The patient came to the clinic 25-February-2017 complaining of LBP for 40 days with right sciatica with numbness all toes right foot after falling down 13-January-2017. MRI lumbar spine performed 20-February-2017 showing huge extruded disc L4-5 with right foraminal occlusion and severe segmental stenosis. The patient is a known diabetic for 3 years under treatment and very obese weighting 160 Kg.  He is in aspirin.

On examination, the patient is in agonizing pain, unable to stand and walk to evaluate the scoliotic stance.  He was examined in the right lateral position. SLRS was 70 degrees both sides with pain in the left side. There is drop right foot , weak dorsiflexion left foot 3/5 and weak planterflexion both feet -4/5. ESR was 40 mm/h and CRP was 48 mg/dL. The patient was advised to stop anticoagulant for 1 week and start Zinnat 500 mg twice daily to avoid postoperative discitis. ESR repeated 02-March-2017 showing 34 mg/dL and ESR was 18 mm/h.

Partial decompressive laminectomy L4-5. Foraminotomy both L5 roots. The extruded disk was removed lateral to the axilla of both L5 roots. Bilateral cleaning of L4-5 was performed. Using MultiGen, bipolar motor stimulation of the right L5 was achieved with 2.5 V, bipolar motor stimulation of the left L5 was achieved with 0.7 V. 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 motor stimulation of the right L5 was achieved with 2.2 V, bipolar motor stimulation of the left L5 was achieved with 0.7 V . Routine closure of the wound.

Smooth postoperative recovery. The power of the left foot normalized and slight improvement of the right foot power. He was sciatica free and sent to the ward.

The patient still having an estimated postoperative recurrence more than 7%, because the disc space is still not shallow and he is diabetic and obese.

This is the 110th 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 there was slight improvement of the threshold of stimulation power of motor stimulation of the right L5. The left root remained the same.

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 anaesthesia protocol also the same.

The L5 root with drop foot could response with 2.5 V before application of BPRF and slight improvement was noticed. Time will show if these data are predictive for good recovery.