10-APRIL-2025  DUAA MUHAMED AL-FADEL 36 YEARS EXTRUDED DISC L5-S1 WITH RIGHT FORAMINAL-EXTRAFORAMINAL OCCLUSION.

The patient came to the clinic 03-April-2025 complaining of LBP with right sciatica for 35 days. The patient is in agonizing pain with severe scoliotic stance.

On examination, the patient is in agonizing pain. SLRS was 80 degrees with pain right side and 90 degrees without pain in the left. There is weak dorsiflexion right foot 3/5.

MRI lumbar spine done 20 days ago bad quality showing bulge L3-4, L4-5 and L5-S1. It was repeated 07-April-2025 showing extruded disc L5-S1 with far right foraminal and extraforaminal extrusion.

Using C-arm, the level of L5-S1 was identified, Incision above the level was created and right S1 foraminotomy was done.  Right L5-S1 disc cleaning was done with removal of the far lateral extrusion. Using MultiGen, bipolar stimulation of the right S1 root responded to 0.9 Volts. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to the right S1 root  was achieved using 2 bended catheters 10 mm exposed length. Further bipolar stimulation of the right S1 root responded to 0.8 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. 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 284th 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.