New Tool Measures Outcomes of Brachial Plexus Surgery

Researchers at the Hospital for Special Surgery (HSS, New York, NY, USA) conducted a search of Medline--the US national Library of Medicine's bibliographic database--using the keywords brachial plexus, surgery, and outcomes to discern studies that reported outcomes of this surgery. The search identified 660 articles on adult brachial plexus injuries over the past three years; after excluding articles that did not discuss surgical outcomes for this condition, they identified 49 articles that qualified for the final analysis. The researchers analyzed the type of brachial plexus outcome parameters and the consistency of outcomes reporting between authors and centers, and found that reporting was very inconsistent.

Muscle strength, the most commonly reported outcome, was discussed in 84% of articles. Range of motion, however, was reported in less than half of the papers. No papers measured motion of the entire upper extremity, and only 14% of papers detailed how the motion was measured. Functional outcome scores were recorded in only 12% and scores were recorded using different tools, so comparing studies was difficult. Functional outcome scores were recorded using a variety of different tools, including the Disabilities of the Arm, Shoulder, and Hand measure (DASH), the Constant Score for Shoulder Function, the visual analog scale (VAS) functional score, or institution-specific questionnaires. Only 27% of papers measured sensation and only 8% recorded assessments of pain, and no article reported all five outcome measurements: strength, range of motion, functional scores, sensibility, and pain.

To overcome these problems and discrepancies, the researchers developed a first draft of a tool that they hope clinicians can use, so that the reporting of outcomes is standardized. The key elements of the instrument are measurements of motion, strength, and function for seven critical domains of the upper extremity: shoulder elevation, shoulder external rotation, elbow flexion, elbow extension, wrist extension, finger flexion, and intrinsics (the distance the fingers can be spread apart). The tool involves assessing tasks such as touching the back of the head, touching the mouth and holding a utensil. The researchers hope that the tool can be further refined so that outcomes can be standardized across research centers and across continents.

"We had to take elements of different instruments as well as elements that we designed to derive a complete system," said study coauthor Scott Wolfe, MD. "We needed to design an innovative way to analyze and report outcomes, because we're simultaneously assessing nerve, muscle, and joint recovery. By way of example, although a patient's nerves could recover beautifully in a particular case, if their shoulder is frozen or their hand atrophied, the patient may not have a functional recovery; unless all elements are assessed, the analysis is incomplete."


Injuries to the brachial plexus, the nerves that conduct signals to the shoulder, arm, and hand, can have devastating consequences, including loss of function and chronic pain. These nerves originate at the spinal cord and correspond to four neck and one thoracic vertebra. Symptoms include partial or complete inability to move the arm. The injury most frequently occurs from high-energy impact activities such as motor vehicle or motorcycle accidents, falls from significant heights, and high impact sporting injuries.

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