15-JUNE-2026  NASER ABDEL-QADER NOFEL  54 YEARS  EXTRUDED DISC L3-4 WITH RIGHT FORAMINAL OCCLUSION.

The patient came to the clinic 10-June-2026 complaining of agonizing LBP with right sciatica for 3 weeks.

On examination, the patient is limping with severe scoliotic stances. SLRS right side was 70 degrees with pain and 90 degrees in the left with pain shooting to right. There is weak dorsi and planterflexion right foot 4/5. There is hypalgesia right L5 root.

The patient was sent for investigation and MRI lumbar done 11-June-2026 showing huge extruded disc L3-4wuth right foraminal occlusion and causing stenosis to the level. Dynamic studies ruled out overmobility. Lab investigations are normal.

Prone position. The level of L3-4 was identified and foraminotomy right L4 root was done.  Due to severe compression, the dura around the root was lacking. Right sided L3-4 disc cleaning was done with removal of the extrusion. Using MultiGen, bipolar stimulation of the right L4 root responded to 0.6 Volts. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to the right L4 root  was achieved using 2 bended catheters 10 mm exposed length. Further bipolar stimulation of the right L4 root responded to 0.5 Volts. A muscle with pedicle was transferred to cover the root. Water-tight closure of the wound to avoid postoperative CSF leak. The patient showed improvement of the power, but still feeling pain in the right hip. He was sent to the ward.

Still early now.

The extruded disc was occluding the right L4 root and surgery will improve the related to the extrusion problems. It is the first time seeing that the root is lacking dural cover due to severe compression.

This is the 303d 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 still persisting and regained improvement of power of the 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.