14-DECEMBER-2025  MANSOUR MUHAMED AHMAD ISMAEEL  60 YEARS  EXTRUDED DISC L5-S1 WITH LEFT FORAMINAL AND EXTRAFORAMINAL OCCLUSION.

The patient a Yemeni citizen came 09-December-2025 complaining of agonizing left sciatica down to the heel left foot for 4 months with LBP. MRI lumbar spine done 15-September-2025 showing bulge disc L4-5 and small extruded disc L5-S1 left side (bad quality). MRI dorsal spine done 08-December-2025 showing T9-10 left facet hypertrophy.

On examination, the patient is limping with scoliotic stance, using crutches. SLRS right side was 90 degrees with tightness and 10 degrees in the left with agonizing pain. There is weak dorsi and planterflexion left foot 3/5.There is sensory deficit from the left D3 level and below.

The patient was sent for investigations. MRI cervical spine showing severe stenosis C5-6 with stenosis, but the patient is not complaining of neck pain. MRI pelvis showed mild accumulation of synovial fluid around the left femoral head, but TWIST was normal. Lab investigations showed elevation of anti beta 2 glycoprotein Ig G 7.6 in the upper border of the elevation.

The patient is urging for surgery, for what another good quality MRI done to the lumbar spine showing extruded disc L5-S1 with left  fragment occluding the  the canal.

Turning the patient to the operating table was done with extreme caution to avoid complication to his cervical spine for what neck collar was applied. The level of L5-S1 was identified and foraminotomy left S1 root was done.  Left sided L5-S1 disc cleaning was done with removal of the left far lateral migrating extrusion. Using MultiGen, bipolar stimulation of the left S1 root responded even to 0.9 Volts. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to the left S1 root  was achieved using 2 bended catheters 10 mm exposed length. Further bipolar stimulation of left L5 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 dramatic recovery. He was sent to the ward.

Too early now.

The extruded disc was occluding the left S1 root and surgery will improve the related to the extrusion problems.

This is the 295th 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 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.