The patient came to the clinic 29-May-2016 complaining of LBP and right sciatica for more than 3 years with right sciatica. He underwent surgery for extruded disc L3-4  3 years ago without improvement. MRI cervical spine performed 13-September-2015 showing mild stenosis at C4-5. MRI brain done 19-September-2015 was normal. MRI lumbar spine showed recurrent extrusion L3-4 with right downward migration. The patient has arterial hypertension for 8 years. He suffered postoperative infection of the wound. He has hyperkinesia left hand for 6 years. He underwent exploratory laparatomy for bullet injury 8 months ago.

On examination: the patient is limping with shuffling gait, exaggerated scoliotic stance. SLRS was 20 degrees with pain in the right and 45 degrees with tightness left side. There is weak dorsi and planterflexion right foot 4/5.

The patient was sent for investigations and repeat MRI performed 29-May-2016 showing the extrusion of L3-4 right with downward migration and lateral translation of L3-4. Dynamic studies showed spondylolisthesis D12-L1, L3-4 and scoliotic deformity of the lumbar spine from D12 down to L5 with Cob's angle 20 degrees at L2. ESR 30 mm/h and CRP was <5 mg/L. The patient was sent for cardio evaluation and Senimet was started for the hyperkinesia.

Skeletonization of L1 down to L5 with exposure of the transverse processii of these levels. Using the C-arm, the L3-4 level was identified and foraminotomy right L4 root  with removal all the compressive elements. The disc space was very narrow. Transpedicular fixation and correction of L1 down to L5 was performed with distraction of the left side. Cross connector was used. During insertion of the blunt gear to the right side of L2, CSF came with blood. The feeler showed a tiny defect at the medial wall of the hole. The screw was inserted more vertical to swing the screw away from the root.   Using MultiGen, stimulation of of all the screws was acceptable, but the mentioned above screw showed response at lower voltage around 4.5 V. It was considered acceptable, since a previous knowledge of the event. The right L4 root was stimulated with 2.4 V. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to right L4 root was achieved using 2 bended catheters 10 mm exposed length. Further motor stimulation done to the same root and the response was at 1.8 V. The harvested bone was put lateral to the rods. Routine closure of the wound.

Smooth postoperative recovery. The patient is sciatica free. The power of right foot normalized and he was sent to the ward. The patient the next day showed considerable weakness of the right iliopsoas and quadriceps muscles. and he was complaining of abdominal pain.

The patient has many problems of his lumbar spine, which need surgical correction and decompression.

This is the 65th 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.