21-JUNE-2025  SEHAM ODEH ISEED  72 YEARS  EXTRUDED DISC L3-4 WITH BILATERAL FORAMINAL OCCLUSION.

The patient was seen by me since 2003 for several complains, among them convexital meningioma right side , which was operated elsewhere 2009. She is receiving Depakine chrono twice daily for controlled epileptic attacks. The patient then came 11-June-2025 complaining of difficult walking for 2 months with LBP, numbness both feet more the right  with waddling gait, varicous veins both lower limbs and pain of the right knee.

On examination, SLRS was 80 degrees without pain right side and 85 degrees in the left. There is  weak dorsi and planterflexion left foot due to old brain surgery. No sensory deficit.

MRI lumbar spine , pelvis and right knee done the same day showing extruded disc L3-4 with bilateral foraminal and extraforaminal extrusion. The hips have bilateral trochanteric bursitis with torn meniscus right knee and extrusion of the meniscus. CRP was negative, ESR 15 mm/h.

The level of L3-4 was identified and L3 laminectomy, upper third of L4 and foraminotomy both L4 roots was done.  Right sided L3-4 disc cleaning was done with removal of the extrusions piercing the root. Inspection of the left side was negative. Using MultiGen, bipolar stimulation of the right L4 root responded to 0.6 Volts. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to the right L4 root  was achieved using 2 bended catheters 10 mm exposed length. Further bipolar stimulation of right L4 root responded to 0.5 Volts. Bipolar stimulation of the left L4 root responded to 0.9 Volts. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to the right L4 root  was achieved using 2 bended catheters 10 mm exposed length. Further bipolar stimulation of left L4 root responded to 0.7 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 normal recovery. She was sent to the ward.

Too early now.

The extruded disc was occluding bilateral L3-4 foramen with extension extraforaminal.

This is the 286th 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 decreased in the right leg.

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.