26-DECEMBER-2024  KAFA MUHAMED NIMER AL-SHANTI  62 YEARS  SPONDYLOLISTHESIS L4-5 WITH SEVERE STENOSIS.

The patient came to the clinic 26-August-2017  complaining of right sciatica for one month. She was limping with exaggerated scoliotic stance. At that time she had SLRS 70 degrees right side with pain. There was weak dorsiflexion right foot 3/5, planterflexion same foot -4/5. Dorsiflexion left foot was 4/5. The patient was sent for investigations: MRI showed spondylolisthesis L4-5 with severe stenosis with bulge L3-4. Dynamic studies confirmed presence of GII spondylolisthesis L4-5. The patient was advised for surgery, but she was reluctant and disappeared. The patient then came 17-December-2024 telling that the last 3 months progressed bilateral sciatica more the left. The patient underwent surgeries for cataract both eyes 1 year ago with local anesthesia.

On examination, the patient is in agonizing pain, limping with exaggerated scoliotic stance. SLRS was 70 degrees right side with pain and 70 degrees left side with more pain. There is weak dorsiflexion right foot 2/5 and planterflexion same foot -4/5. The left foot dorsiflexion 1/5 and planterflexion 5/5.

The patient was sent for investigations  and MRI showing severe stenosis L4-5 with spondylolisthesis L4-5. Dynamic studies confirmed the GII spondylolisthesis L4-5. Cardio consultation revealed hypertension and she was treated accordingly.

Transpedicular fixation L4-5 using Stryker XIA 3 system with cross connector 43 mm and 4 polyaxial screws 6.5x4.0 mm applied to L3-4 and 2 polyaxial screws 6.5x45 mm to L5. Before applying the rods, using MultiGen with 5 Volts monopolar motor stimulation  did not show any motor response confirming that the screws are away from neural structures. Decompressive laminectomy L4 and upper half of L5 with flavotomy L3-4 with lower half of L3 with foraminotomy both L5 roots. Using MultiGen, bipolar motor stimulation of the right L5 root responding to 2.0 Volt. The left root did not respond to even 4.0 Volts. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to both L5 roots  was achieved using 4 bended catheters 10 mm exposed length. Further bipolar motor stimulation of the left L5 root was not achieved with even 4 Volts. The right L5 root responded to 1.8 Volt. The left rod was distracted 5 mm to achieve reduction and correction of the involved segment. The patient was put in Reverse Trendelenburg position with Valsalva maneuver and hyperventilation. No CSF leak. The harvested bone was milt and applied lateral to the rods. Routine closure of the wound. The power of the left foot improved dramatically, but the right foot dorsiflexion improved and she was sent to the ward.

The patient came 08-January-2025 with full power both feet without crutch and no more sciatica, not limping with clean wound with check X-rays done the day of the visit.

The patient has persistent clinical manifestations and need surgery since 2017, but she was reluctant and when further deterioration took place she agreed for surgery.

This is the 278th 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, the sciatic pain disappeared and dramatic improvement of the power of the 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.