Patient-reported outcomes following nerve transfer surgery for brachial plexus injury: A systematic review of the literature
Chloe Emma Haldane, BHSc, MScPT, MD1, Geoff Frost, BASc, MHSc, MD1, Emmanuel Ogalo, BKin1, Sean Bristol, MD, FRCSC2, Christopher Doherty, MD, FRCSC3 and Michael James Berger, MD, PhD, FRCPC, CSCN Diplomate (EMG)4, (1)University of British Columbia, Vancouver, BC, Canada, (2)University of British Columbia, Division of Plastic and Reconstructive Surgery, Vancouver, BC, Canada, (3)Plastic and Reconstructive Surgery, St. Joseph's Health Care Center, University of British Columbia, Division of Plastic and Reconstructive Surgery, Vancouver, BC, Canada, (4)University of British Columbia, Division of Physical Medicine and Rehabilitation, Vancouver, BC, Canada
Introduction: Literature on surgical interventions for brachial plexus injury (BPI) has historically focused on measures of strength with manual muscle testing. This may not correlate with long-term functional status, quality of life, or patient satisfaction. A greater appreciation of the patient-reported experience, in conjunction with muscle strength outcomes, is required. The purpose of this systematic literature review was to determine the impact of nerve transfer surgery for BPI on (1) activity and participation; (2) patient satisfaction; (3) quality of life; and (4) pain outcomes.
Materials and Methods: MEDLINE, EMBASE, and CINAHL were searched on September 25, 2019 and screened in duplicate for relevant studies. Data were collected regarding injury type, surgical technique, post-operative rehabilitation, complications, follow-up duration and outcome measures. Study quality was assessed in duplicate using the Methodological Index for Non-Randomized Studies (MINORS) criteria.
Results: Nineteen studies that involved 475 patients were included in outcome analyses. The average mean follow-up was 43.2±31.6 months. Mean patient age was 35.0±9.2 and 89.6% of participants were male. Several surgical techniques were used in isolation or combination. The Oberlin's transfer was the most common (used in 52.6% of studies) followed by spinal accessory-to-suprascapular nerve transfer (used in 47.3% of studies). All studies reported on strength measures, primarily with Medical Research Council (MRC) grading. Pain was assessed in twelve studies, most commonly by visual analogue scale (VAS), with an average preoperative score of 4.5 (3.7-5.0) and an average postoperative score of 3.7 (3.0-4.9). The most commonly used outcome measure to assess activity and participation was the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, with a mean improvement of 15.46 (2-30.7) after surgery. Across five studies, 66.0% of patients who were reported as working, or presumed to be working at the time of injury, returned to work. Patient satisfaction was assessed in four studies (primarily by questionnaire) with a mean satisfaction of 68.4%.
Conclusions: Subjective measures of function including participation and activity, patient satisfaction, quality of life and pain outcomes following nerve transfer for BPI, are not frequently reported in the literature. However, the studies included in this review provide important insights toward the impact of nerve transfer on clinically important outcomes other than muscle strength. Participants demonstrated modest improvement in pain with significant improvement for activity and participation (DASH), return to work and patient satisfaction.
Level of Evidence: Level IV, systematic review of Level II - IV
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