for investigations  and MRI done 19-January-2025 showing small extruded disc L5-S1 pinching the right S1 root. MRI pelvis was uneventful. It was advised to keep in conservative treatment, but she is urging for surgery. ESR was 4 mm/h and CRP 13 mg/L and Hb 13.6 and WBC 13.

The old incision was refreshed and right S1 foraminotomy. The right S1 root was exposed and right sided cleaning of L5-S1 was achieved to decompress the nerve. Using MultiGen, bipolar stimulation of the right S1 root did not respond even to 4 Volts. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to right S1 root  was achieved using 2 bended catheters 10 mm exposed length. Further bipolar stimulation of the right S1 root did not respond even to 4 Volts. The patient was put in Reverse Trendelenburg position with Valsalva maneuver and hyperventilation. No CSF leak. Considering that the root suffered micro tears, the root was covered with muscle and fat to prevent possible postoperative leak. Routine closure of the wound. She was sent to the ward.

Too early now.

The small disc was pinching the nerve root for what she was crying from pain despite cover with massive pain-killers.

This is the 280th 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, 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 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.