Inomed Stockert Neuro N50. A versatile
RF lesion generator and stimulator for
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Multigen RF lesion generator .
30-JANUARY-2017 HEJAR MUHAMED BEKAWI 64 YEARS
SPONDYLOLISTHESIS L4-5, RESIDUAL AFTER WRONG LEVEL FIXATION OF L3-4.
The patient came to the clinic 26-April-2012
complaining of LBP for 7 years with
with numbness both feet after performing surgery
at KHMC 2008 for spondylolisthesis "L4-5?". The
patient did not improve after surgery and she
suffered from CSF leak for 4 months after
surgery. MRI lumbar spine performed
30-March-2009 showing spondylolisthesis L4-5
II degree with severe stenosis with
transpedicular fixation of L3-4.
She could walk 100 meters with difficulty. There
was weak dorsiflexion both feet -4/5 with
hypalgesia left L5 root. The patient was advised
to redo surgery, but she escaped. The patient
then came 02-January-2017 with further
deterioration and difficult walking with help of
2 persons with walker and bilateral
On examination, the patient is walking with help
of 2 persons. SLRS
was 60 degrees right side with pain. There is weak
both feet dorsiflexion 3/5, dorsiflexion, weak
planterflexion right foot 4/5 and hypalgesia
right L5 territory. There is dripping urine for
unknown period of time.
The patient was advised to stop anticoagulants
and to be seen by cardiologist. ESR was 38 mm/h
and CRP was 24.5 mg/L. She was started in Zinnat
500 twice daily before admission.
Skeletonization of L3,4,5 and
until the lateral processes of L5 were
identified with exposure of the old construct.
It was Medtronic Legacy system with all screws
polyaxial version. The right
lower screw was loose and extruded backward. The
rods were removed and the right lower polyaxial
screw was inserted back to get proper alignment
with other screws. Using Zodiac system AlphatecSpine system with 2
monoaxial screws 6.5X45 mm were inserted to the
L5 body. Motor stimulation was applied to all
screws with 8 V and there was no response
confirming that the screws are away from the
Two bended rods 100 mm to accept the natural
curve of the spine were used. Distraction
reduction of L4-5 was added and fusion of L3-4-5
was achieved. Cross-connector was applied. Using MultiGen, bipolar motor stimulation of
both L5 roots was achieved extraforaminal with 1.8 V right side
and 0.4 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 1.5
V and the left was 0.4 V with more
brisk responses. The harvested bone was melt and
applied lateral to the rods. Routine closure of the
Smooth postoperative recovery. The power of
the left foot improved dramatically, but the
right foot showing slight deterioration. She was sciatica free.
She was sent to the ward.
The patient, the next postoperative day still
the same. with decrease of the LBP.
The patient was operated in the wrong
level for what she continued to suffer with further
deterioration. The right lower screw migrated backward due
to overmobility of L4-5 segment.
This is the 106th 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 in the right side but the left root showed good
response before and after application. It seems that the
right L5 root suffered from longstanding trauma.
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.
The electrodes were applied in this case
extraforaminal without performing foraminotomy.
In the next case, it is better to apply
motor response to the roots of interest to see if there is
deterioration of motor conductivity after applying
distraction. In such case it is better to decrease the
magnitude of distraction to avoid deterioration of the root