The patient is bedridden and was admitted to Shmaisani hospital 21-January-2020. He was operated 7 years ago for dorsal and lumbar canal stenosis at D10-L1 and L4-5 elsewhere without improvement. He is hypertensive and diabetic for 4 years in medication. He is bedridden for 8 months with deterioration the last month.

On examination: The patient is bedridden with severe tetraparesis-plegia below C3. Crania nerves are intact with good power of the SCMMs and both trapezii. Both deltoids 1/5, right biceps 0/5, left 1/5, grip and extension both hands 0/5, both triceps 3/5. Both quadriceps femori 0/5, right foot dorsi and planterflexion 0/5, left foot 1/5. Abduction and adduction both knees 2/5. Hypalgesia-anesthesia below C3 level both sides. Controlling micturition. All pathologic reflexes are present with clonus of the upper limbs and spastic lower limbs. The breathing pattern is shallow due to weak intercostal muscles. 

The patient was thoroughly investigated and MRI of the brain was uneventful. MRI of the cervical spine showing severe stenosis of C3-4, 4-5 with malacia of the spinal cord at these levels. The dorsal and lumbar showing the residual of previous surgeries. Dynamic studies of the cervical spine ruled out overmobility. CXR and chest CT-scan were normal. Cardio and pulmonary consultations were asked and they ruled out presence of local morphologic changes. Blood gases were among investigations with pO2 65 mm Hg.

Decompressive laminectomy of C 3,4 and upper part of C5 and the lower half of C2 without violating the epidural space. Using MultiGen, bipolar motor stimulation of both C5 roots was achieved with 2 Volts. Routine closure of the wound.

Smooth postoperative recovery. Mild improvement of the power of his four limbs. pO2 after surgery was 168.5 mm Hg. He was sent to the ward.

The first surgeries did not provide its final goal because the essential problem was ignored.

This is the 195th 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.

The running nerves above and below the lesion are acceptable in motor stimulation threshold, which denote excellent recovery.

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 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 4 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 the level of the axilla.