The patient suffered epileptic attack while driving and was hospitalized elsewhere 06-September-2023. He regained his conciseness at the hospital to find that he got mid back pain with bilateral drop feet. He was operated 1988 for replacement of the aortic valve of old version and he is in Digoxin, warfarin, concor and keppra 750 mg twice daily. He was transferred to another hospital and the sons came to the clinic 09-September-2023 with CT-scan showing burst fracture of D12 with bone element compressing the spinal cord and fracture of the lamina. The sons were told to be seen by cardiologist and they admitted him the next day without my permission. I saw him in the ward and he is fully conscious with analgesia below the right L1 and the left L3 level. There is drop both feet with planterflexion both feet 3/5. He can control urination and defecation and there sensation around the anal region. The cardiologist saw him and decided to stop warfarin and start heparin infusion and he was discharged with this protocol to be readmitted 13-September-2023. The patient was readmitted 13-Sptember-2023 and under supervision of the cardiologist. 4 units packed cells and 6 units FFP were asked before surgery.

Skeletonization of D10 down to L2 down to the lateral processes and costo-vertebral junctions in the dorsal part.  Using Legacy CD Horizon, transpedicular screws were inserted using 4 screws 5,5 X40 mm at D10 and D11, 2 screws 6.5 X40 mm at L1 and 2 screws 6.5X4.5 mm at L2. Using MultiGen with monopolar stimulation 5 Volts did not show any reactions. A rod was bended to accept the natural curve of the area 5.5 diameter and 25 cm length. Stepwise distraction between D11 and L1 was achieved and 22 mm was regained until the interspinous ligament became very tight. Check X-ray was performed and acceptable reduction was achieved. Strict hemostasis was achieved and routine closure of the wound. The power of the feet showed very minimal improvement. He was sent to the ward.

The patient showed immediate improvement of the sensation and planterflexion both feet 5/5 and slight improvement of dorsiflexion of the toes. CT-scan done the second postoperative day showing excellent reduction. (See the fig. below).

The patient has unstable fracture of D12 and surgery was performed to prevent further deterioration of his condition.

This is the 263d 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 screws are far from the roots.

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.