The patient was operated by me 15-November-2011 for PLD L4-5 and did well. The patient then came  24-May-2017 transferred from another hospital with full blown picture of cauda equina syndrome for 5 days with drop left foot for 5 days and drop right foot and dripping urine for 3 days.

On examination, the patient is in agonizing pain, sent by imbalance, lying in the left side, very difficult to exam him. SLRS was 35 degrees in the right with pain and 10 degrees with more pain in the left. Dorsiflexion both feet and planterflexion left foot was 0/5. Planterflexion right foot 3/5. There is hypalgesia below the left knee and below the right L5 root territories. Loss of urine control.

The patient was sent for investigations and MRI of the dorsal spine showed huge extrusion D7-8 and lumbar spine performed the same day showing extruded disc L2-3 with left foraminal occlusion and severe segmental stenosis.

Discectomy D7-8 was performed from right fenestration. Decompressive laminectomy L2-3 was achieved. Foraminotomy of both L3 roots was performed. The extruded disk was removed subaxillary of the left L2 root. Left sided intradiscal cleaning of L2-3 disc space was performed. The left L3 root was inspected to rule out any remnants of extrusion. Inspection of the other right side was uneventful. Using MultiGen, bipolar motor stimulation of both L3 roots was achieved with 0.6 V. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to both L3 roots was achieved using 4 bended catheters 10 mm exposed length. Further bipolar motor stimulation of both L3 roots was achieved with 0.6 V. Routine closure of the wounds.

Smooth postoperative recovery. The power of the right foot considerably improved, but the left foot still the same and he was sciatica free. He was sent to the ward.

The patient still having an estimated postoperative recurrence around 7%, because the disc space is still not shallow. The 2 extrusions could be blamed for his dilemma, for what discectomy both extrusions with adequate decompression of L2-3 was performed.

This is the 121st case using the BPRF mode with MultiGen. This procedure regained routine acceptance.  It became a usual part of the spine and peripheral nerves surgery. Click here for reference.

It still unclear to evaluate the differences of pre and post application motor responses. The only sure thing that it tells that the electrodes did not migrate during the procedure and the nerve is functioning properly. Here the motor response was the same before and after BPRF.

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 is the same and the anesthesia protocol also the same.

We stopped the several motor activations before BPRF in several sessions, because we got a clear idea and here the damaged roots are at the cauda equina level.