The patient came to the clinic 27-July-2016 complaining of LBP with left sciatica for 10 days after falling down. X-rays pelvis showing linear fracture of the right inferior pubic ramus of no clinical significance. LSS X-ray showing spondylolisthesis L4-5. She is diabetic for 4 years in insulin. and has exposure keratitis of the left eye since childhood. She is allergic to penicillin.

On examination, the patient was limping with exaggerated scoliotic stance. SLRS was 20 degrees with pain in left side. There is weak dorsiflexion both feet -4/5.

The patient was sent for neurophysiologic investigations and MRI lumbar spine performed the same day showing spondylolisthesis L4-5 with severe segmental stenosis with left extraforaminal extrusion. Dynamic studies confirmed the overmobility of L4-5 segment. The patient was sent for cardiologic evaluation and ESR was 75 mm/h, CRP 40 mg/dL. The patient was advised to take Zinnat for 20 days followed by Dalacine-C 300 mg twice daily until the inflammatory process or the unknown source of infection subside. The last lab performed 01-September-2016 showed ESR 55 mm/h and CRP less then 6 mg/dL. Cardio consultation was uneventful.

Skeletonization of L4,5 and upper sacrum until the lateral processes of L4 and L5 were exposed. Transpedicular fixation was achieved using Zodiac system AlphatecSpine with 4 monoaxial screws to L4, L5 levels 6.5x45 mm. Decompressive laminectomy L4 and upper half of L5 laminae with removal of all flail fragments. Foraminotomy left L4 and L5 roots. It seems that the left L4 root was severely compressed with fractured left facet. There is no disk extrusion at this level. Using MultiGen, bipolar motor stimulation of left L4 was achieved with 1.2 V, left L5 root was achieved with 1.9 V. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to both L4 and L5 roots was achieved using 4 bended catheters 10 mm exposed length. Further motor stimulation done to the same roots and the response was 1.1 V in the left L4 and 1.6 V in the left L5 root with more brisk response. Bended 2 rods 5.5 mm with 50 mm length with cross connector were used to obtain fusion and slight distraction reduction. The harvested bone was melt and applied lateral to the rods. All stages of surgery were guided using the C-arm. Routine closure of the wound.

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

The patient has a progressive spondylolisthesis, which needs surgical correction. The extruded disk with left extraforaminal location taking precedence.

This is the 77th 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. Here there was decrease of the threshold of stimulation power of motor stimulation after the procedure in all  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.