Factors Identified That Influence 30-Day Adverse Events After Brachial Plexus Surgery
Key findings
- This retrospective study, based on a large national database, determined factors associated with 30-day complication, readmission, and reoperation rates after brachial plexus neurolysis
- Among 691 patients, longer operative time was associated with a significantly higher risk of 30-day complications and reoperations
- The 30-day hospital readmission rate was significantly higher when concomitant rib resection was performed, adding to the evidence against routine concomitant first rib resection for the treatment of neurogenic thoracic outlet syndrome
- Hand surgeons should consider attempting to decrease operative time by involving a dedicated team of surgeons in decision-making and different procedure components
The frequency of neurolysis of the brachial plexus is increasing in the U.S. for indications such as treating traumatic brachial plexus injury or neurogenic thoracic outlet syndrome. Even so, this procedure is still uncommon.
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Researchers affiliated with the Mass General Brigham Brachial Plexus Program conducted the first large study of factors associated with episode-of-care adverse events following brachial plexus surgery. Dafang Zhang, MD, orthopedic hand & arm surgeon at Brigham and Women's Hospital, Rohit Garg, MBBS, orthopedic hand & arm surgeon in the Department of Orthopaedic Surgery at Massachusetts General Hospital, Bassem T. Elhassan, MD, co-chief of the Shoulder Service and co-director of the Harvard Shoulder & Elbow Fellowship at Mass General, and Jonathan Winograd, MD, plastic and reconstructive surgeon at Mass General, report their findings in the Journal of Hand Surgery Global Online.
Methods
The data source for the study was the American College of Surgeons' National Surgical Quality Improvement Program database, which contains validated, risk-adjusted data on adults who undergo major surgical procedures in more than 700 hospitals.
The research team identified 691 patients (57% women) who underwent brachial plexus neurolysis between January 1, 2011, and December 31, 2020. Both traumatic and nontraumatic indications for the surgery were represented, and 73% of patients underwent a concurrent procedure, most commonly rib resection (42% of all patients).
Complications
2.9% of patients developed any complication during the 30-day postoperative period. In the bivariate analysis, longer operative times were significantly associated with complications (P<0.05). No other variable met the P<0.05 criterion for inclusion in multivariable logistic regression analysis.
It should be considered that the study cohort was heterogeneous with regard to indications and concurrent procedures. However, when the data were stratified, undergoing a current procedure was not in itself associated with 30-day complications.
Readmissions
4.5% of patients were readmitted to the hospital within 30 days. In the bivariate analysis, only concurrent rib resection was associated with 30-day readmission (P<0.05).
A systematic review published in The Journal of Hand Surgery concluded soft tissue release alone has a higher success rate than rib excision when treating neurogenic thoracic outlet syndrome, with fewer complications. This study adds to that literature and calls routine rib resection into question when soft tissue release alone may be successful.
Reoperations
3.2% of patients underwent reoperation during the 30-day study period. In bivariate analysis, body mass index, operative time, smoking, and bleeding disorder were associated with reoperation. On multivariable analysis, lower BMI (OR, 0.913; P<0.05) and longer operative time (OR, 1.003; P<0.05) were independently associated with reoperation within 30 days.
Considerations for the Profession
The researchers urge colleagues to:
- Make exposure to brachial plexus surgery an educational goal in hand surgery fellowships
- Decrease operative time by involving a dedicated team of surgeons in decision-making and different procedure components
- Consider establishing supraregional brachial plexus surgery centers to optimize patient outcomes
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