The patient is my wife, started to complain of hips pain for 14 months and the edema of the right upper limb for several days, one year ago. Radiological studies and fine needle aspiration confirmed the presence of Ca breast right side with involvement of the pleural ipsilateral to tumor with lymph node involvement and scattered metastasis in the cervical, dorsal, lumbar and pelvis with tendency to grow inside the bones. The right shoulder bones were also involved in the process. The tumor was progesterone positive and she underwent 6 sessions of combined chemotherapy followed with femara. The last month, the femara was ineffective and caused all the side effects. The tumor regional metastasis at the right brachial plexus showed drop wrist for 4 months, then the other branches of the the brachial plexus took place with the right upper limb became useless, but with agonizing pain.  

2 weeks ago, the plan for lumpectomy and exploration of the brachial plexus was anticipated, and preoperative investigations showed Hb 7 mg/L with ESR and CRP and high enzymes of the liver. She was given 4 units blood and 4 units FFP. MRI of the cervical spine was showing intraossal involvement of the metastasis with the bony structures acceptable. MRI of the right brachial plexus showed escalation of the lymph nodes metastasis involving the supra and subclavicular region. MR mammography ruled out the presence of the lump. During this an intrapleural effusion of the right chest was noted, for what chest CT-scan was performed and CT-scan of the cervical spine was performed. The fluid was evacuated the next day and sent for investigations. CXS showed no bacterial growth. Cardiologist was consulted and he noticed mild pericardial effusion. Consultation of the oncologist gave green line for surgery to explore the right brachial plexus. Since the lump in the breast is not seen, then lumpectomy discarded from the plan.

Incision behind the right SCMM and running 2 cm above the right clavicle. The platysma was bisected and the hard highly vascular mass was identified. The right IJV was followed inferior and the omohyiod muscle was seen and left intact. The phrenic nerve was followed and the the cleavage between the right anterior scalene and medial scalene was identified. The tumor was totally removed. It was stony hard and pushing the trunks inferior. It was sent for histopathologic studies. Inspection of the supra and retroclavicular regions revealed no remnants of the tumor. The transverse cervical artery was coagulated and cut during surgery, because it was feeding the tumor. During dissection most of the time Inomed TC bipolar forceps with N50 was used with continuous stimulation to avoid neural injury. Using MultiGen, bipolar motor stimulation of the upper trunk gave brisk response to 4.4 V, the middle trunk for 3.25 V and the lower trunk with 1.8V. MultiGen with 2 Hz with 240 ms duration and 42 degrees was applied to all three trunks. Routine closure of the wound. Before extubation the pleural fluid in the the right chest was evacuated and around 35 ml was achieved. It was sent to histological studies.

Smooth postoperative recovery.  The patient got some movement of the right upper limb more pronounced in the distal muscles. She was sent to the ward.

The patient is my wife, and she is urging for surgery, to alleviate the agonizing pain of her non-functioning right brachial plexus. All my long-standing experience I must give her, even if the results are under question.

This is the 139th case using the BPRF mode with MultiGen. This procedure regained routine acceptance.  It became a usual part of the spine and peripheral nerves surgery. Click here for reference.

The plan for infraclavicular exploration was omitted because the trunks  was responding in acceptable fashion.