Frequency and Risk Factors for Prolonged Opioid Prescriptions After Surgery for Brachial Plexus Injury

Pain Interference Prior to and 1 Year After Surgery for Adult Traumatic Brachial Plexus Injury

PURPOSE

Pain after brachial plexus injury (BPI) can be severely debilitating and is poorly understood. We hypothesized that pain interference (PI) ("the extent to which pain hinders engagement in life") would be predicted by depression, anxiety, severity of pain symptoms, and poorer preoperative muscle function.

METHODS

Among patients in a prospective multicenter BPI cohort study, 37 completed Patient-Reported Outcomes Measurement Information System (PROMIS) PI questionnaires before and 1 year after surgery. At both times, participants completed anxiety and depression questionnaires and BPI-specific measures of pain symptoms, physical limitations, and emotional recovery. Surgeon-graded muscle testing, injury severity, age at the time of injury, body mass index, and time from injury to surgery were included. We performed a bivariate analysis of predictors for preoperative and 1-year PROMIS PI followed by multivariable regression modeling using stepwise selection and Bayesian Information Criterion to select covariates.

RESULTS

Before surgery, the mean PROMIS PI score was 60.8 ± 11.0, with moderate correlations between PROMIS PI and depression, as well as between PROMIS PI and functional limitations. At 1 year after surgery, the mean PROMIS PI score was 59.7 ± 9.5. There was no difference in preoperative and 1-year PROMIS PI. There were strong correlations between PROMIS PI and pain symptoms, functional limitations, and emotional aspects of recovery at the 1-year follow-up that remained significant in multivariable regression. There were no notable associations between muscle testing and PI.

CONCLUSIONS

Pain interference remained substantial and elevated in BPI patients 1 year after surgery. We noted strong associations between PI and pain symptoms, functional limitations, and emotional aspects of recovery. These findings demonstrate the persistence of pain as a feature throughout life after BPI and that its treatment should be considered a priority alongside efforts to improve extremity function.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognosis IV.

Predicting Persistent Opioid Use after Hand Surgery: A Machine Learning Approach

BACKGROUND

The aim of this study was to evaluate the use of machine learning to predict persistent opioid use after hand surgery.

METHODS

The authors trained 2 algorithms to predict persistent opioid use, first using a general surgery data set and then using a hand surgery data set, resulting in 4 trained models. Next, the authors tested each model's performance using hand surgery data. Participants included adult surgery patients enrolled in a cohort study at an academic center from 2015 to 2018. The first algorithm (Michigan Genomics Initiative model) was designed to accommodate patient-reported data and patients with or without prior opioid use. The second algorithm (claims model) was designed for insurance claims data from patients who were opioid-naive only. The main outcome was model discrimination, measured by area under the receiver operating curve (AUC).

RESULTS

Of 889 hand surgery patients, 49% were opioid-naive and 21% developed persistent opioid use. Most patients underwent soft-tissue procedures (55%) or fracture repair (20%). The Michigan Genomics Initiative model had AUCs of 0.84 when trained only on hand surgery data, and 0.85 when trained on the full cohort of surgery patients. The claims model had AUCs of 0.69 when trained only on hand surgery data, and 0.52 when trained on the opioid-naive cohort of surgery patients.

CONCLUSIONS

Opioid use is common after hand surgery. Machine learning has the potential to facilitate identification of patients who are at risk for prolonged opioid use, which can promote early interventions to prevent addiction.

The Influence of Psychosocial Factors on Disability and Expected Improvement Before Surgery for Adult Traumatic Brachial Plexus Injury

PURPOSE

Psychosocial factors influence pain and recovery after extremity trauma and may be targets for early intervention. This may be of particular interest for patients with adult traumatic brachial plexus injury (BPI), given the broad and devastating impact of the injury. We hypothesized that there would be an association between depressive symptoms, anxiety, and pain interference with preoperative disability and expectations for improvement after BPI surgery.

METHODS

We enrolled 34 patients into a prospective multicenter cohort study for those undergoing surgery for adult traumatic BPI. Before surgery, participants completed Patient-Reported Outcome Measurement Information System scales for pain interference, anxiety, and depressive symptoms, and a validated BPI-specific measure of disability and expected improvement. We performed Pearson correlation analysis between pain interference, anxiety symptoms, and depressive symptoms with (A) disability and (B) expected improvement. We created separate linear regression models for (A) disability and (B) expected improvement including adjustment for severity of plexus injury, age, sex, and race.

RESULTS

Among 34 patients, there was a moderate, statistically significant, correlation between preoperative depressive symptoms and higher disability. This remained significant in a linear regression model adjusted for severity of plexus injury, age, sex, and race. There was no association between severity of plexus injury and disability. Depressive symptoms also were moderately, but significantly, correlated with higher expected improvement. This remained significant in a linear regression model adjusted for severity of plexus injury, age, sex, and race.

CONCLUSIONS

Depressive symptoms are associated with greater disability and higher expected improvement before BPI surgery. Screening for depressive symptoms can help BPI teams identify patients who would benefit from early referral to mental health specialists and tailor appropriate expectations counseling for functional recovery. We did not find an association between severity of BPI and patient-reported disability, suggesting either that the scale may lack validity or that the sample is biased.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Daily Life Impact of Brachial Plexus Reconstruction in Adults: 10 Years Follow-Up

PURPOSE

Reconstructive surgery of brachial plexus injury in adults remains a challenge. Short- and midterm follow-up results have been described in terms of impairments, such as muscle strength grading. However, psychologic management has been shown to be a major contributor in long-term results. A new, specific brachial plexus injury scale, including functional and psychologic components, was described. Objectives of this study were: (1) to assess functional long-term brachial plexus reconstruction outcomes; and (2) to validate the Mancuso scale at 10 years of follow-up.

METHODS

Twenty patients with at least 10 years of follow-up were included in the study. Four patients had C5-C6 palsy and 16 had a C5-T1 injury. Shoulder abduction and elbow flexion were assessed with Medical Research Council grades. Shoulder function was evaluated with a Constant score. The 36-item short-form survey (SF36) was used to assess quality of life, and the quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) was used for patient reports of disability. The Mancuso scale was assessed and correlated to the different scores used.

RESULTS

At the last follow-up, the Medical Research Council grade was at least grade 3 in 10 cases (50%) of shoulder abduction and in 12 cases (60%) of elbow flexion. The Constant score was 31.4 (SD, 15.1). The SF36 score was 67.5 (SD, 4.25) and the QuickDASH was 50 (SD, 15.9). We found a correlation between the symptom score (Mancuso score) and the different quality-of-life scores (QuickDASH: coefficient, 0.491; SF36: coefficient, -0.565; limitations score: coefficient, 0.445).

CONCLUSIONS

This study reported results from the Mancuso scale at a minimum of 10 years of follow-up of reconstructive surgery for brachial plexus injury in adults. Correlations between this composite scale and the SF36 and QuickDASH scores suggest construct validity.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Trends in Brachial Plexus Surgery: Characterizing Contemporary Practices for Exploration of Supraclavicular Plexus

BACKGROUND

There is variability in treatment strategies for patients with brachial plexus injury (BPI). We used qualitative research methods to better understand surgeons' rationale for treatment approaches. We hypothesized that distal nerve transfers would be preferred over exploration and nerve grafting of the brachial plexus.

METHODS

We conducted semi-structured interviews with BPI surgeons to discuss 3 case vignettes: pan-plexus injury, upper trunk injury, and lower trunk injury. The interview guide included questions regarding overall treatment strategy, indications and utility of brachial plexus exploration, and the role of nerve grafting and/or nerve transfers. Interview transcripts were coded by 2 researchers. We performed inductive thematic analysis to collate these codes into themes, focusing on the role of brachial plexus exploration in the treatment of BPI.

RESULTS

Most surgeons routinely explore the supraclavicular brachial plexus in situations of pan-plexus and upper trunk injuries. Reasons to explore included the importance of obtaining a definitive root level diagnosis, perceived availability of donor nerve roots, timing of anticipated recovery, plans for distal reconstruction, and the potential for neurolysis. Very few explore lower trunk injuries, citing concern with technical difficulty and unfavorable risk-benefit profile.

CONCLUSIONS

Our analysis suggests that supraclavicular exploration remains a foundational component of surgical management of BPI, despite increasing utilization of distal nerve transfers. Availability of abundant donor axons and establishing an accurate diagnosis were cited as primary reasons in support of exploration. This analysis of surgeon interviews characterizes contemporary practices regarding the role of brachial plexus exploration in the treatment of BPI.

Preoperative Patient-Reported Data Indicate the Risk of Prolonged Opioid Use After Hand and Upper Extremity Surgeries

PURPOSE

Opioids play an important role in pain management after surgery but also increase the risk of prolonged opioid use in patients. The identification of patients who are more likely to use opioids after intended short-term treatment is critical for employing alternative management approaches or targeted interventions for the prevention of opioid-related problems. We used patient-reported data (PRD) and electronic health record information to identify factors predictive of prolonged opioid use after surgery.

METHODS

We used our institutional registry containing data on all patients who underwent elective upper extremity surgeries. We evaluated factors associated with prolonged opioid use in the cohort from the year 2018 to 2019. We then validated our results using the 2020 cohort. The predictive variables included preoperative PRD and electronic health record data. Opioid use was determined based on patient reports and/or filled opioid prescriptions 3 months after surgery. We conducted bivariate regression, followed by multivariable regression analyses, and model validation using area under the receiver operating curve.

RESULTS

We included 2,114 patients. In our final model on the 2018-2019 electronic health records and PRD data (n = 1,589), including numerous patient-reported outcome questionnaire scores, patients who were underweight and had undergone trauma-related surgery had higher odds of being on opioids at 3 months. Additionally, each 5-unit decrease in the preoperative Patient-Reported Outcomes Measurement Information System Global Physical Health score was associated with a 30% increased odds of being on opioids at 3 months. The area under the receiver operating curve of our model was 70.4%. On validation using data from the 2020 cohort, the area under the receiver operating curve was 60.3%. The Hosmer-Lemeshow test indicated a good fit.

CONCLUSIONS

We found that preoperative questionnaire scores were associated with prolonged postoperative opioid use, independent of other variables. Furthermore, PRD may provide unique patient-level insights, alongside other factors, to improve our understanding of postsurgical pain management.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Cervical selective nerve root injection alleviates chronic refractory pain after brachial plexus avulsion: a case report

Background

Intractable chronic pain, as well as motor, sensory, and autonomic neuropathy, significantly reduces the quality of life of brachial plexus avulsion (BPA) patients. We report the successful application of cervical selective nerve root injection (CSNRI) in a patient with BPA.

Case presentation

A 40-year-old man had been diagnosed with complete left BPA due to a motorcycle accident and underwent intercostal nerve transplantation at the age of 18 years and had been experiencing pain ever since. His pain increased after fracture of the left humerus, and he was referred to our pain management clinic. As his exacerbated pain was suspected to be due to peripheral nerve hypersensitivity, we performed repetitive ultrasound-guided CSNRI (3 mL of 1% mepivacaine of each) targeted C5 and 6 intervertebral foramina, and his symptoms gradually improved.

Conclusions

Repetitive CSNRI may help diagnose and treat BPA-associated peripheral neuropathic pain, even in patients diagnosed with BPA.

Team Approach: Management of Brachial Plexus Injuries

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Traumatic brachial plexus injuries are relatively rare but potentially devastating injuries with substantial functional, psychological, and economic consequences.

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Prompt referral (ideally within 6 weeks of injury) to a center with a team of experts experienced in the diagnosis and management of these injuries is helpful to achieving optimal outcomes.

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Preoperative and intraoperative decision-making to diagnose and plan reconstructive procedures is complex and must take into account a number of factors, including the time from injury, concomitant injuries, preservation of cervical nerve roots, and the availability of intraplexal and extraplexal donor nerves for nerve transfer.

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A team approach is essential to ensure accurate localization of the pathology before surgery and to maximize rehabilitation after surgery, necessitating close contact between the surgical team, physiatrists, radiologists, and therapists.

Long-Term Opioid Use Following Surgery for Symptomatic Neuroma

BACKGROUND

 Identifying patients at risk for prolonged opioid use following surgery for symptomatic neuroma would be beneficial for perioperative management. The aim of this study is to identify the factors associated with postoperative opioid use of >4 weeks in patients undergoing neuroma surgery.

METHODS

 After retrospective identification, 77 patients who underwent surgery for symptomatic neuroma of the upper or lower extremity were enrolled. Patients completed the Patient-Reported Outcomes Measurement Information System (PROMIS) depression, Numeric Rating Scale (NRS) pain score, and a custom medication questionnaire at a median of 9.7 years (range: 2.5-16.8 years) following surgery. Neuroma excision followed by nerve implantation (n = 39, 51%), nerve reconstruction/repair (n = 18, 23%), and excision alone (n = 16, 21%) were the most common surgical treatments.

RESULTS

 Overall, 27% (n = 21) of patients reported opioid use of more than 4 weeks postoperatively. Twenty-three patients (30%) reported preoperative opioid use of which 11 (48%) did not report opioid use for >4 weeks, postoperatively. In multivariable logistic regression, preoperative opioid use was independently associated with opioid use of >4 weeks, postoperatively (odds ratio [OR] = 4.4, 95% confidence interval [CI]: 1.36-14.3, p = 0.013).

CONCLUSION

 Neuroma surgery reduces opioid use in many patients but patients who are taking opioids preoperatively are at risk for longer opioid use. Almost one-third of patients reported opioid use longer than 4 weeks, postoperatively.

Impact of Nerve Surgery on Opioid and Medication Use in Patients with Chronic Nerve Injuries

Introduction:

Limited information is available regarding the ability of nerve surgery to affect medication use patterns in patients with chronic pain or neuropathy due to nerve injury.

Methods:

A retrospective survey was distributed to all operative patients (N = 767) from a single nerve surgeon’s practice between 2014 and 2020. Data collected included demographics, specifics of the injury and symptoms, medication and opioid use before surgery, and medication/opioid use following surgery.

Results:

Out of the 767 patients, 209 (27.2%) completed the survey. Average age was 48.8 (SD = 19.1) years; 68.9% female and 31.1% male. More than 50% of the patients took at least three medications. More than 50% of the patients after surgery did not need medication or had significant reduction; 54.1% of the patients took opioid medication daily, and 97.3% of patients reported that narcotic medications did not resolve their problem. Patients rated the effectiveness (Likert scale 0–10) of opioid medications in general at an average 3.25 ± 2.03. Of patients who took opioids regularly, 61.6% reported a negative effect of these medications on daily or professional activities. After surgery, more than 50% of the patients did not need opioids or had a significant reduction in opioid usage.

Conclusions:

Untreated nerve injuries lead to ongoing chronic pain, explaining why medications are mostly ineffective in eliminating symptoms. In this study, nerve surgery targeting the anatomical source of symptoms effectively reduced both opioid and nonopioid medication use.

Management of Adult Brachial Plexus Injuries

Adult brachial plexus injuries result in profound functional deficits, debilitating pain, substantial mental health implications, and extensive economic impacts. Their initial evaluation includes a detailed physical examination, electrodiagnostic studies, advanced imaging, and patient counseling. A team-based approach, led by a peripheral nerve surgeon and including hand therapists, electrodiagnosticians, mental health experts, and pain-management specialists, is used to provide optimal longitudinal care during the lengthy recovery process. The options for the surgical management of brachial plexus injuries include exploration, neurolysis, nerve grafting, nerve transfer, free functional muscle transfer, tendon transfer, arthrodesis, and amputation. When treated within 6 months, the outcomes are favorable for the restoration of essential shoulder and elbow function. Free functional muscle transfer is a powerful tool to address elbow flexion and rudimentary grasp in both primary and delayed settings. The restoration of hand function remains a challenge for patients with complete brachial plexus injury. The purpose of this review is to summarize foundational concepts in diagnosis and management, discuss current trends and controversial topics, and address areas for future investigation.

Variability in Surgeon Approaches to Emotional Recovery and Expectation Setting After Adult Traumatic Brachial Plexus Injury

Purpose

Increasing emphasis has been placed on multidisciplinary care for patients with traumatic brachial plexus injury (BPI), and there has been a growing appreciation for the impact of psychological and emotional components of recovery. Because surgeons are typically charged with leading the recovery phase of BPI, our objective was to build a greater understanding of surgeons’ perspectives on the care of BPI patients and potential areas for improvement in care delivery.

Methods

We conducted semistructured qualitative interviews with 14 surgeons with expertise in BPI reconstruction. The interview guide contained questions regarding the surgeons’ practice and care team structure, their attitudes and approaches to psychological and emotional aspects of recovery, and their preferences for setting patient expectations. We used inductive thematic analysis to identify themes.

Results

There was a high degree of variability in how surgeons addressed emotional and psychological aspects of recovery. Whereas some surgeons embraced the practice of addressing these components of care, others felt strongly that BPI surgeons should remain focused on technical aspects of care. Several participants described the emotional toll that caring for BPI patients can have on surgeons and how this concern has affected their approach to care. Surgeons also recognized the importance of setting preoperative expectations. There was an emphasis on setting low expectations in an attempt to minimize the risk for dissatisfaction. Surgeons described the challenges in effectively counseling patients about a condition that is prone to substantial injury heterogeneity and variability in functional outcomes.

Conclusions

Our results demonstrate wide variability in how surgeons address emotional, psychological, and social barriers to recovery for BPI patients.

Clinical relevance

Best practices for BPI care are difficult to establish because of the relative heterogeneity of neurologic injury, the unpredictable impact and recovery of the patient, and the substantial variability in physician approach to the care of these patients.

"Pill Pushers and CBD Oil"-A Thematic Analysis of Social Media Interactions About Pain After Traumatic Brachial Plexus Injury

Purpose

Brachial plexus injury (BPI) patients use on-line groups for peer support, often seeking information from Facebook groups devoted to BPI. We hypothesized that a qualitative thematic analysis of posts from BPI Facebook groups would demonstrate the areas in which patients were seeking information regarding treatment of BPI and reveal potential sources of misinformation that patients may encounter.

Methods

We identified the 2 most popular public Facebook groups for BPI by searching key words “traumatic brachial plexus injury.” We selected posts containing comments regarding BPI from November 1, 2018 through October 31, 2019. We excluded posts regarding brachial plexus birth injury. We used iterative inductive and deductive thematic analysis for the qualitative data to identify recurring topics, knowledge gaps, potential roles of patient educational interventions, and patient interaction dynamics. Two investigators independently coded all posts and resolved discrepancies by discussion.

Results

A total of 7,694 posts from 2 leading Facebook support groups were analyzed. Three themes emerged: (1) When discussing pain management, there was recurring anti-opioid sentiment. Posters who currently used opioids or supported those who did discussed perceived effects of the opioid epidemic on their treatment, on their relationships with care providers, and on availability of the medication. (2) Posters advocated for alternatives to traditional approaches to pain management, referring to prescribers as pill pushers and touting cannabinoids as a safer and more effective replacement. (3) There was strong anti-gabapentinoid sentiment owing to reported adverse effects and a perceived lack of efficacy, despite its role as a first-line treatment for neuropathic pain.

Conclusions

Examination of posts from Facebook support groups for BPI revealed recurring themes, questions, misinformation, and opinions from posters with regard to treatment of neuropathic pain. These findings can help clinicians who care for BPI patients identify areas to focus on during patient encounters to address neuropathic pain that commonly occurs with BPI.

Clinical relevance

Brachial plexus injury surgeons should be aware of information, misinformation, and opinions on social media, because these may influence patient–surgeon interactions.