Inomed Stockert Neuro N50. A versatile
RF lesion generator and stimulator for
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Multigen RF lesion generator .
26-APRIL-2017 BADIA AHMAD AREF 60
YEARS EXTRUDED DISC L4-5 WITH LEFT FORAMINAL OCCLUSION.
The patient was operated by me
for PLD L3-4 and did well. The patient then came
several times for different reasons, among them
herpes Zoster neuritis of the right L 1 root in
26-November-2011 and treated accordingly. The
patient then came to the clinic
complaining of LBP with left sciatica with
exacerbation last 3 months and inability to walk
more than 100 meters.
On examination at that time, the patient is in agonizing
pain, limping with mild scoliotic stance. SLRS
was 80 degrees without pain in both sides. There is weak
dorsiflexion left foot 3/5, and planterflexion
left foot 4/5 with hypalgesia below the left
The patient was sent for investigations and MRI
lumbar spine performed the same day showing
extruded disc L4-5 with left foraminal
occlusion. Dynamic studies ruled out
overmobility of the spine, but ESR was 47 mm/h
and CRP was 7 mg/L. The patient had UTI for what
antibiotic treatment was started. The patient
then came 23-April-2017 after cardiologic
evaluation and new MRI of the spine requested
confirming the same previous data. ESR was 28
mm/h and CRP was 6 mg/L.
Foraminotomy of the left L5
root was achieved. There is slight mobility of
the L4 spinous process. The extruded disk was removed
lateral to the axilla of the left L5 root.
It was noticed from the start, that the dura was
transparent at the point of maximum compression
and all precautions were paid to avoid CSF leak. Left sided intradiscal cleaning of L4-5 disc space was performed.
The left L5 root was inspected to rule out any
remnants of extrusion. Using
MultiGen, bipolar motor stimulation of the left
was achieved with 1.2 V. Waiting 4 minutes the same procedure
repeated and bipolar motor stimulation of the
left L5 was achieved with 1.1 V. A
bipolar pulsed mode
RF with 42 Celsius, 240 sec, 2 Hz and 20 msec
duration to left L5 root was achieved using
2 bended catheters 10 mm exposed length. Further
bipolar motor stimulation of the left L5 was
achieved with 0.9 V.
Valsava maneuver was applied to rule out CSF
leak. A piece of muscle was applied over the
transparent dura anterior to the axilla. Routine closure of the
Smooth postoperative recovery. The power of
left foot normalized and she was sciatica free.
She was sent to the ward.
The patient still having an estimated
postoperative recurrence around 7%, because the disc
space is still not shallow.
This is the 116th 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
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 considerable improvement of the threshold of stimulation
power of motor stimulation of the left L5 root.
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 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 4 minute session. This trail was
performed intentionally to confirm or exclude such this
conclusion. Here we noticed that the motor response of the
nerve improved after first stimulation, confirming that the
improvement came as a result of previous stimulation and
BPRF still adding further improvement.