14-APRIL-2025  ASIA RATEB NAASAN 50 YEARS HUGE RECURRENCE  L4-5 DISC WITH LEFT DOWNWARD MIGRATION.

The patient was operated by me 10-September-2018 for PLD L4-5 for right huge extrusion right downward migration. The patient then came 17-December-2018 and MRI was done showing no recurrence. The patient then came 16-February-2025 telling that the last 2 weeks got LBP with bilateral sciatica.

On examination, the patient is in agonizing pain. SLRS was 70 degrees without pain right side and 70 degrees with pain in the left. There is  no motor, nor sensory deficit.

MRI lumbar spine done the same day showing extruded disc L5-S1 with far right foraminal and extraforaminal extrusion. The patient then came 13-April-2025 urging for surgery and she had flue 10 days ago and CRP was 33.4, ESR 20 mm/h and antibiotic was started. There is weak dorsiflexion right foot 4/5.

The old incision refreshed and foraminotomy left L5 root was done.  Left L4-5 disc cleaning was done with removal of the down migrating extrusion. Using MultiGen, bipolar stimulation of the left L4 root responded to 1.1 Volts. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to the left L4 root  was achieved using 2 bended catheters 10 mm exposed length. Further bipolar stimulation of left L4 root responded to 0.9 Volts. there was a tiny dural defect at the lateral wall of the root, which was coagulated to shrink the defect and covered with piece of muscle. 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. She was sent to the ward.

Too early now.

The extruded disc was occluding the right L5-S1 foramen with extension extraforaminal.

This is the 285th 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 with improvement of power 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.