Severe Peripheral Nerve Injury: Barriers to Surgical Intervention
Julie C Beveridge, MD, MSc1, Allison Beveridge, BSc2, Rajiv Midha, MD, MSc2, Michael J Morhart, MD, M.Sc3, Jaret Olson, MD3 and K. Ming Chan, MD4, (1)University of Alberta, Edmonton, AB, Canada, (2)University of Calgary, Calgary, AB, Canada, (3)Division of Plastic and Reconstructive Surgery, University of Alberta, Edmonton, AB, Canada, (4)Division of Physical Medicine & Rehabilitation, University of Alberta, Edmonton, AB, Canada
Introduction: The timing of nerve transfer or graft after peripheral nerve injury is critical, and accepted to be approximately 3 to 6 months. However, in practice, patients often present in a delayed manner for surgical intervention.This study describes the timing of surgery after peripheral nerve injury for adult patients in Alberta, and explores patient perspectives regarding barriers to care for peripheral nerve injury.
Design and Methods:A retrospective analysis of adult patients undergoing peripheral nerve transfer or grafting in Alberta from 2005 to 2017 was completed. One hundred and sixty-six patients who underwent distal nerve transfers or grafts for either upper or lower limb peripheral nerve injuries were included in the analysis of time to surgery. One hundred and twenty-nine patients with a minimum of one year follow up, after peripheral nerve surgery, were included in the analysis of factors affecting clinical outcomes.
Outcome Measures: A Cox Proportional Hazard Regression was completed to determine correlation of patient, injury and systemic factors with time to surgical intervention after injury. Additionally, a clustered multivariable logistic regression analysis was completed to examine the association of time to surgery, patient, injury and operative characteristics on MRC strength outcomes.
Results:The mean (SD) time to surgery was 221 (118.1) days. A referral made by a surgeon approximately doubled the hazard of earlier surgery as compared to a general practitioner (p=0.006). An increase in one comorbidity resulted in the adjusted hazard of earlier surgery decreasing by 16% (p=0.014).
Numerous factors are associated with post-operative strength outcomes including: time to operative intervention, operative procedure, and injury. For every week increase from injury to time of surgery, the adjusted odds of the patient achieving a MRC strength grade ≥ 3 decreases by 3% (p=0.02). If a patient received a nerve transfer instead of a nerve graft the adjusted odds of the patient achieving a MRC strength grade ≥ 3 was 388% (p=0.003). The adjusted odds of achieving a MRC ≥ 3 decreased 65% if the injury sustained had a component of pre-ganglionic injury (p=0.05).
Conclusions:The timing of operative intervention after peripheral nerve injury is critical, and delays in surgical intervention are best explained by both patient and systemic factors. These areas of deficiency in the peripheral nerve injury service pathway require further exploration and improvement in order to optimize patient care.
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