The patient came to the clinic 31-May-2021 after suffering bicycle accident on 10-January-2021, experienced the clinical picture of avulsed right brachial plexus.

On examination, the patient has profound atrophy of the deltoid, biceps, suprascapular and infrascapular muscles right side. The right pectoralis major and minor hypotrophied, but have some contraction. The serratus muscles right side functioning. Right hand flexion, extension and wrist extension are week 3/5. Sensation of the right hand preserved. except the little finger. The brachioradialis is week 3/5. The triceps muscle 2/4.

The patient was sent for investigation and MRI of the cervical spine showed absence of pseudomeningocele denoting absence of roots avulsion.

The patient in supine position with the chin rotated to the left. \the right sural nerve area was prepared in advance incase of needing graft. 2 cm above the right clavicle and parallel to it was created lateral to the lateral edge of SCMM. Exposure of the right brachial plexus, starting from the right C5,6,7,8 and Th1. The omohyiod muscle was isolated and shifted laterally and some times medially as needed. The external jugular vein was double ligated and bisected. The upper trunk was enlarged but there is no segmental atrophy of neuroma in continuity. Before surgery Inomed ISIS 32 channel Neuroexplorer was prepared so the MultiGen.  The upper trunk was stimulated using MultiGen and response to the deltoid, supraspinatus, infraspinatus, biceps  and triceps all responded well to 2.5 Volts. Severe scar was noted at this area and neurolysis of the upper trunk was achieved until it became free movable and the sheath was opened to eliminate all constrictive elements. Using MultiGen, a bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to the upper trunk  was achieved using 2 bended catheters 10 mm exposed length.  Another motor stimulation of the same trunk was achieved with 1.5 Volts. Dissecting down the upper trunk and isolate the suprascapular nerve, it gave a brisk response even to 1.2 Volt. Considering that the patient complaining of dysesthesia of the right upper limb, the C7 , C8 and Th1 roots were exposed and they respond to 1.6 Volt. Application of BPRF was achieved to all these roots and motor stimulation after that was the same. Doprofos was irrigated to the wound to minimized postoperative scar formation. Routine closure of the wound. Small incision was done over the lateral edge of the contracted pectoral muscle to gain some release. Smooth postoperative recovery. He was sent to the ward.

MultiGen

The patient admitted and be followed by Dr. Ali Al-Bayyati.

This is the 217th case using MultiGen. This procedure regained routine acceptance.  It became a usual part of the spine and peripheral nerves surgery. Click here for reference.

It is the first time we use such protocol to the sensory branch to the little finger to ameliorate the dysesthesia.

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.

MultiGen in this case was superior to ISIS Inomed Neuroexplorer, because it was not only diagnostic but also promoting recovery of the nerves.