Inomed Stockert Neuro N50. A versatile
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Multigen RF lesion generator .
22-JANUARY-2017 AHMAD FAYEQ ABU-SAMHAN 35 YEARS HUGE
RECURRENT DISC L4-5 WITH RIGHT UPWARD MIGRATION.
The patient came to the clinic 17-January-2017
complaining of LBP and right sciatica for 20
days with numbness all toes right foot. He was
operated elsewhere for PLD L4-5 for right
sciatica 20 years ago. MRI lumbar spine performed
02-January-2017 showing recurrent disc L4-5 with
right upward migration.
On examination, the patient is not limping with
mild scoliotic stance. SLRS was
50 degrees in the right and 65 degrees in left side
with pain both sides. There is weak
right foot dorsiflexion -4/5, planterflexion
same foot -5/5. The patient has very long
incision extending to the coccygeal region.
The patient was sent for new investigations and
dynamic studies were
Right L4 neurolysis and foraminotomy
was achieved. The Level of the L4-5 was
identified with scarolysis of the right L5 root. The extruded disk was removed
lateral to the axilla under the L4 root. Right sided cleaning of L4-5 was
performed. Using MultiGen, bipolar motor stimulation of
the right L4 was achieved with 1.8 V. A
bipolar pulsed mode
RF with 42 Celsius, 240 sec, 2 Hz and 20 msec
duration to the 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 0.6 V in the right L4 with more
brisk response. The right L5 root was not
scarolysed since it was below the operative
activity. Routine closure of the
Smooth postoperative recovery. The power of
the right foot improved and he was sciatica free.
He was sent to the ward.
The patient still having an estimated
postoperative re-recurrence less than 7%, because the disc space
is shallower than before.
This is the 101st case using the BPRF mode
with MultiGen. This procedure regained routine acceptance.
It became a usual part of the spine and peripheral nerves
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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, but adhesions were relatively minimal around the
root, for what considerable improvement was achieved.
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Axial and Saggital view showing the recurrence at L4-5 with upward
In this case the VITOM was inferior and binocular loops head mounted
was used because the VITOM is static in position and visual aid is
not stereoscopic as the loops, taking into consideration the wound
is full of scars and rapid action is required to perform the
Notice: Not all operative activities
can be recorded due to lack of time.
Notice: Head injuries and very urgent surgeries are also
escaped from the plan .