Saturday, January 23, 2016

What do patients expect from brachial plexus surgery?

This post is the beginning of a series of posts dedicated to exploring the patient experience after brachial plexus injury.

Patient responses when asked about what they expected for outcomes after brachial plexus surgery:
  • "I expect to get movement again in my arm. I do not expect 100%, that is unrealistic. But I expect 90%."
  • "I know it can never be 100%. I was told there is no guarentee, but maybe 80%."
  • "I expect to hold my baby like a normal person would."
(Mancuso CA, Lee SK, Dy CJ, Landers ZA, Model Z, Wolfe SW; HAND 2015. Link)

As a whole, brachial plexus surgeons tend to focus on outcomes related to recovery of specific muscle strength (see link here for a paper that I wrote about this; Dy CJ, et al - J Hand Surg 2015). We probably feel that this is most objective and reliable way for us to assess improvement after injury and after surgery. We target our surgeries to improve specific muscle function (elbow flexion, shoulder abduction, etc.). But in doing so, we likely lose perspective of what is most important to the patient - can I do what I need to do in order to function independently?

As an orthopedic surgery resident at Hospital for Special Surgery in NYC, I was fortunate to work with two experienced brachial plexus surgeons (Drs. Scott Wolfe and Steve Lee) who had enough insight to recognize and investigate the importance of the patient experience in brachial plexus injury. We teamed up with a brilliant qualitative researcher (Dr. Carol Mancuso) and developed a study to perform detailed, in-depth interviews to ask about what patients expected after their brachial plexus injuries. This is ultimately important because it helps us, as surgeons, understand what you, as patients, are expecting in terms of ultimate recovery after surgery. If we see eye-to-eye and are able to level these expectations before surgery, it is more likely that we will both be pleased with the result. However, if we are on completely different pages before surgery, it will be a difficult postoperative course, filled with frustration - I might be happy that you are flexing your elbow, but you might be frustrated that you cannot hold your baby or are not functioning at 90% of normal.

The detailed results of this carefully conducted study are published in the journal HAND (link HERE; email me if you would like a copy of the paper). What struck me the most is the amount of variability in what patients expected after brachial plexus surgery. Certainly this speaks to the tremendous variability in the severity of injury (ie: upper trunk vs complete plexus... and every iteration in between), but it also tells me that a lot of what patients expect is shaped by what they have been told by other medical personnel and what they have found on the internet for themselves. And I truly believe that this is a critically important part of how we can make a difference for patients - educating other medical providers about what can (and cannot) be done for brachial plexus patients and publishing reasonable and reliable information on the internet regarding brachial plexus injury and brachial plexus surgery. These are life-altering and immediately-devastating injuries, and our patients deserve the best possible (and realistic) information about their injuries.

This project was incredibly beneficial for me as a brachial plexus surgeon. In my office, I take every effort to understand the magnitude of how this injury has affected the life of each patient (and the lives of their family and friends, who typically "step up" tremendously to help out). And I make sure to ask every patient what they expect before surgery... and then I take some time to make sure that we are on the exact same page in terms of realistic expectations for outcomes, both in terms of function and in terms of time. 

So now I ask the multitude of patients on the internet with brachial plexus injuries - what did you expect from your surgery? (if you had one). And for the BPI surgeons on the web - what type of expectations do your patients have for surgery? 

Christopher J. Dy, MD MPH
My Bio at Washington University Orthopedics

Wednesday, January 6, 2016

Timing is Everything...

"We will refer the patient for a brachial plexus surgery evaluation, although they will not do surgery until a year after the injury..."

This is a direct quote from the chart of a patient referred to me by a neurologist and an orthopaedic surgeon in another state. To me, this is maddening - absolutely drives me nuts! For that particular patient's injury, waiting more than a year to do the surgery would have left us with minimal chance of success after a nerve reconstruction.

Timing is incredibly important in the treatment of traumatic brachial plexus injuries. I often find myself discussing the importance of timing of treatment with both patients and referring physicians, so I thought this would be a good place to share my thoughts.

After a traumatic nerve injury occurs, the clock starts ticking. When a muscle no longer receives input from a nerve, it can become atrophic - essentially, when it has no signal to perform its function, it withers away. These changes are evident in human muscle at approximately 3 months - sometimes sooner, sometimes later. Somewhere around 12 months, these changes become irreversible, leaving the muscle essentially useless - even if you are able to establish a good nerve signal into the muscle with surgery or spontaneous recovery. At the same time as the muscle withers away, the distal part of the injured nerve (the part of the nerve "downstream" from the injury) also starts to degenerate. This makes it even harder to reconstruct a nerve injury after a long period of time, whether you excise and replace the injured nerve with a nerve graft or bypass the injured nerve with a nerve transfer.

What I wrote above it based on a number of animal studies and laboratory studies of human tissue, but has also been borne out in the clinical experience. While brachial plexus injuries (and this "timing" issue, in particular) are really tough to study with rigorous clinical trials, the collective experience and case series from multiple surgeons reflect that there is a relationship between clinical outcomes and timing of surgery - essentially, the sooner the better.

I prefer to see any patient with a brachial plexus injury or complex peripheral nerve injury as soon after the injury as possible. A pretty good number of these injuries may get better on their own without surgery - with careful watching, repeated examinations, and physical therapy. I would rather have a patient go through that process with me from as close to "day 1" as possible, so that if the recovery is inadequate by 3 months (or 5 months, etc... depending on the specifics of the case), we can be ready to intervene surgically at a time that is optimized for success.