The patient came to the clinic 02-November-2016 complaining of neck pain for 18 months with progressive deterioration the last 3 months after performing left carpal tunnel release. MRI cervical spine performed 12-January-2016 showing severe stenosis at C2-3, 3-4 levels with malacia of the spinal cord. Cervical X-ray showing congenital fusion of C2 and C3

On examination, the patient has fasciculation of all muscles of both upper limbs. Weak both deltoids 3/5, both biceps -4/5, flexion both hands 4/5, extension both hands  and both triceps -4/5. There is hypalgesia from C3 down the median distribution both upper limbs. There is weak dorsiflexion both feet -4/5 and both quadriceps femori 4/5. .DTR are exaggerated more the left side with Hoffmann positive left side. Babinski positive left side. Absent abdominal reflexes.

The patient was sent for neuro-radiologic evaluation and MRI cervical spine performed 03-November-2016 confirming the above mentioned data and dynamic studies showing spondylolisthesis of C4-5.

Decompressive laminectomy C2-3, 4 was achieved using step wise drilling and thinning of the bone to prevent surgical trauma to the spina cord. There is overmobility of C3-4 and C4-5. Using Vertex Select system with 4 polyaxial screws 3.5x15 mm to C4 and C5 and 2 screws 3.5x14 mm to the left C3 and right C2 lateral masses because the right C3 lateral mass was almost hypoplastic. A bended rod 3.2 mm was used both sides.  Bipolar motor stimulation of left C3 was achieved with 1.4 V and the left C4 with 0.9 V. The right C3 root was responding to 1.0 V and the right C4 was responding to 1.1 V. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 240 msec duration to both C3 and C4 roots both sides was achieved using 4 bended catheters 10 mm exposed length extradural . Further motor stimulation done to the same roots and the response was 1.1 V to the left C3 root, with more brisk response and 0.8 V to the left C4 root. The right C3 root was responding to 0.6 V and the right C4 was responding to 0.9 V. The harvested bone was melted and applied lateral to the rods Routine closure of the wound. All stages of surgery were performed under C-arm guidance. Routine closure of the wound.

Smooth postoperative recovery. The power of four limbs became better. He was sent to the ward.

The patient has severe stenosis with malacia of the cervical spinal cord with overmobility of C4-5. The sooner the surgical correction, the better the outcome.

This is the 93d case using the BPRF mode with MultiGen. This procedure regained routine acceptance.  It became a usual part of the spine 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 tell that the electrodes did not migrate during the procedure and the nerve is functioning properly. Here there was no change of the threshold of stimulation power of motor stimulation after the BPRF in one root and improvement of the other.

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.

In this case the roots were reached extradural from the exposed laminectomy areas.