The patient was operated by me 14-January-2021 for spondylolisthesis L5-S1 and check CT-scan done the next day showed an acceptable lateral position of both L5 screws for what she was reoperated 17-January- 2021 and correction of the position of the screws was performed. Repeat CT-scan with ORS Visual done before discharge confirmed acceptable position of the screws. The patient had elevated ASLOT ESR, CRP all the time  and Dalacine-C was prescribed to her but it caused to her complications. Several  check X-rays during 2021 performed showing good alignment of the construct. The patient then came 21-February-2023 complaining of left sciatica for 1 month and hypalgesia with numbness of the left L5 territory. X-ray of the spine done 14-February-2023 showing fracture mid-shaft of the right S1 screw. The patient then came 29-May-2023 with exacerbation of LBP and left foot pain and limping during walk and sent for though investigation, which showed the the left L5 screw was shifted medially inside the canal. EMG done confirming bilateral moderate TTS. Lab investigations repeated 26-June-2023 showed still high ESR, CRP and ASLOT for what Zinnat was started. The patient deny that she suffered trauma?

Exposure of the construct and the left rod  were removed. Using MultiGen, the left S1 screw were not responding to monopolar stimulation of 5 Volts, except the left L5 screw, which showed brisk reaction. The left L5 screw was removed and new Legacy Medtronic screw repositioned more laterally to go inside the pedicle. The new screw is not responding to 5 Volts. The same rod was inserted. Inspection of the right rod and the lower S1 screw showed proper position with no signs of loosening. It was decided not to violate it. Routine closure of the wound. She was sent to the ward.

Too early now.

The patient has several problems which needs correction.

This is the 260th 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.

Monopolar stimulation is a good practice to know if the screw is near the root.

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 remove the tourniquet before performing motor stimulation.

This is the third case in my life that the screw was broken inside the bone and in the 2 previous cases it was neglected, but here due shifting of another screw, inspection was done and the broken screw was solid stable and left in place.