20-MAY-2026  FATMEH KHALEEL BARHUMA  52 YEARS EXTRUDED DISC L3-4 LEFT EXTRAFORAMINAL WITH RETROLISTHESIS L3-4 AND UNSTABLE LEFT L3-4 FACET CAUSING SEGMENTAL SCOLIOSIS 20 DEGREES COBS ANGLE TO THE LEFT.

The patient came to the clinic 12-May-2026 complaining of neck and LBP for 1 month with exacerbation of LBP and left sciatica down to the left knee. MRI bad quality done 24-January-2026 showing bulge C3-4 and C4-5. Possible evidence of extruded disc L3-4 left side. EMG ruled out CTS. Dynamic studies of cervical spine ruled out overmobility. LS Spine X-ray showing segmental scoliosis at L3-4 with Cobs angle 20 degrees to the left. The patient has spring allergy receiving Histocare once daily.

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

MRI done 13-May-2026 showing huge extruded disc L3-4 with huge left extraforaminal occlusion with retrolisthesis L3-4.

Prone position. The level of L3-4 was identified and foraminotomy left L4 root was done.  Left sided L3-4 disc cleaning was done with removal of the extrusion. Using MultiGen, bipolar stimulation of the left L4 root responded to 3.5 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 the left L4 root responded to 3.1 Volts. Using Nuvasive Armada polyaxial screws 6.4x 4.5 inserted to L3-4-5 levels with distraction and reduction  and cross connector with the harvested bone lateral to the bended rods. 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 left L4 root and surgery must be done to correct all the problems in the area to improve the related to the extrusion and other problems.

This is the 301st 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 mild 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 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.

The patient is denying that she felt won, but the data showing the oposite.