The patient came to the clinic 08-January-2017 complaining of LBP for 7 years with left sciatica for 1 month. MRI lumbar spine performed 05-January-2017 showing spondylolisthesis L4-5 II degree with bulge disci L3-4 and L5-S1. Dynamic studies confirming the overmobility of L4-5. The patient is a known diabetic for 2 years in treatment and hypertensive for 15 years.

On examination, the patient is limping with exaggerated scoliotic stance. SLRS was 30 degrees left side with pain. There is weak left foot dorsiflexion 3/5, dorsiflexion and hypalgesia left L5 territory.

The patient was advised to stop anticoagulants and to be seen by cardiologist. ESR was 33 mm/h and CRP was 5.9 mg/L. She was started in Zinnat 500 twice daily before admission.

Skeletonization of L3,4,5 and upper sacrum until the lateral processes of L4 and L5 were identified. Using AlphatecSpine system with 2 polyaxial screws 6.5X45 mm to L5 body, 6.5X45 mm to the left side of L4 and 7.5X45 mm polyaxial to the right side of L4 body and cross-connector 55 mm  and bended rods 5.5 mm thickness and 50 mm length, transpedicular distraction reduction and fixation of L4-5 was achieved. Foraminotomy both L5 roots. Using MultiGen, bipolar motor stimulation of both L5 roots was achieved with 1.1 V right side and 1.5 V left side. 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 motor stimulation done to the right root was 1.0 V and the left was 1.3 V with more brisk responses. The harvested bone was melt and applied lateral to the rods. Routine closure of the wound.

Smooth postoperative recovery. The power of the feet improved and she was sciatica free. She was sent to the ward.

The patient still having an estimated postoperative recurrence around 7%, because the disc space is still not shallow.

This is the 104th case using the BPRF mode with MultiGen. This procedure regained routine acceptance.  It became a usual part of the spine and peripheral nerves 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 considerable improvement of the threshold of stimulation power of motor stimulation after the BPRF.

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 is the same and the anaesthesia protocol also the same. In this case adhesions could be a factor for initial high voltage requirement to achieve motor response.