Case Study · 05
Mechanical low back pain in a patient who was never a surgical candidate
A patient in their forties with a decade of mechanical low back pain, no prior spine surgery, no radicular symptoms, and imaging showing only degenerative change. Multifidus dysfunction on examination and imaging. Treated with restorative neurostimulation.
At a glance
- Patient
- Late 40s
- Region
- Axial lumbar only
- Procedure
- Restorative neurostimulation, L2 medial branch
- Outcome
- Progressive gain over 24 months
The pain is real, the imaging is unremarkable, and no surgeon will operate. Is there a therapy aimed at impaired muscle control rather than dorsal-column pain-signal modulation?
Patient names are omitted from this account. The clinical course and reported outcome describe an actual treated case and do not predict another person's response.
Clinical Summary
What the patient came in with
Presentation
Ten years of low back pain described as a deep fatigue and giving-way sensation rather than a sharp pain. Worse with sustained postures, better with movement, notably worse at the end of the working day. Baseline 6/10 average with frequent escalations to 9/10 that lasted days.
No leg pain, no numbness, no weakness. The pattern was unmistakably mechanical and unmistakably axial.
Prior treatment
Multiple courses of physical therapy over a decade with benefit that never outlasted the programme. Chiropractic care, dry needling, medial branch blocks and radiofrequency ablation with partial and temporary relief. NSAIDs, muscle relaxants, and a trial of duloxetine.
Two spine surgeons had declined to operate — correctly, as there was no structural lesion to correct.
Examination and imaging
MRI showed moderate degenerative disc disease without stenosis, and fatty infiltration of the lumbar multifidus. Examination demonstrated poor lumbar extensor endurance and an inability to hold a prone extension position.
This phenotype fits the pattern considered for restorative neurostimulation. The FDA indication is broader and requires intractable chronic low back pain associated with multifidus dysfunction evidenced by imaging or physiological testing, failed medication and physical therapy, and no candidacy for spine surgery.
Why not conventional SCS
Spinal cord stimulation is designed to modulate pain signaling in the dorsal columns; it is not designed to rehabilitate multifidus control. ReActiv8 instead uses motor activation of the multifidus as its intended primary mechanism.
Restorative neurostimulation targets the L2 medial branch of the dorsal ramus bilaterally where it crosses the L3 transverse process. The patient initiates prescribed sessions, typically two 30-minute sessions daily, and remains positioned as instructed while the multifidus contracts episodically.
Procedure
Bilateral leads at a single level
This is a one-stage permanent implant rather than the temporary trial-then-implant sequence used for spinal cord stimulation. The intended restorative response is evaluated over time, not during a one-week trial.
01
AP fluoroscopic view
Target identification
The L2 medial branch of the dorsal ramus identified fluoroscopically where it crosses the L3 transverse process.
02
Oblique fluoroscopic view
Lead placement
Lead advanced to the target with test stimulation confirming a strong, visible multifidus contraction — the contraction, not a sensory response, is the endpoint being sought.
03
AP fluoroscopic view
Contralateral side
The procedure mirrored on the opposite side. Bilateral stimulation is required; the muscle works as a pair.
04
Intraoperative
Generator implantation
Leads tunnelled to a generator pocket. Final imaging confirms lead position and the absence of migration before closure.
05
Two weeks post-implant
Therapy initiation
Device activated after healing. The patient begins the prescribed sessions, typically two 30-minute sessions daily, while prone as directed in the current patient instructions.
Follow-Up
What happened afterwards
Months one to three
Little change in pain scores initially, which had been anticipated and discussed in advance. This is the phase where patients on a signal-blocking therapy would have expected relief already, and where clear expectation-setting matters most.
Contraction quality improved noticeably over the first six weeks; the patient reported the contraction feeling stronger and more coordinated.
Months four to twelve
Average pain fell from 6/10 to 4/10, with escalation episodes becoming less frequent and shorter. The 'giving way' sensation resolved before the pain did.
Physical therapy restarted at month five and, for the first time in a decade, produced gains that persisted after the programme ended.
Months thirteen to twenty-four
Continued gradual improvement rather than a plateau — average pain 2–3/10 at twenty-four months, with disability scores improving in parallel.
Daily sessions maintained. The patient describes the device as something they use rather than something they have.
Outcome
Slow, and still improving
6/10 → 2–3/10
Average pain at 24 months
- Trajectory
- Progressive, not front-loaded
- Instability sensation
- Resolved by month 9
- Physical therapy
- Gains retained for the first time
- Complications
- None
Clinical pearl
The right therapy sometimes works on a completely different timescale from the one a patient expects. If a restorative therapy is judged by the standards of an analgesic one at three months, it will look like a failure at exactly the point it is starting to work.
Individual results vary. This case is presented for education and does not predict the outcome of any therapy in any other patient.
Put this case in context
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