15-JANUARY-2025  YUSRA ABDEL- MUNIM ABDEL-LATIF 62 YEARS  SPONDYLOLISTHESIS L4-5 WITH FRACTURE OF LEFT L2-3 FACET JOINT WITH SCOLIOTIC DEFORMITY.

The patient was operated by our team 13-September-2015 for spondylolisthesis L3-4 with stenosis L2-3 and L3-4, using XIA 3 Stryker transpedicular screws. The patient was doing well until she came to the clinic 12-January-2025 telling that she got LBP for 3 months with left sciatica with numbness right lower limb for 1 week with inability to walk more than 50 meters.

On examination, the patient is in agonizing pain, limping with exaggerated scoliotic stance. SLRS was 55 degrees right side with pain and 60 degrees left side with less pain. There is weak dorsiflexion both feet 4/5.

The patient was sent for investigations  and MRI done 12-January-2025 showing spondylolisthesis L4-5. Dynamic studies confirmed the GI-II spondylolisthesis L4-5.  There is scoliotic deformity at L2-3 with fracture of left L2-3 facet joint .  Dynamic studies revealed spondylolisthesis L4-5 with the the old screws at L3-4 in position. There is scoliosis at the level of the fracture. Cardio consultation revealed was uneventful.

The old construct was exposed and the cross connector and rods removed. Transpedicular fixation L4-5 and exploration of the left L2-3 facet was involved in fracture, for what using Stryker XIA 3 system with cross connector 43 mm and 2 monoaxial screws 6.5x4.0 mm applied to L5 and 2 polyaxial screws 6.5x45 mm to left non fractured pedicle of L2. Insertion of the screw to the left side was unacceptable, for what the polyaxial screw was inserted to the left L1 pedicle. Before applying the rods, using MultiGen with 7 Volts monopolar motor stimulation  did not show any motor response confirming that the screws are away from neural structures. The left rod part between L1-3 was distracted 5 mm to achieve reduction and correction of the involved segment. Routine closure of the wound. The power of both feet improved dramatically and she was sent to the ward.

Too early now.

The patient mostly suffered injury to the spine, causing spondylolisthesis of L4-5 and fracture of left L2-3 facet joint and pedicle.

This is the 279th 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.

For indication for surgery click here.