An Exploration of Severe Peripheral Nerve Injuries: Barriers to Timely Surgical Intervention

  • Author / Creator
    Beveridge, Julie
  • Introduction: The timing of nerve transfer or graft after peripheral nerve injury is critical, and accepted to be approximately 3 to 6 months. However, in practice, patients often present in a delayed manner for surgical intervention.

    This study describes the timing of surgery after peripheral nerve injury for adult patients in Alberta, and explores factors influencing time to surgical intervention and clinical outcomes.

    Design and Methods: A retrospective analysis of adult patients undergoing peripheral nerve transfer or grafting in Alberta from 2005 to 2017 was completed. One hundred and sixty-six patients who underwent distal nerve transfers or grafts for either upper or lower limb peripheral nerve injuries were included in the analysis of time to surgery. One hundred and twenty-nine patients with a minimum of one year follow up, after peripheral nerve surgery, were included in the analysis of factors affecting clinical outcomes.

    Additionally, qualitative semi-structured interviews were conducted with patients who underwent surgery through the Northern Peripheral Nerve Clinic in order to explore patient perceived barriers and experiences accessing care for severe peripheral nerve injuries.

    Intervention(s) and Outcome Measures: A Cox Proportional Hazard Regression was completed to determine correlation of patient, injury and systemic factors with time to surgical intervention. Additionally, a multivariable logistic regression analysis was completed to examine the association of time to surgery, patient, injury and operative characteristics on MRC strength outcomes. Thematic analysis was utilized to examine the qualitative data collected from the semi-structured interviews.

    Results: The mean (SD) time to surgery was 221 (118.1) days. A referral made by a surgeon approximately doubled the hazard of earlier surgery as compared to a general practitioner (p=0.006). An increase in one comorbidity resulted in the adjusted hazard of earlier surgery decreasing by 16% (p=0.014).

    Patients identified three main themes of concern: delays in diagnosis, issues with resource accessibility, and lack of support as barriers to accessing the Peripheral Nerve Clinic and subsequent surgery.

    Numerous factors are associated with post-operative strength outcomes including: time to operative intervention, operative procedure, and injury. For every week increase from injury to time of surgery, the adjusted odds of the patient achieving a MRC strength grade ≥ 3 decreases by 3% (p=0.02). If a patient received a nerve transfer instead of a nerve graft the adjusted odds of the patient achieving a MRC strength grade ≥ 3 was 388% (p=0.003). The adjusted odds of achieving a MRC ≥ 3 decreased 65% if the injury sustained had a pre-ganglionic injury component (p=0.05).

    Conclusions: The timing of operative intervention after peripheral nerve injury is critical, and delays in surgical intervention are best explained by both patient and systemic factors. These areas of deficiency in the peripheral nerve injury service pathway require further exploration and improvement in order to optimize patient care.

  • Subjects / Keywords
  • Graduation date
    Fall 2019
  • Type of Item
  • Degree
    Master of Science
  • DOI
  • License
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