The patient came to the clinic 14-April-2021 complaining of LBP with left sciatica for 6 months. The last 2 days progressed right sciatica. MRI lumbar spine done 21-March-2021 showing extruded disc L4-5, more to the left. At that time, she was limping with exaggerated scoliotic stance. SLRS was 30 degrees right side with prominent pain and 35 degrees left side with less pain. Weak dorsiflexion right foot 4/5 and left foot 3/5. The patient was sent for investigation, but she disappeared, then she came 14-September-2021 telling that she underwent discectomy twice at Farah Hospital 05-May-2021 and 19-May-2021. She is complaining of left sciatica  and MRI lumbar spine performed 1 week ago showing huge recurrence of L4-5. The patient was advised to perform investigations and to undergo surgery, but she disappeared. The patient then came 25-Febuary-2023 with LBP and right sciatica after falling down today.

On examination, the patient is in agonizing pain, limping with exaggerated scoliotic stance. SLRS was 7 degrees right side with pain and 7 degrees left side with less pain. There is weak dorsiflexion right foot 4/5.

The patient was sent for investigations and MRI lumbar spine done the same day showing huge recurrent disc L4-5 more to the left. Dynamic studies ruled out overmobility. Lab investigations showed ESR 25 mm/h. CRP was 12 mg/dL. The patient was advised to start antibiotic and repeat Lab, which was done 18-March-2023 and ESR was 16 and CRP 12.

Decompressive laminectomy L4-5 with foraminotomy both L5 roots with left sided removal of the extrusion lateral to the axilla and bilateral cleaning L4-5 disc space. Subaxillary inspection for remnants was negative. There was a massive scar all over, that in the right corner CSF took place and the source was unidentified. Using MultiGen, bipolar stimulation of the right L5 root was not responding even to 3.5 Volts, bipolar stimulation of the left L5 root showed flickering respond to 3.5 Volts. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to both L5 roots  was achieved using 4 bended catheters 10 mm exposed length. Further bipolar stimulation of the right L5 root was responding to 1.3 Volts, bipolar stimulation of the left L5 root was responding to 1.3 Volts. The suspected corners of CSF leak were covered with muscles and fat, to prevent postoperative CSF Leak. The patient was put in Reverse Trendelenburg position with Valsalva maneuver and hyperventilation. No CSF leak. The power of the left foot normalized and the right still showing slight weakness. She was sent to the ward.

Too early now.

The recurrence rate here is below 7%, because the disc space is shallow.

This is the 254th 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. The nerve did not change to motor stimulation after performed 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 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.