Brachial plexus nerve exploration-repair: Microsurgery at Thai government hospital

After a hazy eight months in the clouds with this Brachial Plexus Injury (BPI) which has had my left shoulder / arm paralyzed, it was finally time to shed some real light on the matter—never mind all the expensive tests i.e. MRI, EMG, Meyelogram CT Scan which at best, only gave conflicting speculations about what was (not) going on within my peripheral nervous system.

Following through with a long awaited state operation queue of three months since appeasing the doctor’s request for a meylogram CT-scan (around the five month mark), my day would prove to be now or never. If I let the opportunity pass, there would be no telling when the next calling would be—with my muscles slowly dying towards the point of no return, though it was not the most ideal timing recommended for such primary nerve surgery (3 to 6 months since trauma), it was certainly not the worst.

On Sunday, I waved goodbye to my frolicking son and his mother at Siam Center, catching the twenty baht train to Sala Daeng Station. From there, I walked o’er Silom Road on the skywalk bridge, crossing Rama IV road to my home for the next several days: Chulalongkorn Memorial Hospital.

Though I was scheduled to go under the knife late Monday morning, they needed me in earlier to prepare i.e. draw blood, enforce-regulate fasting the night before, etc.

Initially, I was given the choice of reserving a special / private bed-room for pre-post operation rest at a rate of 1600 baht and 2100 baht / night respectively (including nurse fees), however, I just settled for the 500 baht communal room as I wasn’t anticipating much if any visitors. Aha-I got bed number nine (as opposed to eight or thirteen), and as far as Thais are concerned, nine or gao เก่า is a positive number as it also means ‘step up-forward.’

Checked and settled in, the anticipation could begin. Throughout Sunday and early Monday morning, several of my doctor’s assistances, as well as an anesthesiologist came to inspect/interview/prep me for the big day. For them, it was their regular duty, routine, and job—for me it was so much more. Other than an X-ray, nothing much of excitement happened other than the agony of lying around anticipation; reading a karma book, browsing the internet on my mobile, making phone calls, washing up, shaving…

A little bit after eleven, Monday morning a hospital staff came to escort me. Rapidly, the butterflies begin to occupy my hungry stomach. Though I was completely OK to walk at the time, it only seemed right to be escorted in the wheelchair provided. Through the mazes of hospital grounds, up an elevator, and finally I was ready to enter the double push doors of the operation ward. Immediately they had me lye down on a thin wheeled bed and scooted me in, parking me next to a supply room.

Within the ward, it was typical of what one could expect with green and cream walls, complimented with a feeling of urgency all around. There were at least fifteen others in med greens scurrying about from a hall in and out of an office.

A chubby shirtless Chinese man was wheeled past, clearly still knocked out. It was presumed he had just been operated on. Now they were preparing for Monday’s second queue, me.

Two assistances came to give me a plastic hair cap, and soon were nervously making me nervous, struggling to fix the IV properly in my hand. A senior woman who spoke good English came to help them, engaging me in conversation. Though my Thai can hold its own, she kindly insisted on me speaking English to her as she said it wasn’t often she gets to speak much anymore.

Asking about my personal details, she seemed sincere, and was somewhat effective in taking my mind off of the coming operation.

Soon, I saw a familiar face walk by—was it my doctor? He seemed too busy. And then his assistant who I’d be corresponding with the past few days came to greet me. She told me that once I was knocked out, they were going to need to stick a tube in my penis so that I’d be able to urinate after the long operation, expected to be at least four hours.

Then, I was rolled into the actual operation room, under some large surgery lighting equipment. There must have been ten others in there, all with their own specific preparatory tasks, attaching things all over me. Then, a mask was put on my face. ‘Oxygen’, they said. ‘Just take long deep breaths.’ Blank.

The very next instant, I vaguely heard them calling my name. Was it over already? That seemed instant! I felt like crap. Something was in my throat, I had a strong pain to pee. And then the vomit came. After that, I was only in pain and just wished to be put back to sleep as they rolled me back to my quarters.

Apparently, I skipped over six hours under anesthesia, brought out at about 5.30 pm. I re-awoke later at about 8pm, still feeling groggy and blurred but not as bad as when I initially came out. My throat hurt, and sure enough a tube attached to my special limb, though surprisingly not painful (until they pulled it out the next day).

The operation findings were better than they expected, the docs finding only one of the nerves near the spine(C5) severed, though not at the cervical root as initially expected, but further down at the trunk. And so, it was decided that the rootlet which was still attached and hanging from my spine was salvageable, grafted (reconnected) using a 5 cm nerve harvested from my calf (sural nerve).

It will be a matter of approximately eight months before we know if it worked, seeing that the nerve grows the length from the graft site down my shoulder and arm. If the nerve grows and is still firing, this will be good news granted my muscles are maintained and able to reconnect.

To be safe, in addition to the graft, a nerve transplant in my bicep was conducted to try to bring back basic compensated flexion sooner, rather than only wait for the grafted nerve to grow back—which is not guaranteed.

Known as the Oberlin Procedure, using part of my healthy ulnar nerve (as seen from my wrist flexion), the transplant (rerouting) was made to my inactive musculotaneous nerve within my bicep. Its expected that this will take about four months to kick in, which if successful, will give my muscles more time to wait for the grafted nerve to grow back and offer much more firing power than the compensated nerve transfer.

Nerves grow about an inch a month, so assuming the graft worked/works, I got about eight inches to cover before the nerve would reach my bicep area.

In the meantime, I have to let these wounds heal with my arm/shoulder completely immobilized for at least two to three weeks. I’m back at my apartment now standing by, stocked up on meds and supplements.

I am grateful to have finally been operated on. Waiting for the hospital to call back these last three months, I was almost about to forget about the operation, relying completely on the natural path. Now I’m glad my fortune wasn’t dictated like that.

So is my bank account. The grand total of all the hospital expenses including stay, operation and meds, out of pocket was a mere 9000 baht ! Adding about another thousand baht for some Vitamins and supplements I bought at a pharmacy outside, that’s about $300.00 USD ! Mind you, had I went through Thai social system procedure of registration and referring doctors, I would have paid little to nothing.

Well, will see and report whether it proves worthy in due time. Stay tuned.

The scar:

surgery-scar-2-days

surgery-scar-18-days-c

Wilbert says:

Had brachial plexus nerve injury in 2003 and wish to go for surgery

samaher muhamad nahar says:

dear dr ,my sister had upper braxial plexus injury since birth
age:5years
i seek for her operation for muscle transfer
with thanks
i dr work in a&e

Jao Moragoat says:

UPDATE

just got back from the doc to remove my stitches, and wanted to clarify that the doc didn’t mess with c7 because of meningoceles cfc leak risks (root avulsion) so basically my understanding is c6 and c7 were irreparable, and c5 was what was (hopefully) spared with a graft at its trunk rupture

so finally, my most likely case is three out of five arm-hand nerves firing wence this graft works (C8, and T1 stretched plus c5 graft), not best,not worst case and it is what it is and will be.

now waiting and working for biceps and shoulder to reap benefits of oberlin procedure (part of ulnar rerouted into musculotaneous bracialas in bicep) and c5 continuity to grow from the plexus and beyond
Could/Should be 4 to 12 months I suppose before the next major benchmark-update. hopefully it’s good news

jj katri says:

Congrats! Keep positive and know now that you have done everything possible for the best possible recovery. Take supplements,do whatever you can to help, whether it helps mentally or physically it doesn’t matter as long as you feel it is helping you. Take care, JJ. (Humboldtmtnbkr on UBPN)