The patient came to the clinic 13-September-2018 complaining of LBP  with left sciatica for 7 months with exacerbation last 3 weeks. MRI lumbar spine performed 5 months ago showing extruded disc L5-S1 (bad quality with no information supporting that it belong to him).

On examination: He is limping with exaggerated scoliotic stance. SLRS was 80 degrees right side and 5 degrees in the left with severe pain. The left AJ is absent. There was weak dorsiflexion left foot -4/5 with weak planterflexion same foot 4/5.

The patient was sent for investigations and MRI lumbar spine performed 13-September-2018 showing extruded disc L5-S1 with left foraminal occlusion. ESR was normal, but CRP 16 mg/L for what Zinnat 500 twice daily was started to prevent escalation of infection.

Foraminotomy left S1 root with removal of the extrusion lateral to the axilla and left sided cleaning L5-S1 disc space with preservation and reflection of the ligamentum flavum to the right. Using MultiGen, bipolar motor stimulation of the left S1 root was achieved with 1.0 V. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to left S1 root was achieved using 2 bended catheters 10 mm exposed length. Further bipolar motor stimulation of the left S1 root was achieved with 0.9 V. The patient was put in Reverse Trendelenburg position with Valsalva maneuver. No CSF leak. Routine closure of the wound after repositioning of the ligamentum flavum.

Smooth postoperative recovery. The power of left foot became normal. He was sciatica free. He was sent to the ward.

There is still an estimated postoperative recurrence around 7%, because the disc space height is not shallow.

This is the 168th 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. Here the threshold of stimulation power of motor stimulation of the affected roots after application improved dramatically.

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 is 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 4 minute session in most cases.