18-FEBRUARY-2025  UMAR HAMZEH HAYMOUR  55 YEARS EXTRUDED DISC L3-4 WITH RIGHT EXTRAFORAMINAL MIGRATION AND STENOSIS.

The patient was operated by me 03-December-2002 for extruded disc L4-5 with severe stenosis and wide-based extrusion, for what bilateral cleaning of L4-5 was done. The patient then came 04-February-2025 complaining of LBP for 3 years with right sciatica not reaching the right knee for one week. He is using crutch for 4 days.

On examination, the patient is in agonizing pain. Scoliotic stance and limping. SLRS was 0 degrees with pain right side and 70 degrees without pain in the left. There is right hip pain.

The patient was sent for investigations  and MRI lumbar spine showing severe stenosis L3-4 with extrude disc L3-4 and right foraminal occlusion. MRI pelvis unremarkable. 

Incision above the old one was created and decompressive laminectomy L3 and lower third of L2 and right L4 foraminotomy. The right L4 root was exposed and right sided cleaning of L3-4 disc space was achieved to decompress the nerve. The nerve was damaged due to severe compression. Using MultiGen, bipolar stimulation of the right L4 root responded to 3.5 Volts. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to right L4 root  was achieved using 2 bended catheters 10 mm exposed length. Further bipolar stimulation of the right S1 root responded to 2.5 Volts. The dural defect was not showing CSF leak, but a piece of muscle and fat was put to cover the defect, The patient was put in Reverse Trendelenburg position with Valsalva maneuver and hyperventilation. No CSF leak. Routine closure of the wound. He was sent to the ward.

Too early now.

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

This is the 281st 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.

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.