The scoring system that we (as surgeons) often use to grade outcomes after brachial plexus surgeons is flawed: although we grade muscles in a way that is supposed to be standardized, there is A LOT of inter- and intra-observer variability in grading muscle strength. It would make a lot more sense for us to center our perspective on outcomes that are based on the patient experience. For example, were you satisfied after the surgery? Would you do it again? Is your overall function improved? Unfortunately, only 4 of the 88 studies that we looked at in our systematic review included a measure of function and only 3 studies reported patient satisfaction (J Hand Surg 2015).
We have a long way to go with regard to reporting patient-centered outcomes in brachial plexus surgery, but here is what I have been able to learn from what is reported in our literature:
Thomas Kretschmer's group from Germany (Neurosurgery 2009) reported that 87% of patients who underwent BPI surgery were satisfied with their outcome, with 83% saying that they would have surgery again. This is despite functional scores (as measured by the DASH) reflecting a tremendous amount of residual disability. An article from Susan Mackinnon's and David Kline's groups (from the plastic surgery division here at Wash U and from the neurosurgery department at LSU, respectively; J Hand Surg 1997) showed similar high marks (78%) for satisfaction after BPI surgery, with a similar finding of remarkable residual effect on overall quality of life.
A more recent study from Kevin Chung's group in Michigan (J Hand Surg 2014) used qualitative research techniques to study a small group of patients with BPI. Again, the majority of the patients were satisfied, despite the fact that substantial functional disability still existed after surgery. Interestingly, patient satisfaction hinged on what they expected from the surgery. Certainly, this provides more support for having in-depth discussions before surgery about realistic expectations for ultimate functional recovery. The representative remarks from the patients in this study will resonate with any patient affected by BPI and with any health care provider who has cared for BPI patients.
BPI are devastating injuries, but the limited literature that is available indicates that most patients are satisfied with the surgical treatment that they receive. Certainly the experiences and trauma associated with BPI will influence the patient's perspective on what a satisfactory outcome is, but there is still a tremendous amount of room for improvement in how we deliver care for BPI, both in how we counsel patients and in the technical limitations in our current procedures.
Christopher J. Dy, MD MPH