11-MAY-2026  ABEER JAMEEL AL-NAWAYSEH  46 YEARS  EXTRUDED DISC L4-5 WITH RIGHT FORAMINAL OCCLUSION.

The patient was operated by me 29-July-2002 for extruded disc L5-S1 with left sciatica. The patient then came to the clinic 21-April-2026 complaining of agonizing right sciatica for 1 year with exacerbation last 3 days down to the heel right foot. MRI done 12-July-2025 showing extruded disc L4-5 with right foraminal occlusion. The patient has rheumatoid arthritis for what she is receiving Prednisolone 5 mg twice a day and L-thyroxin 50 microgram a day for 1 year.

On examination, the patient is limping with severe scoliotic stances. SLRS right side was 80 degrees with pain and 90 degrees in the left without pain. There is weak dorsi and planterflexion right foot 4/5. There is sensory deficit right L5 and S1 root territory. The patient was given medication and sent for investigation

MRI done showing huge extruded disc L4-5 with huge right foraminal occlusion with right downward migration.

Prone position. The level of L4-5 was identified and foraminotomy right L5 root was done.  Right sided L4-5 disc cleaning was done with removal of the extrusion. Using MultiGen, bipolar stimulation of the right L5 root did not responded even to 3.5 Volts. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to the right L5 root  was achieved using 2 bended catheters 10 mm exposed length. Further bipolar stimulation of the right L5 root did not responded to 3.5 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 dramatic recovery. She was sent to the ward.

Still early now.

The extruded disc was occluding the right L5 root and surgery will improve the related to the extrusion problems.

This is the 300th 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 no improvement of the motor stimulation after BPRF because the nerve is mostly severely damaged but the sciatic pain disappeared and regained almost normal power of the right foot.

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.