17-JULY-2025  AHMAD ABDEL-KAREEM AL-MAHARMAH  27 YEARS  EXTRUDED DISC L4-5 WITH LEFT FORAMINAL OCCLUSION.

The patient came 15-July-2025 complaining of agonizing left sciatica down to the heel left foot for 3 months with LBP. MRI lumbar spine done 13-July-2025 showing huge extruded disc L4-5 with left foraminal occlusion.

On examination, the patient not limping with scoliotic stance. SLRS right side was 50 degrees with tightness and 50 degrees in the left with more pain. There is  weak dorsiflexion left foot 4/5. No sensory deficit.

Lab investigations were uneventful. CRP was negative, ESR 15 mm/h.

The level of L4-5 was identified and foraminotomy left L5 root was done.  Left sided L4-5 disc cleaning was done with removal of the extrusion. Using MultiGen, bipolar stimulation of the left L5 root responded to 1.7 Volts. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to the left L5 root  was achieved using 2 bended catheters 10 mm exposed length. Further bipolar stimulation of left L5 root responded to 1.5 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 normal recovery. He was sent to the ward.

Too early now.

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

This is the 289th 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 disappeared and regained normal power of the left 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.