06-APRIL-2025  RAMI UMAR MUHAMED AL-HASHAM  52 YEARS  EXTRUDED DISC L2-3 WITH FAR UP AND DOWNWARD MIGRATION WITH ELEMENTS OF CAUDA EQUINA MORE TO LEFT.

The patient came to the clinic 29-March-2025 complaining of LBP with left sciatica for one month. The patient is in agonizing pain with inability to walk, using wheelchair. The patient is known diabetic and hypertensive for 10 years, insulin dependent.

On examination, the patient is in agonizing pain. Cannot be evaluated for scoliotic stance and limping. SLRS was 90 degrees without pain right side and 80 degrees with tightness in the left. There is left hip pain. There is weak left quadriceps  an left iliopsoas muscles 3/5. The power and sensation of both feet were normal. He has partial loss of urination and constipation.

MRI lumbar spine done the same day showing extruded disc L2-3 with far upward, downward migration and left foraminal occlusion.

Using C-arm, the level of L2-3 was identified, Incision above the level was created and decompressive laminectomy L2 and upper 2/3 third of L3 and left L3 foraminotomy. The left L3 root was exposed and left sided cleaning of L2-3 disc space with inspection of the right side. . The nerve was damaged due to severe compression. Using MultiGen, bipolar stimulation of the left L3 root responded to 3.0 Volts. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to left L3 root  was achieved using 2 bended catheters 10 mm exposed length. Further bipolar stimulation of the left L3 root responded to 3.0 Volts. There was massive bleeding from the bone and epidural veins which was controlled  by  a piece of muscle and fat was put to cover the dural bleed, The patient was put in Reverse Trendelenburg position with Valsalva maneuver and hyperventilation. No CSF leak. Routine closure of the wound. The patient showed difficult extubation with extended recovery. He was sent to the ward.

The patient is pale after surgery and Hb was done showing 9.8 for what 2 units blood was given.

The patient showed improvement of the power of the left quadriceps and iliopsoas, but drop left foot with worsening of the left L5, S1. The sensation was preserved, but the cauda equina syndrome showed mild worsening. The patient was discharged 4 days after surgery to continue physiotherapy and to be seen after 2 weeks.

The extruded disc was occluding the right L3-4 foramen with extension extraforaminal.

This is the 283d 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 no improvement of the motor stimulation after BPRF, and the sciatic pain still persist.

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.