The way that clinicians report outcomes of surgery for a traumatic nerve injury involving the arm is not standardized, and it is thus difficult to compare the efficacy of different surgical treatments, according to a study by researchers at Hospital for Special Surgery (HSS) in New York. In a second HSS study, investigators say they have developed a tool to measure outcomes that they hope can be refined and used worldwide.
“There is a great deal of discrepancy in how the results of brachial plexus surgery are reported. This makes it hard to compare and contrast studies and understand outcomes of brachial plexus surgeries across centers and across continents. From this work, we have determined that there is a need for a standardized outcomes measurement system or tool,” Steve K. Lee, MD, an associate professor in the department of orthopedic surgery at New York University Hospital for Joint Diseases and who will serve as the center’s research director, stated in a press release. “To advance the science, you can only compare what we are doing here and what others are doing in other countries if we are all speaking the same outcomes language and using the same tool.
To investigate, they conducted a search of Medline using the keywords brachial plexus, surgery and outcomes. The search identified 660 articles on adult brachial plexus injuries over the past 3 years. After excluding articles that did not discuss surgical outcomes for this condition, they identified 49 articles that qualified for the final analysis. Lee; Scott W. Wolfe, MD, hand and upper extremity surgeon and director of the soon-to-open Hospital for Special Surgery Center for Brachial Plexus and Complex Nerve Injury; and Rohit Garg, MD, analyzed the type of brachial plexus outcome parameters and the consistency of outcomes-reporting between authors and centers. They found that reporting was inconsistent.
Muscle strength, the most commonly reported outcome, was discussed in 84% of articles. Range of motion, however, was reported in less than half of the papers. No papers measured motion of the entire upper extremity and only 14% of papers detailed how the motion was measured. Functional outcome scores were recorded in only 12% and scores were recorded using different tools, so comparing studies was difficult. Functional outcome scores were recorded using a variety of different tools, including the Disabilities of the Arm, Shoulder, and Hand measure, as well as other tools such as the Constant Score for Shoulder Function, VAS functional score, or institution-specific questionnaires. Only 27% of papers measured sensation and only 8% recorded assessments of pain. No article reported all five outcome measurements: strength, range of motion, functional scores, sensibility and pain. The maximum number of outcomes a paper reported was three, and the remaining articles reported only one or two outcomes.
In a second study, the same investigators describe a first draft of a tool that they hope clinicians can use so that the reporting of outcomes is standardized.
Wolfe said they had looked at different tools that doctors were using to see if they could come up with one that would work for brachial plexus surgery, but none of them were adequate and inclusive.
“We had to take elements of different instruments as well as elements that we designed to derive a complete system,” Wolfe said. “We’re studying an injury of several critical nerves, an injury that affects the arm in a way that is very different from that of a fracture or degenerative disease. We needed to design an innovative way to analyze and report outcomes, because we’re simultaneously assessing nerve, muscle and joint recovery. By way of example, although a patient’s nerves could recover beautifully in a particular case, if their shoulder is frozen or their hand atrophied, the patient may not have a functional recovery; unless all elements are assessed, the analysis is incomplete.”