Discussion: Do Surgeons Treat Their Patients’ Upper Extremity Nerve Palsies as They Would Treat Their Own?

Nerve injuries remain challenging for both patients and surgeons. Considerable debate exists about the optimal management for a particular injury, with decisions varying based on patient-specific factors, cause of injury, and surgeon experience and preference. In this study, the authors sought to identify differences in the ways surgeons approach the treatment of upper extremity nerve palsies, with regard to the interventions they would offer their patients compared with what they would want done for themselves.1 Patients often ask the question, “what would you do if you had this injury?” when discussing treatment options with their surgeon. The authors have previously explored this topic in a 2015 article that examined surgical decision-making for a selection of hand and upper extremity diagnoses. The group found that for certain abnormalities, surgeons were more likely to offer surgery to patients than they would be to seek surgery for themselves.2 That study did not include upper extremity nerve palsies, and thus, they endeavored to address this specific question within this article. This survey-based study of surgeons with experience treating upper extremity nerve palsies prompted respondents to make treatment decisions for a series of clinical scenarios involving both traumatic and nontraumatic upper extremity nerve palsies. Respondents were asked to decide whether to intervene operatively, and to determine the recommended operation. Surgeons involved in the study were separated into 2 groups: the first was asked to make decisions for a hypothetical patient, and the second was told to choose how they would want to be treated if they were diagnosed with the same problem. When responses were compared between groups, there were no differences in either the likelihood of offering surgery or the type of procedure offered. Although the authors should be commended for their efforts to better understand decision-making for nerve injuries, there are several limitations of this study that merit discussion. Both the complexity and nuance related to decision-making for upper extremity nerve palsies are difficult to capture in a survey-based study. The clinical scenarios presented do not incorporate the myriad factors that guide choices for surgeons and their patients—such as age, comorbid conditions, patient desires/goals, and expected capacity for either spontaneous or postsurgical recovery (among others). The study’s presentation of each nerve palsy as a “black-and-white” entity oversimplifies these scenarios and introduces bias in the responses. Inclusion of more specific, granular clinical scenarios would likely have led to more useful information related to the differences between what surgeons would offer their patients compared with their personal desires for a particular situation. Another limitation of the study is the exclusive grouping of respondents; no surgeon was asked to decide on treatment both for a hypothetical patient and for themselves. Although the a priori power analysis indicated a sufficiently sized sample to detect differences in treatment decisions with 69 respondents, it seems a missed opportunity to not have respondents provide both their recommendations for patients and their own preferences. This would have increased their sample size, provided the most direct answer to their study question, and also accounted for differences in surgeon training/experience and personal practice patterns (ie, degree of surgical “aggressiveness” for nerve injuries). Perhaps the most valuable points of discussion center on the individual scenarios in which respondents were more or less likely to pursue surgical intervention and how these scenarios align with the described natural history. A generally accepted algorithm advocates for exploration of nerve palsies following sharp penetrating injuries and observation for blunt traumatic or closed injuries, idiopathic palsies, and postoperative iatrogenic palsies in which there was no obvious intraoperative injury. The authors interestingly state that spontaneous recovery rates in closed traumatic brachial plexus injuries and idiopathic spinal accessory nerve palsies are quite poor, and operative intervention can play an important role in improving outcomes. Interestingly, these scenarios were among the least likely to prompt survey respondents to decide on surgery, which was most often chosen in radial and ulnar nerve palsies following fractures of the humerus and distal radius, respectively. Although rare, ulnar nerve palsy following distal radius fracture is an entity that seems to benefit from early intervention.3–5 However, the high rates of spontaneous recovery of radial nerve palsies, both in the setting of acute humerus fractures and following surgical fixation, may argue against operative intervention.6–8 Surgeon training, experience, and expertise factor into the decision-making for intervention, although it is the preference of the senior author of this discussion (K.R.E.) to intervene surgically in many (if not most) clinical presentations of acute traumatic and postoperative nerve palsies, as exploration can identify potentially unrecognized nerve injuries, provide additional clinical information for prognostication, and afford nerve decompression, which may help in facilitating nerve recovery. This article highlights the uncertainty that continues to challenge patients and surgeons when treating nerve palsies. Additional data are needed to better understand the clinical situations necessitating intervention, the proper timing of surgery, and selection of the optimal intervention. This will then foster development of personalized treatment algorithms to help optimize surgeon and patient decision-making for such challenging nerve injuries. DISCLOSURE The authors have no financial interest in any of the drugs, products, or devices mentioned in this Discussion or in the associated article.