The patient came to the clinic 26-October-2016 complaining of weak right upper limb for 30 days with agonizing pain of the right upper limb and discoloration of the right side of the tongue and cramps of the left little toe. MRI performed 16-October-2016 was normal with EMG done 24-October-2016 confirming plexopathy.

On examination, the patient has intolerable pain of the right upper limb neuralgia like, that he is protecting her from any external stimulation. The right biceps muscle is 2/5, flexion right hand 2/5, extension 0-1/5, right triceps 2/5, There is hypalgesia of the right median and ulnar nerve distribution. here is no neck pain upon moving it. DTR D=S, no pathologic reflexes. There is pain upon palpating the right axillary artery. No frozen shoulder nor TOS. There is no myelopathic syndrome.

The patient was sent for neuro-radiologic evaluation and MRI of the right plexus and right shoulder were performed 30-October-2016 showing plexitis of the right brachial plexus at the level of the axillary fossa. All available lab investigations were normal.

With the patient awaken, with the right upper limb extended to expose the right axillary fossa, 4 catheters were inserted n both sides of the right axillary artery.  Bipolar motor stimulation of right brachial plexus was achieved with 1.2 V. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 240 msec duration to this segment was achieved using 2 bended catheters 10 mm exposed length. Further motor stimulation done to the same points and the response was 1.1 V with more brisk response. The same procedure was repeated 3 cm above the mentioned level lateral to the axillary artery to ensure more proximal branches. Bipolar motor stimulation of right brachial plexus was achieved with 1.2 V. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 240 msec duration to this segment was achieved using 2 bended catheters 10 mm exposed length. Further motor stimulation done to the same points and the response was 1.1 V with more brisk response. Bipolar motor stimulation of right median nerve was achieved with 1.7 V. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 240 msec duration to this segment was achieved using 2 bended catheters 10 mm exposed length. Further motor stimulation done to the same points and the response was 0.7 V with more brisk response. Bipolar motor stimulation of the right ulnar nerve above the cubital tunnel was achieved with 1.5 V. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 240 msec duration to this segment was achieved using 2 bended catheters 10 mm exposed length. Further motor stimulation done to the same points and the response was 1.4 V with more brisk response. Bipolar motor stimulation of right radial nerve from behind was achieved with 0.5 V. A bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 240 msec duration to this segment was achieved using 2 bended catheters 10 mm exposed length. Further motor stimulation done to the same points and the response was 0.7 V with more brisk response. This procedure was dictated by the patient feedback of his pain and it was continued until he became mostly pain free and the range of motion improved and the strength of the muscles dramatically improved.

He was sent to the ward for discharge.

The patient has agonizing pain due to plexitis and all conservative measures to ease his pain failed.

This is the 94th case using the BPRF mode with MultiGen. This procedure regained routine acceptance.  It became a usual part of the spine surgery. Click here for reference.

It is the first case using this procedure in awake patient confirming that the procedure is effective and yielding good results without using Marcain or Depomedrol. Time will tell the length of the effect of this procedure.

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 no change of the threshold of stimulation power of motor stimulation after the BPRF in one root and improvement of the other.

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.

To my knowledge, it is the first case in human practice, that using such technique in brachial plexus neuralgia after neuritis giving an excellent result making the patient and the neurosurgeon happy.