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Barriers to Surgical Intervention and Factors Influencing Motor Outcomes in Patients with Severe Peripheral Nerve Injury: A Province Wide Cohort Study
Published online by Cambridge University Press: 23 November 2023
Abstract:
Introduction:
Despite the importance of timing of nerve surgery after peripheral nerve injury, optimal timing of intervention has not been clearly delineated. The goal of this study is to explore factors that may have a significant impact on clinical outcomes of severe peripheral nerve injury that requires reconstruction with nerve transfer or graft.
Materials and Methods:
Adult patients who underwent peripheral nerve transfer or grafting in Alberta were reviewed. Clustered multivariable logistic regression analysis was used to examine the association of time to surgery, type of nerve repair, and patient characteristics on strength outcomes. Cox proportional hazard regression analysis model was used to examine factors correlated with increased time to surgery.
Results:
Of the 163 patients identified, the median time to surgery was 212 days. For every week of delay, the adjusted odds of achieving Medical Research Council strength grade ≥ 3 decreases by 3%. An increase in preinjury comorbidities was associated with longer overall time to surgery (aHR 0.84, 95% CI 0.74–0.95). Referrals made by surgeons were associated with a shorter time to surgery compared to general practitioners (aHR 1.87, 95% CI 1.14–3.06). In patients treated with nerve transfer, the adjusted odds of achieving antigravity strength was 388% compared to nerve grafting; while the adjusted odds decreased by 65% if the injury sustained had a pre-ganglionic injury component.
Conclusion:
Mitigating delays in surgical intervention is crucial to optimizing outcomes. The nature of initial nerve injury and surgical reconstructive techniques are additional important factors that impact postoperative outcomes.
Résumé :
Obstacles à une intervention chirurgicale et facteurs influençant les résultats moteurs chez des patients souffrant de graves lésions du nerf périphérique : une étude de cohorte à l’échelle de l’Alberta.
Malgré l’importance de bien choisir le moment d’une chirurgie après une lésion nerveuse périphérique, le moment optimal d’une telle intervention n’a pas été clairement défini. L’objectif de cette étude est donc d’explorer les facteurs qui peuvent avoir un impact notable sur l’évolution clinique de patients atteints de graves lésions nerveuses périphériques qui nécessitent une reconstruction par transfert ou greffe de nerf.
Des patients adultes ayant subi un transfert ou une greffe de nerf périphérique en Alberta ont été passés en revue. Une analyse groupée de régression logistique à variables multiples a ainsi été utilisée pour examiner l’association entre le délai avant une intervention chirurgicale, le type de réparation nerveuse et les caractéristiques du patient sur les résultats obtenus en matière de force musculaire. Le modèle de régression à risques proportionnels de Cox a par ailleurs été utilisé pour examiner les facteurs corrélés avec l’allongement des délais d’intervention chirurgicale.
Sur 163 patients identifiés, le délai médian avant une intervention chirurgicale était de 212 jours. Pour chaque semaine de retard, les chances ajustées d’obtenir un score de ≥ 3 à l’échelle de force musculaire de la Medical Research Council (MRC) ont diminué de 3 %. Une augmentation des comorbidités avant lésion a été associée à un délai global plus long avant une intervention chirurgicale (aRR 0,84 ; IC 95 % 0,74-0,95). Les cas d’aiguillage faits par des chirurgiens ont été associés à un délai plus court par rapport aux médecins généralistes (aRR 1,87 ; IC 95 % 1,14-3,06). Chez les patients traités par transfert de nerf, la probabilité ajustée d’obtenir une force musculaire antigravitaire était de 388 % par rapport à la greffe de nerf, tandis que cette même probabilité ajustée diminuait de 65 % si la lésion subie avait une composante préganglionnaire.
Il apparaît donc essentiel de réduire les délais d’intervention chirurgicale pour optimiser l’évolution clinique post-opératoire des patients. La nature de la lésion nerveuse initiale et les techniques de reconstruction chirurgicale sont d’autres facteurs importants qui ont un impact sur cette même évolution.
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- © The Author(s), 2023. Published by Cambridge University Press on behalf of Canadian Neurological Sciences Federation
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