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Muhlestein WE, Chang KWC, Justice D, Johnson S, Brown S, Popadich M. Developing interdisciplinary research teams in neurosurgery: key elements to success in brachial plexus and peripheral nerve surgery. J Neurosurg 2023; 139:1552-1559. [PMID: 37178028 DOI: 10.3171/2023.4.jns222254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 04/07/2023] [Indexed: 05/15/2023]
Abstract
The highest-impact medical literature is increasingly produced by interdisciplinary teams. The field of neurosurgery, which involves complex pathologies and recoveries, is particularly amenable to interdisciplinary research approaches. However, research in the medical context regarding the characteristics of effective teams, as well as how to develop and maintain interdisciplinary teams, remains lacking. Here, the authors used the business literature to identify the characteristics of effective teams. They then used the University of Michigan Brachial Plexus and Peripheral Nerve Program, founded under the leadership of the late Dr. Lynda Yang, as a case study for how these principles can be applied to build and operationalize a successful interdisciplinary team. They suggest that these same techniques can be used to create interdisciplinary research groups in other areas of neurosurgery.
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Muhlestein WE, Chang KWC, Smith BW, Yang LJS, Brown SH. Quantifying long-term upper-limb activity using wearable motion sensors after nerve reconstruction for neonatal brachial plexus palsy. J Neurosurg Pediatr 2022:1-6. [PMID: 35334468 DOI: 10.3171/2022.2.peds21478] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 02/02/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Standard, physician-elicited clinical assessment tools for the evaluation of function after nerve reconstruction for neonatal brachial plexus palsy (NBPP) do not accurately reflect real-world arm function. Wearable activity monitors allow for the evaluation of patient-initiated, spontaneous arm movement during activities of daily living. In this pilot study, the authors demonstrate the feasibility of using body-worn sensor technology to quantify spontaneous arm movement in children with NBPP 10 years after nerve reconstruction and report the timing and magnitude of recovered arm movement. METHODS Eight children with NBPP who underwent brachial plexus reconstruction approximately 10 years prior were recruited to take part in this single-institution prospective pilot study. Per the treatment protocol of the authors' institution, operated patients had severe, nonrecovering nerve function at the time of surgery. The patients were fitted with an activity monitoring device on each of the affected and unaffected arms, which were worn for 7 consecutive days. The duration (VT) and power (VM) with which each arm moved during the patient's normal daily activities were extracted from the accelerometry data and ratios comparing the affected and unaffected arms were calculated. Demographic data and standard physician-elicited clinical measures of upper-extremity function were also collected. RESULTS Three children underwent nerve grafting and transfer and 5 children underwent graft repair only. The mean (± SD) active range of motion was 98° ± 53° for shoulder abduction, 130° ± 24° for elbow flexion, and 39° ± 34° for shoulder external rotation. The median Medical Research Council grade was at least 2.5 for all muscle groups. The median Mallet grade was at least 2 for all categories, and 13.5 total. The VT ratio was 0.82 ± 0.08 and the VM ratio was 0.53 ± 0.12. CONCLUSIONS Wearable activity monitors such as accelerometers can be used to quantify spontaneous arm movement in children who underwent nerve reconstruction for NBPP at long-term follow-up. These data more accurately reflect complex, goal-oriented movement needed to perform activities of daily living. Notably, despite severe, nonrecovering nerve function early in life, postsurgical NBPP patients use their affected arms more than 80% of the time that they use their unaffected arms, paralleling results in patients with NBPP who recovered spontaneously. These data represent the first long-term, real-world evidence to support brachial plexus reconstruction for patients with NBPP.
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Affiliation(s)
| | | | - Brandon W Smith
- 2Department of Neurosurgery, Duke University, Durham, North Carolina
| | | | - Susan H Brown
- 3School of Kinesiology, University of Michigan, Ann Arbor, Michigan; and
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Smith BW, Chang KWC, Parmar HA, Ibrahim M, Yang LJS. MRI evaluation of nerve root avulsion in neonatal brachial plexus palsy: understanding the presence of isolated dorsal/ventral rootlet disruption. J Neurosurg Pediatr 2021; 27:589-593. [PMID: 33711804 DOI: 10.3171/2020.9.peds20326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 09/21/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The evaluation, treatment, and prognosis of neonatal brachial plexus palsy (NBPP) continues to have many areas of debate, including the use of ancillary testing. Given the continued improvement in imaging, it is important to revisit its utility. Nerve root avulsions have historically been identified by the presence of pseudomeningoceles or visible ruptures. This "all-or-none" definition of nerve root avulsions has many implications for the understanding and management of NBPP, especially as characterization of the proximal nerve root as a potential donor remains critical. This study examined the ability of high-resolution MRI to more specifically define the anatomy of nerve root avulsions by individually examining the ventral and dorsal rootlets as they exit the spinal cord. METHODS This is a retrospective review of patients who had undergone brachial plexus protocol MRI for clinical evaluation of NBPP at a single institution. Each MR image was independently reviewed by a board-certified neuroradiologist, who was blinded to both established diagnosis/surgical findings and laterality. Each dorsal and ventral nerve rootlet bilaterally from C5 to T1 was evaluated from the spinal cord to its exit in the neuroforamen. Each rootlet was classified as avulsed, intact, or undeterminable. RESULTS Sixty infants underwent brachial plexus protocol MRI from 2010 to 2018. All infants were included in this study. Six hundred individual rootlets were analyzed. There were 49 avulsed nerve rootlets in this cohort. Twenty-nine (59%) combined dorsal/ventral avulsions involved both the ventral and dorsal rootlets, and 20 (41%) were either isolated ventral or isolated dorsal rootlet avulsions. Of the isolated avulsion injuries, 13 (65%) were dorsal only, meaning that the motor rootlets were intact. CONCLUSIONS A closer look at nerve root avulsions with MRI demonstrates a significant prevalence (approximately 41%) of isolated dorsal or ventral nerve rootlet disruptions. This finding implies that nerve roots previously labeled as "avulsed" but with only isolated dorsal (sensory) rootlet avulsion can yet provide donor fascicles in reconstruction strategies. A majority (99%) of the rootlets can be clearly visualized with MRI. These findings may significantly impact the clinical understanding of neonatal brachial plexus injury and its treatment.
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Smith BW, Chang KWC, Koduri S, Yang LJS. Nerve graft versus nerve transfer for neonatal brachial plexus: shoulder outcomes. J Neurosurg Pediatr 2020; 27:87-92. [PMID: 33096523 DOI: 10.3171/2020.6.peds2027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 06/29/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The decision-making in neonatal brachial plexus palsy (NBPP) treatment continues to have many areas in need of clarification. Graft repair was the gold standard until the introduction of nerve transfer strategies. Currently, there is conflicting evidence regarding outcomes in patients with nerve grafts versus nerve transfers in relation to shoulder function. The objective of this study was to further define the outcomes for reconstruction strategies in NBPP with a specific focus on the shoulder. METHODS A cohort of patients with NBPP and surgical repairs from a single center were reviewed. Demographic and standard clinical data, including imaging and electrodiagnostics, were gathered from a clinical database. Clinical data from physical therapy evaluations, including active and passive range of motion, were examined. Statistical analysis was performed on the available data. RESULTS Forty-five patients met the inclusion criteria for this study, 19 with graft repair and 26 with nerve transfers. There were no significant differences in demographics between the two groups. Understandably, there were no patients in the nerve grafting group with preganglionic lesions, resulting in a difference in lesion type between the cohorts. There were no differences in preoperative shoulder function between the cohorts. Both groups reached statistically significant improvements in shoulder flexion and shoulder abduction. The nerve transfer group experienced a significant improvement in shoulder external rotation, from -78° to -28° (p = 0.0001), whereas a significant difference was not reached in the graft group. When compared between groups, there appeared to be a trend favoring nerve transfer in shoulder external rotation, with the graft patients improving by 17° and the transfer patients improving by 49° (p = 0.07). CONCLUSIONS In NBPP, patients with shoulder weakness experience statistically significant improvements in shoulder flexion and abduction after graft repair or nerve transfer, and patients with nerve transfers additionally experience significant improvement in external rotation. With regard to shoulder external rotation, there appear to be some data supporting the use of nerve transfers.
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Affiliation(s)
- Brandon W. Smith
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Kate W. C. Chang
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Sravanthi Koduri
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Lynda J. S. Yang
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
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Kirsch M, Brown S, Smith BW, Chang KWC, Koduri S, Yang LJS. The Presence and Persistence of Unrealistic Expectations in Patients Undergoing Nerve Surgery. Neurosurgery 2019; 86:778-782. [DOI: 10.1093/neuros/nyz335] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 06/06/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
Unrealistic expectations of the outcomes of peripheral nerve surgery reduce patient satisfaction. Most clinicians can recall patients with unrealistic expectations despite verbal preoperative education.
OBJECTIVE
To assess patients’ baseline level of understanding regarding nerve surgery and appropriate expectations. Additionally, we tested the effect of a written, preoperative educational handout on the patients’ retention of knowledge.
METHODS
This cross-sectional survey recruited patients scheduled to undergo peripheral nerve surgery at a single institution in 2016 to 2017. During the preoperative visit, a specialized nurse practitioner reviewed perioperative protocols, risks and benefits of the surgery, and postoperative care. Patients immediately completed a survey to assess their preoperative understanding of the verbally reviewed information. During the same visit, an additional written handout was given to patients in a randomized fashion. At their first postoperative visit, all patients completed the survey again.
RESULTS
A total of 60 patients (mean age 52 yr) were enrolled of which 62% were male. Immediately following verbal instruction, 31% of patients had erroneous (unrealistic) expectations regarding pain, 30% had erroneous expectations regarding postoperative motor outcome, and 41% had erroneous expectations regarding the timing of postoperative recovery. There was no significant difference between patients who received the written handout vs those who did not, on retesting in the postoperative period.
CONCLUSION
Patients undergoing peripheral nerve procedures demonstrated a high baseline level of unrealistic expectations despite standard in-person verbal counseling by specialty providers. A written handout did not have clear benefit in the retention of preoperative surgical teaching. Further investigation into more effective preoperative patient counseling is needed.
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Affiliation(s)
- Michael Kirsch
- School of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Shawn Brown
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Brandon W Smith
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Kate W C Chang
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Sravanthi Koduri
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Lynda J S Yang
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
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Smith BW, Chang KWC, Yang LJS, Spires MC. Comparative accuracies of electrodiagnostic and imaging studies in neonatal brachial plexus palsy. J Neurosurg Pediatr 2018; 23:119-124. [PMID: 30485196 DOI: 10.3171/2018.7.peds18193] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 07/18/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe incorporation of ancillary testing in the preoperative setting for patients with neonatal brachial plexus palsy (NBPP) remains controversial, but the recommendation for early nerve reconstruction when a baby has a preganglionic lesion at the lower nerve roots is generally accepted. At some specialty centers, nerve surgeons use preoperative electrodiagnostic testing (EDX) and imaging to aid in lesion localization and the preoperative planning of the nerve reconstruction. EDX and imaging have been evaluated for their abilities to detect pre- and postganglionic lesions, but their accuracies have never been compared directly in the same set of patients. The aim of the present study was to evaluate the accuracy of imaging and EDX in an NBPP population.METHODSA retrospective review was conducted of 54 patients with operative NBPP seen between 2007 and 2017. The patients underwent EDX and imaging: EDX was performed, and the results were reviewed by board-certified electrodiagnosticians, and imaging was reviewed by board-certified neuroradiologists. The gold standard was considered to be the findings at surgical exploration. Descriptive and analytical statistics were utilized to compare the accuracies of imaging and EDX.RESULTSThe mean age at surgery was 6.94 mos (± 4 mos). Fifteen patients (28%) were Narakas grade I-II, and 39 (72%) were Narakas grade III-IV. For all nerve roots, the overall accuracy of detecting preganglionic lesions was 74% for EDX and 69% for imaging. The overall sensitivity of detecting preganglionic lesions by EDX was 31%, but the specificity was 90%. The overall sensitivity of detecting preganglionic lesions by imaging was 66%, and the overall specificity was 70%. However, at C8, EDX was 37.5% sensitive and 87.5% specific, whereas imaging was 67.7% sensitive but only 29.4% specific.CONCLUSIONSEDX outperformed imaging with regard to specificity and accuracy of identifying preganglionic injuries. This finding is especially relevant in the lower nerve roots, given that lower plexus preganglionic lesions are an accepted indication for early intervention.
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Smith BW, Chulski NJ, Little AA, Chang KWC, Yang LJS. Effect of fascicle composition on ulnar to musculocutaneous nerve transfer (Oberlin transfer) in neonatal brachial plexus palsy. J Neurosurg Pediatr 2018; 22:181-188. [PMID: 29856295 DOI: 10.3171/2018.3.peds17529] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Neonatal brachial plexus palsy (NBPP) continues to be a problematic occurrence impacting approximately 1.5 per 1000 live births in the United States, with 10%-40% of these infants experiencing permanent disability. These children lose elbow flexion, and one surgical option for recovering it is the Oberlin transfer. Published data support the use of the ulnar nerve fascicle that innervates the flexor carpi ulnaris as the donor nerve in adults, but no analogous published data exist for infants. This study investigated the association of ulnar nerve fascicle choice with functional elbow flexion outcome in NBPP. METHODS The authors conducted a retrospective study of 13 cases in which infants underwent ulnar to musculocutaneous nerve transfer for NBPP at a single institution. They collected data on patient demographics, clinical characteristics, active range of motion (AROM), and intraoperative neuromonitoring (IONM) (using 4 ulnar nerve index muscles). Standard statistical analysis compared pre- and postoperative motor function improvement between specific fascicle transfer (1-2 muscles for either wrist flexion or hand intrinsics) and nonspecific fascicle transfer (> 2 muscles for wrist flexion and hand intrinsics) groups. RESULTS The patients' average age at initial clinic visit was 2.9 months, and their average age at surgical intervention was 7.4 months. All NBPPs were unilateral; the majority of patients were female (61%), were Caucasian (69%), had right-sided NBPP (61%), and had Narakas grade I or II injuries (54%). IONM recordings for the fascicular dissection revealed a donor fascicle with nonspecific innervation in 6 (46%) infants and specific innervation in the remaining 7 (54%) patients. At 6-month follow-up, the AROM improvement in elbow flexion in adduction was 38° in the specific fascicle transfer group versus 36° in the nonspecific fascicle transfer group, with no statistically significant difference (p = 0.93). CONCLUSIONS Both specific and nonspecific fascicle transfers led to functional recovery, but that the composition of the donor fascicle had no impact on early outcomes. In young infants, ulnar nerve fascicular dissection places the ulnar nerve at risk for iatrogenic damage. The data from this study suggest that the use of any motor fascicle, specific or nonspecific, produces similar results and that the Oberlin transfer can be performed with less intrafascicular dissection, less time of surgical exposure, and less potential for donor site morbidity.
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Affiliation(s)
| | | | - Ann A Little
- 2Neurology, University of Michigan, Ann Arbor, Michigan
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Chang KWC, Wilson TJ, Popadich M, Brown SH, Chung KC, Yang LJS. Oberlin transfer compared with nerve grafting for improving early supination in neonatal brachial plexus palsy. J Neurosurg Pediatr 2018; 21:178-184. [PMID: 29219789 DOI: 10.3171/2017.8.peds17160] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The use of nerve transfers versus nerve grafting for neonatal brachial plexus palsy (NBPP) remains controversial. In adult brachial plexus injury, transfer of an ulnar fascicle to the biceps branch of the musculocutaneous nerve (Oberlin transfer) is reportedly superior to nerve grafting for restoration of elbow flexion. In pediatric patients with NBPP, recovery of elbow flexion and forearm supination is an indicator of resolved NBPP. Currently, limited evidence exists of outcomes for flexion and supination when comparing nerve transfer and nerve grafting for NBPP. Therefore, the authors compared 1-year postoperative outcomes for infants with NBPP who underwent Oberlin transfer versus nerve grafting. METHODS This retrospective cohort study reviewed patients with NBPP who underwent Oberlin transfer (n = 19) and nerve grafting (n = 31) at a single institution between 2005 and 2015. A single surgeon conducted intraoperative exploration of the brachial plexus and determined the surgical nerve reconstruction strategy undertaken. Active range of motion was evaluated preoperatively and postoperatively at 1 year. RESULTS No significant difference between treatment groups was observed with respect to the mean change (pre- to postoperatively) in elbow flexion in adduction and abduction and biceps strength. The Oberlin transfer group gained significantly more supination (100° vs 19°; p < 0.0001). Forearm pronation was maintained at 90° in the Oberlin transfer group whereas it was slightly improved in the grafting group (0° vs 32°; p = 0.02). Shoulder, wrist, and hand functions were comparable between treatment groups. CONCLUSIONS The preliminary data from this study demonstrate that the Oberlin transfer confers an advantageous early recovery of forearm supination over grafting, with equivalent elbow flexion recovery. Further studies that monitor real-world arm usage will provide more insight into the most appropriate surgical strategy for NBPP.
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Affiliation(s)
| | - Thomas J Wilson
- 2Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | | | | | - Kevin C Chung
- 4Plastic Surgery, University of Michigan, Ann Arbor, Michigan; and
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Wilson TJ, Chang KWC, Yang LJS. Depression and Anxiety in Traumatic Brachial Plexus Injury Patients Are Associated With Reduced Motor Outcome After Surgical Intervention for Restoration of Elbow Flexion. Neurosurgery 2017; 78:844-50. [PMID: 26516821 DOI: 10.1227/neu.0000000000001086] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Depression has been associated with poor outcomes in neurosurgical patients, including increased pain, poorer functional recovery, delayed return to work, and decreased patient satisfaction. No reports exist regarding an association of psychiatric diagnoses with outcomes after brachial plexus reconstruction. As outcomes and patient satisfaction become increasingly important to payers and physician reimbursement, assessing modifiable preoperative risk factors for their association with poor outcome and patient satisfaction is imperative. OBJECTIVE To analyze patients undergoing brachial plexus reconstruction to assess the relationship of depression/anxiety with functional outcome. METHODS Data were collected retrospectively on all patients who underwent brachial plexus reconstruction to restore elbow flexion between 2005 and 2013. Elbow flexion, graded via the Medical Research Council scale, was assessed at latest follow-up. Multiple variables, including the presence of Axis I psychiatric diagnoses, were assessed for their association with the dichotomous outcome of Medical Research Council scale score ≥3 (antigravity) vs <3 elbow flexion. Standard statistical methods were used. RESULTS Thirty-seven patients met inclusion criteria. The median postsurgical follow-up time was 21 months. Operations included neurolysis (n = 3), nerve graft repair (n = 6), and nerve transfer (n = 28). Depression was present in 10 of 37 patients (27%). Of variables tested, only depression was associated with poor elbow flexion outcome (odds ratio: 6.038; P = .04). CONCLUSION Preoperative depression is common after brachial plexus injury. The presence of depression is associated with reduced elbow flexion recovery after reconstruction. Our data suggest assessment and treatment of preoperative mental health is important in designing a comprehensive postoperative management plan to optimize outcomes and patient satisfaction. ABBREVIATIONS MRC, Medical Research CouncilTBI, traumatic brain injury.
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Affiliation(s)
- Thomas J Wilson
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
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Wilson TJ, Chang KWC, Yang LJS. Prediction Algorithm for Surgical Intervention in Neonatal Brachial Plexus Palsy. Neurosurgery 2017; 82:335-342. [DOI: 10.1093/neuros/nyx190] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 03/20/2017] [Indexed: 11/14/2022] Open
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Mathews AL, Cheng MH, Muller JM, Lin MCY, Chang KWC, Chung KC. Cost Analysis of 48 Burn Patients in a Mass Casualty Explosion Treated at Chang Gung Memorial Hospital. Injury 2017; 48:80-86. [PMID: 27553390 PMCID: PMC5186334 DOI: 10.1016/j.injury.2016.08.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 08/04/2016] [Accepted: 08/15/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Little is known about the costs of treating burn patients after a mass casualty event. A devastating Color Dust explosion that injured 499 patients occurred on June 27, 2015 in Taiwan. This study was performed to investigate the economic effects of treating burn patients at a single medical center after an explosion disaster. METHODS A detailed retrospective analysis on 48 patient expense records at Chang Gung Memorial Hospital after the Color Dust explosion was performed. Data were collected during the acute treatment period between June 27, 2015 and September 30, 2015. The distribution of cost drivers for the entire patient cohort (n=48), patients with a percent total body surface area burn (%TBSA)≥50 (n=20), and those with %TBSA <50 (n=28) were analyzed. RESULTS The total cost of 48 burn patients over the acute 3-month time period was $2,440,688, with a mean cost per patient of $50,848 ±36,438. Inpatient ward fees (30%), therapeutic treatment fees (22%), and medication fees (11%) were found to be the three highest cost drivers. The 20 patients with a %TBSA ≥50 consumed $1,559,300 (63.8%) of the total expenses, at an average cost of $77,965±34,226 per patient. The 28 patients with a %TBSA <50 consumed $881,387 (36.1%) of care expenses, at an average cost of $31,478±23,518 per patient. CONCLUSIONS In response to this mass casualty event, inpatient ward fees represented the largest expense. Hospitals can reduce this fee by ensuring wound dressing and skin substitute materials are regionally stocked and accessible. Medication fees may be higher than expected when treating a mass burn cohort. In preparation for a future event, hospitals should anticipate patients with a %TBSA≥50 will contribute the majority of inpatient expenses.
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Affiliation(s)
- Alexandra L Mathews
- Section of Plastic Surgery, Department of Surgery, The University of Michigan Medical School, United States
| | - Ming-Huei Cheng
- Department of Plastic and Reconstructive Surgery, Center for Tissue Engineering, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taiwan
| | | | - Miffy Chia-Yu Lin
- Department of Plastic and Reconstructive Surgery, Center for Tissue Engineering, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taiwan
| | - Kate W C Chang
- Section of Plastic Surgery, Department of Surgery, The University of Michigan Health System, United States
| | - Kevin C Chung
- Section of Plastic Surgery, Department of Surgery, The University of Michigan Medical School, United States.
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Wilson TJ, Chang KWC, Chauhan SP, Yang LJS. Peripartum and neonatal factors associated with the persistence of neonatal brachial plexus palsy at 1 year: a review of 382 cases. J Neurosurg Pediatr 2016; 17:618-24. [PMID: 26799409 DOI: 10.3171/2015.10.peds15543] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Neonatal brachial plexus palsy (NBPP) occurs due to the stretching of the nerves of the brachial plexus before, during, or after delivery. NBPP can resolve spontaneously or become persistent. To determine if nerve surgery is indicated, predicting recovery is necessary but difficult. Historical attempts explored the association of recovery with only clinical and electrodiagnostic examinations. However, no data exist regarding the neonatal and peripartum factors associated with NBPP persistence. METHODS This retrospective cohort study involved all NBPP patients at the University of Michigan between 2005 and 2015. Peripartum and neonatal factors were assessed for their association with persistent NBPP at 1 year, as defined as the presence of musculoskeletal contractures or an active range of motion that deviated from normal by > 10° (shoulder, elbow, hand, and finger ranges of motion were recorded). Standard statistical methods were used. RESULTS Of 382 children with NBPP, 85% had persistent NBPP at 1 year. A wide range of neonatal and peripartum factors was explored. We found that cephalic presentation, induction or augmentation of labor, birth weight > 9 lbs, and the presence of Horner syndrome all significantly increased the odds of persistence at 1 year, while cesarean delivery and Narakas Grade I to II injury significantly reduced the odds of persistence. CONCLUSIONS Peripartum/neonatal factors were identified that significantly altered the odds of having persistent NBPP at 1 year. Combining these peripartum/neonatal factors with previously published clinical examination findings associated with persistence should allow the development of a prediction algorithm. The implementation of this algorithm may allow the earlier recognition of those cases likely to persist and thus enable earlier intervention, which may improve surgical outcomes.
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Affiliation(s)
- Thomas J Wilson
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan; and
| | - Kate W C Chang
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan; and
| | - Suneet P Chauhan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Texas Health Science Center, Houston, Texas
| | - Lynda J S Yang
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan; and
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Franz EW, Bentley JN, Yee PPS, Chang KWC, Kendall-Thomas J, Park P, Yang LJS. Patient misconceptions concerning lumbar spondylosis diagnosis and treatment. J Neurosurg Spine 2015; 22:496-502. [DOI: 10.3171/2014.10.spine14537] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Patient outcome measures are becoming increasingly important in the evaluation of health care quality and physician performance. Of the many novel measures currently being explored, patient satisfaction and other subjective measures of patient experience are among the most heavily weighted. However, these subjective measures are strongly influenced by a number of factors, including patient demographics, level of understanding of the disorder and its treatment, and patient expectations. In the present study, patients referred to a neurosurgery clinic for degenerative spinal disorders were surveyed to determine their understanding of lumbar spondylosis diagnosis and treatment.
METHODS
A multiple-choice, 6-question survey was distributed to all patients referred to a general neurosurgical spine clinic at a tertiary care center over a period of 11 months as a quality improvement initiative to assist the provider with individualized patient counseling. The survey consisted of questions designed to assess patient understanding of the role of radiological imaging in the diagnosis and treatment of low-back and leg pain, and patient perception of the indications for surgical compared with conservative management. Demographic data were also collected.
RESULTS
A total of 121 surveys were included in the analysis. More than 50% of the patients indicated that they would undergo spine surgery based on abnormalities found on MRI, even without symptoms; more than 40% of patients indicated the same for plain radiographs. Similarly, a large proportion of patients (33%) believed that back surgery was more effective than physical therapy in the treatment of back pain without leg pain. Nearly one-fifth of the survey group (17%) also believed that back injections were riskier than back surgery. There were no significant differences in survey responses among patients with a previous history of spine surgery compared with those without previous spine surgery.
CONCLUSIONS
These results show that a surprisingly high percentage of patients have misconceptions regarding the diagnosis and treatment of lumbar spondylosis, and that these misconceptions persist in patients with a history of spine surgery. Specifically, patients overemphasize the value of radiological studies and have mixed perceptions of the relative risk and effectiveness of surgical intervention compared with more conservative management. These misconceptions have the potential to alter patient expectations and decrease satisfaction, which could negatively impact patient outcomes and subjective valuations of physician performance. While these results are preliminary, they highlight a need for improved communication and patient education during surgical consultation for lumbar spondylosis.
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Affiliation(s)
| | - J. Nicole Bentley
- 2Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Patricia P. S. Yee
- 2Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Kate W. C. Chang
- 2Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | | | - Paul Park
- 2Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Lynda J. S. Yang
- 2Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
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Domino J, McGovern C, Chang KWC, Carlozzi NE, Yang LJS. Lack of physician-patient communication as a key factor associated with malpractice litigation in neonatal brachial plexus palsy. J Neurosurg Pediatr 2014; 13:238-42. [PMID: 24329158 DOI: 10.3171/2013.11.peds13268] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Perinatal disorders are prone to malpractice litigation. Neonatal brachial plexus palsy (NBPP) results from stretching the nerves in the perinatal period and may lead to paresis or paralysis and sensory loss in the affected arm. Little is known about the key factors associated with malpractice litigation by families of patients with NBPP and whether these factors reflect the practice environment or are inherent to the condition. In this study, the authors documented the percentage of families of NBPP patients at a specialty center that had filed a malpractice suit and described the key factors associated with that pursuit of legal action. METHODS The families/caregivers of 51 patients with NBPP who had presented to the University of Michigan Interdisciplinary Brachial Plexus Program participated in this study. A qualitative research design was applied using both a questionnaire to examine psychosocial factors and a dynamic tool to measure health outcomes from the patient perspective via parent proxy (Patient-Reported Outcomes Measurement Information System [PROMIS] assessment instruments). Statistical analysis included the Fisher exact test, chi-square test, and Student t-test. The study protocol was approved by the University of Michigan institutional review board. RESULTS Forty-seven percent of the families pursued malpractice litigation. In comparing patient families that had pursued legal action with those that had not, significant differences were revealed in the perception that the sustained birth injury was unnecessary (p = 0.002), the information received in the perinatal period was inadequate (p = 0.003), family concerns were ignored in the perinatal period (p = 0.005), and family concerns were not adequately addressed (p < 0.001). Sixty-six percent of the families received external advice to pursue legal action. The PROMIS survey revealed significant group differences in depressive symptoms (p = 0.008), fatigue (p = 0.02), pain (p = 0.01), and anger (p = 0.004). In contrast, the extent of NBPP was not associated with malpractice litigation (p = 0.18). Age, sex, and race were not significantly different between litigation and nonlitigation groups. CONCLUSIONS Physician-controllable factors, such as communication in the perinatal period, are associated with malpractice litigation in NBPP. The perceived level of global disability may affect the pursuit of malpractice litigation, whereas the isolated extent of nerve root involvement and/or upper extremity dysfunction are not significant factors in pursuing litigation. Identifying and ameliorating these factors within the practice environment may decrease the animosity between families and health care providers and improve overall outcome for patients with NBPP.
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Affiliation(s)
- Joseph Domino
- School of Medicine, Wayne State University, Detroit; and
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15
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Abstract
OBJECT Neonatal brachial plexus palsy (NBPP) affects 0.4-2.6 newborns per 1000 live births in the US. Many infants recover spontaneously, but for those without spontaneous recovery, nerve and/or secondary musculoskeletal reconstruction can restore function to the affected arm. This condition not only manifests in a paretic/paralyzed arm, but also affects the overall health and psychosocial condition of the children and their parents. Currently, measurement instruments for NBPP focus primarily on physical ability, with limited information regarding the effect of the disablement on activities of daily living and the child's psychosocial well-being. It is also difficult to assess and compare overall treatment efficacy among medical (conservative) or surgical management strategies without consistent use of evaluation instruments. The purpose of this study is to review the reported measurement evaluation methods for NBPP in an attempt to provide recommendations for future measurement usage and development. METHODS The authors systematically reviewed the literature published between January 1980 and February 2012 using multiple databases to search the keywords "brachial plexus" and "obstetric" or "pediatrics" or "neonatal" or "congenital." Original articles with primary patient outcomes were included in the data summary. Four types of evaluation methods (classification, diagnostics, physical assessment, and functional outcome) were distinguished among treatment management groups. Descriptive statistics and 1-way ANOVA were applied to compare the data summaries among specific groups. RESULTS Of 2836 articles initially identified, 307 were included in the analysis, with 198 articles (9646 patients) reporting results after surgical treatment, 70 articles (4434 patients) reporting results after medical treatment, and 39 articles (4247 patients) reporting results after combined surgical and medical treatment. Among medical practitioners who treat NBPP, there was equivalence in usage of classification, diagnostic, and physical assessment tools (that focused on the Body Function and Structures measure of the International Classification of Functioning, Disability, and Health [ICF]). However, there was discordance in the functional outcome measures that focus on ICF levels of Activity and Participation. Of the 126 reported evaluation methods, only a few (the Active Movement Scale, Toronto Scale Score, Mallet Scale, Assisting Hand Assessment, and Pediatric Outcomes Data Collection Instrument) are specifically validated for evaluating the NBPP population. CONCLUSIONS In this review, the authors demonstrate disparities in the use of NBPP evaluation instruments in the current literature. Additionally, valid and reliable evaluation instruments specifically for the NBPP population are significantly lacking, manifesting in difficulties with evaluating the overall impact and effectiveness of clinical treatments in a consistent and comparative manner, extending across the various subspecialties that are involved in the treatment of patients with NBPP. The authors suggest that all ICF domains should be considered, and future efforts should include consideration of spontaneous (not practitioner-elicited) use of the affected arm in activities of daily living with attention to the psychosocial impact of the disablement.
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