What Are the Predictors for Patient-Reported Disability 1 Year After Surgical Reconstruction for Adult Traumatic Brachial Plexus Injury? Assessment of Muscle Testing and Psychological Factors
Christopher J Dy, MD MPH, FACS1, David M Brogan, MD, MSc1, Mihir J Desai, MD2, Bryan J Loeffler, MD3, R. Glenn Gaston, MD4, Sami H Tuffaha, MD5, Steve K. Lee, MD6, Harvey Chim, MD7, Jeffrey B Friedrich, MD, MC, FACS8 and * PLANeT Study Group, *9, 1Washington University School of Medicine, St. Louis, MO, 2Vanderbilt University Medical Center, Nashville, TN, 3Hand Center, OrthoCarolina Hand Center, Charlotte, NC, 4OrthoCarolina Hand Center, Charlotte, NC, 5Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, 6Hand and Upper Extremity Surgery, Hospital for Special Surgery, New York, NY, 7University of Florida, Gainesville, FL, 8University of Washington, Seattle, WA, 9Lead Site: Washington University School of Medicine, St. Louis, MO
INTRODUCTION: The wide variation in results after surgery for adult traumatic brachial plexus injuries (BPI) has driven interest in determining what factors contribute to these outcomes. We hypothesized that shoulder abduction strength, elbow flexion strength, finger flexion strength, and pain interference (PI) would influence patient-reported disability 1 year after surgery.
METHODS: We enrolled 124 patients into a prospective multi-center cohort study for adult traumatic BPI patients undergoing surgery. Prior to surgery and 1 year after surgery, participants completed PROMIS PI, anxiety, and depression questionnaires and validated BPI-specific measures of physical disability. 38 patients completed one year follow-up (5 lost to follow-up prior to 1-year; all others not yet eligible for 1-year follow-up). We performed univariate analysis of predictors for (A) baseline/preop disability and (B) 1-year disability. For multivariable regression modeling, we used a stepwise selection method and Bayesian Information Criterion to select covariates.
RESULTS: Prior to surgery, BPI disability was 57.9±20.2 (n=124). Univariate analysis demonstrated lack of finger flexion and higher PROMIS PI, depression, and anxiety predicted higher BPI disability. Shoulder abduction and elbow flexion strength were not predictors. Multivariable analysis demonstrated that PROMIS PI (β0.42; 95%CI:0.04-0.80), depression (β0.92; 95%CI:0.51-1.32), and anxiety (β0.39; 95%CI:0.02-0.77) remained significant predictors of baseline/preop disability.
At 1 year after surgery, BPI disability was 47.1±24.3 (n=38). Univariate analysis demonstrated preoperative elbow flexion and higher PROMIS PI, depression, and anxiety scores predicted higher BPI disability. Preoperative shoulder abduction and finger flexion were not predictors. Multivariable analysis demonstrated that PROMIS depression (β1.07; 95%CI:0.51-1.62) and preoperative elbow flexion (≥M3 β-25.2, 95%CI: 38.05,-12.30; M1-2 β-19.1, 95% CI:-54.83-16.54; reference M0) remained significant predictors of 1-year BPI disability.
CONCLUSIONS: Prior to surgery, psychological metrics of depression, anxiety, and PI were significant predictors of disability. In contrast, shoulder abduction or elbow flexion strength were not significant predictors of baseline/preop disability. However, at 1 year after surgery, preoperative elbow flexion strength was a significant predictor of BPI disability, with less disability noted in patients with greater elbow flexion strength. Preoperative shoulder abduction strength did not predict 1-year disability, suggesting that presence of elbow flexion is helpful for counseling and that restoration of elbow flexion may take priority in surgical planning. Furthermore, depression was a significant predictor of disability at both baseline and 1-year, emphasizing the importance of addressing mental health among BPI patients throughout their entire care.
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