The patient after suffering RTA 1998 got traction injury of the left brachial plexus  with multiple fractures of the bones of the left upper limb with crushed injuries to the soft tissues lower third of the arm and upper third of the forearm.

MRI of the cervical spine performed 22-December-1998 showed pseudomeningocele  associated with avulsion of left C6 and 7 roots.

The patient had total non-function of the left brachial plexus. with ugly scar with weak left pectoralis muscle 3/5. Anaesthesia of the left upper limb at ht upper third of the arm and below.

The patient was operated 16-March-1999: exploration of the median and ulnar nerves at the scar site and neurolysis was performed and continuity of both nerves was confirmed.

Exploration of the left brachial plexus was performed 16-May-1999: bridge anastamosis was used to connect the C4 with the avulsed C6 root, using sural graft.

The patient then came 30-January-2000 with the triceps functioning and the biceps and the deltoid 3/5, with the anaesthesia became below the mid third of the arm.

The patient then  26-February-2000 underwent left radial nerve exploration and sural graft was used to fill the deformed and missed gap.

The patient came 24-July-2000 with improvement of the biceps brachii and the brachioradialis muscle 2/3 with the sensation became down to the mid third of the forearm.

The patient then came 12-August-2002 and after studying the case, he was advised to undergo cooptation of the intercostal nerves to the median and ulnar nerves.

The patient came 01-January-2008 urging to perform anything to make him able to use his left hand for support. His neurologic examination was the same as before, except that the left deltoid muscle became worse, due to neglect.

It was explained to the patient, that the improvement of surgery could be low as 20% and arthrodesis of the left wrist must be performed. What the exact plan for the surgery of the neural tissues will be decided during operation. The patient accepted the terms and he was admitted.

Under G.A  IOM monitoring using ISIS Highline Inomed, SEP was obtained from both median and ulnar nerves. There was a delay in latency and decrease in amplitude, but they were obtained from the affected side.

Exposure of both median and ulnar nerves was performed in the axilla. They were looking excellent in shape. Trying to obtain CNAP from both nerves was impossible using different parameters and setups. Using the stimulator alone without recoding electrode, it was possible to see some tiny movements in the ulnar nerve distribution.

Stimulation of the axillary nerve showed excellent contraction of the deltoid muscle.

The left II-IV intercostal nerves were released and sectioned at the site before giving branches. The I intercostal nerve was missing. There was a small running motor nerve running by, which was sectioned to be used for grafting.

It was decided to make a cooptation between these four nerves with the left median nerve. The median nerve was sectioned at the level after the union of the lateral and medial branches, and through a tunnel through the adipose tissue it was transferred to meet the four nerves.

Under magnification, the four nerves were stitched to the median nerve. See picture.

It seems that the four twigs were insufficient to fulfill the median nerve, but they were the only available source in this region. Using saphenous graft to bridge with other intercostal nerves it seemed to be a bad idea.

The wound was closed and arthrodesis of the left wrist with 10 degrees dorsiflexion and continuity with third MC bone was achieved using iliac bone graft and plate with screws 22-16 mm length.

Smooth postoperative recovery.

Cross-anastamosis of the intercostal nerves is only sufficient to provide innervation to only one major nerve. See the picture above and it will be clear, that in no way it could supply the median and ulnar nerves together. It is will known that the median nerve is more important than the ulnar functionally, for that, in case of their equal non-function, priority is paid to the median nerve.

This case is a challenging one from the surgical point and decision making point and intraoperative monitoring side. There was no acceptable nerve to obtain for studying the CNAP, so as to have comparison with the affected nerves.

This case also made a gloomy picture of the suggested surgical treatment of paraplegia using the dorsal roots to be transferred to the lumbo-sacral roots. But. it is early to be disappointed because the postganglionic part of the dorsal roots still having an acceptable diameter, in contrast to the small diameter intercostal nerves.

In the future in similar case, it will be preferable to section the median nerve as proximal as possible, including the merging branches below the emergence of the ulnar and the MCN. By doing this, the length of the graft will be more and the twigs can be stitched to either of the stumps. More precise cooptation and more ample to gather the running twigs of the intercostal nerves.