Medical treatment decision making after total avulsion brachial plexus injury: a qualitative study

Abstract

OBJECT Complete avulsion traumatic brachial plexus injuries (BPIs) can be treated using nerve and musculoskeletal reconstruction procedures. However, these interventions are most viable within certain timeframes, and even then they cannot restore all lost function. Little is known about how patients make decisions regarding surgical treatment or what impediments they face during the decision-making process. Using qualitative methodology, the authors aimed to describe how and why patients elect to pursue or forego surgical reconstruction, identify the barriers precluding adequate information transfer, and determine whether these patients are satisfied with their treatment choices over time. METHODS Twelve patients with total avulsion BPIs were interviewed according to a semi-structured guide. The interview transcripts were qualitatively analyzed using the systematic inductive techniques of grounded theory to identify key themes related to the decision-making process and long-term satisfaction with decisions. RESULTS Four decision factors emerged from our analysis: desire to restore function, perceived value of functional gains, weighing the risks and costs of surgery, and having concomitant injuries. Lack of insurance coverage (4 patients), delayed diagnosis (3 patients), and insufficient information regarding treatment (4 patients) prevented patients from making informed decisions and accessing care. Three individuals, all of whom had decided against reconstruction, had regrets about their treatment choices. CONCLUSIONS Patients with panplexus avulsion injuries are missing opportunities for reconstruction and often not considering the long-term outcomes of surgery. As more Americans gain health insurance coverage, it is very likely that the number of patients able to pursue reconstruction will increase. The authors recommend implementing clinical pathways to help patients meet critical points in care within the ideal timeframe and using a patient- and family-centered care approach combined with patient decision aids to foster shared decision making, increase access to information, and improve patient satisfaction with decisions. These measures could greatly benefit patients with BPI while reducing costs, improving efficiency, and generating better outcomes.

A Thematic Analysis of Online Discussion Boards for Brachial Plexus Injury

“…However, prompt treatment and referral to a BPI specialist was a recurring problem reported by users, and multiple users felt unsupported by their general practitioners when they wished to see a BPI specialist. These reports are substantiated by findings from interviews with BPI patients, 11 who also expressed frustration in trying to find information about BPI from their doctors or on the Internet. Because the option of surgery in BPI is often time-sensitive, this finding suggests the need for health care centers to address patients' BPI at the time of injury and to set up the proper follow-up care after discharge.…”

A Population-Based Analysis of Time to Surgery and Travel Distances for Brachial Plexus Surgery

“…Our population-based evaluation demonstrated at least a 12 month time interval between injury and surgery in 29% of patients who underwent BPI surgery in Florida, New York, and North Carolina. Median times to surgery in case series at two individual centers in the United States were reported as 9 months and 12 months [10,11]. However, both series included patients who underwent free functional muscle transfers, which can be performed at a later time interval than brachial plexus exploration.…”

Nerve transfer versus muscle transfer to restore elbow flexion after pan–brachial plexus injury: a cost-effectiveness analysis

“…26 Reasons for delay in presentation for reconstructive neurosurgery may include delayed diagnosis, lack of awareness about reconstructive techniques, failed prior surgery, or prolonged waiting for spontaneous recovery. 13 Patients who undergo surgical treatment to restore elbow flexion after this window of time may undergo muscle transplantation rather than nerve transfer to restore function.…”

“…2,13,24 The gracilis muscle transplant is most commonly innervated by the SAN or ICNs. 2 While efficacious in achieving adequate elbow function, FFMT exposes patients to additional risks such as possible thrombosis of the newly anastomosed vessels for the gracilis muscle, which may result in graft failure, reoperations, and prolonged hospitalizations with extensive intensive care unit (ICU) monitoring.…”