26-JUNE-2025 SAMIRA ABDALLA MUHAMED  65 YEARS  FRACTURE LEFT L2-3 FACET WITH SCOLIOSIS OVER THE FUSED L3-4-5 SEGMENTS.

The patient was operated by me 15-December-2020 for spondylolisthesis L3-4 and L4-5. The patient then came 11-June-2025 telling that the last 2 weeks got LBP and right hip pain. LSS-X-ray showing the screws in place, but the disc space above the construct at L2-3 showing narrow height in the right and causing segmental scoliosis.

On examination, SLRS was 50 degrees with pain right side and 50 degrees in the left. No sensory or motor deficits.

MRI lumbar spine  done the same day showing extruded disc L2-3 with bilateral foraminal and right extraforaminal extrusion. CRP was negative, ESR 10 mm/h.

The old incision was refreshed to expose the old construct and the wound extended upward to expose the L2-3 level.  Nuvasive polyaxial screws 6.5x45 mm were inserted to L2 body. The left L2-3 facet was fractured for what the disc spaces were unequal both sides, Bilateral foraminotomy of L3 roots performed. Inspection of the left side was negative. Using MultiGen, monopolar stimulation of the screws above 5 Volts stimulation of the screws did not show response, The patient was put in Reverse Trendelenburg position with Valsalva maneuver and hyperventilation. No CSF leak. The rods were removed and new 5.5mmx75 mm rods with more length were inserted with slight traction of the left side to correct the scoliosis was achieved. The left rod was fractured at the connector site for what it was not seen preoperatively. The cross connector returned to place. Routine closure of the wound. The patient showed normal recovery. She was sent to the ward.

Too early now.

The fractured left facet at the L2-3 was the result of more stress at the above the construct. The patient was advised to respect her spine so as to prevent such situation above this or below the construct.

This is the 287th 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.

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.