Abstract
Background
Peripheral nerve decompression (PND) is generally safe, and newer techniques allow frail patients to undergo PND at less common sites. Current literature suggests patient frailty measures may more accurately predict postsurgical complications versus other proxies, but no current literature examines frailty in PND.
Methods
The authors reviewed data from the National Surgical Quality Improvement Program for patients who underwent PND outside the most common sites from 2013 to 2019. The modified 5-Item Frailty Index (mFI-5) and modified Charlson Comorbidity Index (mCCI) scores were calculated, and complications data were gathered. Age, body mass index (BMI), major comorbidities, American Society of Anesthesiologists class, and frailty were compared as predictors of all-cause 30-day complications, 30-day surgical site complications, length of stay, and complication severity, using univariate and multivariate logistic regression.
Results
Of 1120 patients, the mean age was 51.3 (15.4) years and mean BMI was 30.6 (7.0) kg/m2. Patients were predominantly white and healthy. The complication rate was 3.4%. All-cause complications were predicted by ≥3 major comorbidities (odds ratio [OR], 95% confidence interval [CI]: 6.26, 1.36-21.32; P = .007), followed by mFI-5 score and mCCI score. Complication severity was associated with major comorbidities and mFI-5 score, while length of stay was most strongly predicted by age ≥ 65 years (OR, 95% CI: 2.17, 1.37-3.42; P = .0008) and mCCI score of 3 (OR, 95% CI: 1.77, 1.01-3.05; P = 0.041). The only risk factor for readmission was mFI-5 score of 1 (OR, 95% CI: 7.00, 1.68-47.16; P = .016).
Conclusions
Frailty and risk proxies may predict postoperative complications in PND at uncommon sites. Use of frailty indices may expand the age range of patients offered PND. Further research is necessary to delineate contributing risk factors and to clarify 24-hour observation and admissions.
Keywords: Peripheral Nerve, Decompression, Frailty, Diabetic Neuropathy
Introduction
Peripheral nerve decompression (PND) is a common, low-risk1,2 soft tissue surgery typically performed at anatomic compression points in the hand and wrist. The most common nerve decompressions are performed to relieve pain or restore muscle function in the setting of focal median and ulnar nerve compression, such as in carpal tunnel syndrome or cubital tunnel syndrome. However, the general landscape of PND is changing to include less common sites and indications, including head and neck sensory nerve decompression for migraines.3 There are also Level 1 and 2 studies that strongly suggest that lower extremity nerve decompression in patients with diabetic neuropathy significantly decreases rates of ulcer formation, need for amputation, and associated health care costs.4,6 Additionally, with newer regional and local anesthesia techniques, nerve decompression procedures have shifted away from hospitals and toward ambulatory surgery centers and even procedure rooms in an outpatient clinic setting.
Nerve decompression functional outcome studies are well-represented in the literature. However, few studies focus on short-term complications and their risk factors. Most studies that investigate complication risk factors examine hand surgery as a whole or carpal tunnel release in otherwise healthy patients,2 but this may not necessarily accurately reflect the potentially higher risk for complications in patients undergoing the procedure at uncommon anatomic sites and for atypical indications. For example, there is a scarcity of data focused on lower extremity nerve decompression in patients with diabetic neuropathy and vasculopathy.
Given the changing landscape of nerve decompression, with frail patients being referred to ambulatory surgery centers to undergo procedures at uncommon anatomic sites, the ability to accurately predict postsurgical complications is valuable. Previously described risk factors, such as age, smoking status, and comorbidities, provide some insight, but current literature now explores frailty measures, such as the modified 5-Item Frailty Index (mFI-5) and modified Charlson Comorbidity Index (mCCI), as potentially stronger predictors of postsurgical complications in plastic and orthopedic surgery. This study sought to determine whether these frailty measures serve as better predictors of postsurgical complications in PND at less common anatomic sites when compared with previous risk proxies.
Materials and Methods
The authors performed a retrospective review of data from all patients in the American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP) database who underwent PND from 2014 to 2019. Patients aged 18 or older were included if they underwent nerve decompression at the digits or extremities, as defined by Current Procedural Terminology (CPT) codes 64702, 64704, 64708, and 64722. Patients who underwent carpal tunnel release, cubital tunnel release, or Guyon's canal release were excluded. Also excluded were those patients who underwent surgery of the brachial plexus or sciatic nerve proper, surgical treatment of neuromas or nerve lesions, surgery on sites other than the extremities, surgical repair of transected nerves, nerve grafting, or any other concurrent procedure.
Patient factors, such as age, body mass index (BMI), list of major comorbidities, and American Society of Anesthesiologists Physical Status Classification (ASA Class), were gathered and stratified. Age was classified as “young” (aged 18-49 years), “middle age” (aged 50-65 years), or “elderly” (aged > 65 years). BMI was classified as “non-overweight” (< 25.0 kg/m2), “overweight” (25.0-29.9 kg/m2), and “obese” (≥30.0 kg/m2). The mFI-5 score was calculated using the definition per Subramaniam et al.7 Many Charlson Comorbidity Index variants have been created; the authors opted to start with the original criteria by Charlson et al,8 then removed criteria for which NSQIP does not collect data (Table 1).
TABLE 1.
DEFINITION OF FRAILTY INDICES
| Factor | Points | NSQIP variable(s) | ||
|---|---|---|---|---|
| Original Carlson Comorbidity Index a | ||||
| Age | ||||
| Age <50 | 0 | AGE | ||
| Age 50-59 | 1 | AGE | ||
| Age 60-69 | 2 | AGE | ||
| Age 70-79 | 3 | AGE | ||
| Age 80+ | 4 | AGE | ||
| Medical comorbidities | ||||
| History of CHF | 1 | HXCHF | ||
| History of MI | 1 | HXMI | ||
| History of COPD | 1 | HXCOPD | ||
| Peptic ulcer disease | 1 | N/A | ||
| Liver disease, mild | 1 | N/A | ||
| Liver disease, moderate/severe | 3 | ASCITES | ESOVAR | |
| CKD, mild | 0 | N/A | ||
| CKD, moderate/severe | 2 | RENAFAIL | DIALYSIS | |
| Diabetes, diet-controlled | 0 | N/A | ||
| Diabetes, uncomplicated | 1 | DIABETES | ||
| Diabetes, w/end-organ damage | 2 | N/A | ||
| Connective tissue disease | 1 | N/A | ||
| Major vascular disease | 1 | HXPVD | RESTPAIN | |
| Functional status | ||||
| Any dementia | 1 | IMPSENS | COMA | |
| Any TIA or stroke | 1 | HXTIA | CVA | CVANO |
| Hemiplegia or more | 2 | HEMI | PARA | QUAD |
| Oncologic/immunosuppressive | ||||
| No cancer | 0 | N/A | ||
| Solid tumor | 2 | N/A | ||
| DISCANCER | ||||
| Metastatic | 6 | R | ||
| Leukemia | 2 | N/A | ||
| Lymphoma | 2 | N/A | ||
| Fulminant AIDS | 6 | N/A | ||
| Modified Charlson Comorbidity Index | ||||
| Medical comorbidities | ||||
| History of CHF | 1 | HXCHF | ||
| History of COPD | 1 | HXCOPD | ||
| Diabetes, uncomplicated | 1 | DIABETES | ||
| Liver disease, moderate/severe | 3 | ASCITES | ||
| CKD, moderate/severe | 2 | RENAFAIL | DIALYSIS | |
| Functional status | ||||
| None | ||||
| Oncologic/immunosuppressive | ||||
| Metastatic cancer | 6 | DISCANCE | ||
| R | ||||
| Age | ||||
| Age 50-59 | 1 | AGE | ||
| Age 60-69 | 2 | AGE | ||
| Age 70-79 | 3 | AGE | ||
| Age 80+ | 4 | AGE | ||
| Modified 5-Item Frailty Index | ||||
| Medical comorbidities | ||||
| History of CHF | 1 | HXCHF | ||
| History of COPD | 1 | HXCOPD | ||
| Diabetes, any type | 1 | DIABETES | ||
| HTN, requiring medication | 1 | HYPERMED | ||
| Functional status | ||||
| Nonindependent status | 1 | FNSTATUS2 | ||
| Oncologic/immunosuppressive | ||||
| None | ||||
| Age | ||||
| None | ||||
Items in gray were removed in the 2017 NSQIP update. CHF, congestive heart failure; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; HTN, hypertension; MI, myocardial infarction; NSQIP, National Surgical Quality Improvement Program; TIA, transischemic attack.
Data were gathered regarding postoperative 30-day complications. Each complication was assigned its Clavien-Dindo grade, and to produce a proxy of overall complication severity, each patient was given an aggregate Clavien-Dindo score (ACDS) by totaling the Clavien-Dindo grade for all complication occurrences (Table 2). Age, BMI, number of major comorbidities, ASA Class, mFI-5 score, and mCCI score were compared as predictors of all-cause 30-day complications, 30-day surgical site complications of any kind, length of stay, and complication severity (ACDS). Univariate and multivariate logistic regression was performed using the R statistical suite, version 4.1.0. Statistical significance was set at P < .05.
TABLE 2.
DEFINITIONS FOR CLAVIEN-DINDO CLASSIFICATION
| Complications a | Clavien-Dindo score | NSQIP variable, occurrences (yes/no, binary) | NSQIP variable, number of occurrences |
|---|---|---|---|
| Neurologic | |||
| Neurological deficit | 2 | NEURODEF | NNEURODEF |
| Stroke | 4 | CNSCVA | NCNSCVA |
| Coma | 2 | CNSCOMA | NCNSCOMA |
| Cardiac | |||
| Cardiac arrest requiring CPR | 4 | CDARREST | NCDARREST |
| True MI (proven cardiac muscle death) | 4 | CDMI | NCDMI |
| Respiratory | |||
| Unplanned reintubation | 4 | REINTUB | NREINTUB |
| Ventilator >48 hr | 4 | FAILWEAN | NFAILWEAN |
| Pneumonia | 3 | OUPNEUMO | NOUPNEUMO |
| Renal | |||
| Acute renal failure (needs dialysis) | 4 | OPRENAFL | NOPRENAFL |
| Progressive renal failure (no dialysis) | 3 | RENAINSF | NRENAINSF |
| Hematologic/thrombotic | |||
| DVT, requiring treatment | 3 | OTHDVT | NOTHDVT |
| PE | 3 | PULEMBOL | NPULEMBOL |
| Bleed, requiring transfusion | 2 | OTHBLEED | NOTHBLEED |
| Infectious (surgical) | |||
| Superficial SSI incisional | 1 | SUPINFEC | NSUPINFEC |
| Deep SSI incisional | 3 | WNDINFD | NWNDINFD |
| Organ space SSI | 4 | ORGSPCSSI | NORGSPCSSI |
| Sepsis | 3 | OTHSYSEP | NOTHSYSEP |
| Septic shock | 4 | OTHSESHOCK | NOTHSESHOCK |
| Infectious (hospital) | |||
| Clostridium difficile infection | 3 | OTHCDIFF | NOTHCDIFF |
| UTI | 2 | URNINFEC | NURNINFEC |
| Wound | |||
| Wound dehiscence | 4 | DEHIS | NDEHIS |
| Other | |||
| Readmission | 4 | READMISSION1 | |
| Unplanned return to the operating room | 4 | REOPERATION1 | |
| Death | 5 | DOPERTOD (any value other than −99) | |
Mild systemic complications include pneumonia, renal failure (without dialysis), DVT (without PE), bleeds requiring transfusion, sepsis (without shock), Clostridium difficile infection, and UTI. Severe systemic complications include neurological deficit, stroke, coma, cardiac arrest/MI, reintubation/ventilator, renal failure (with dialysis), DVT (with PE), septic shock, and death. CPR, cardiopulmonary resuscitation; DVT, deep venous thrombosis; MI, myocardial infarction; NSQIP, National Surgical Quality Improvement Program; PE, pulmonary embolism; SSI, surgical site infection; UTI, urinary tract infection.
Results
A total of 1120 patients were identified who underwent a PND meeting the study criteria between 2014 and 2019. The mean patient age was 51.3 (15.4) years. Patients had an approximately even sex distribution but were predominantly white (n = 728; 65.0%) and non-Hispanic (n = 798; 71.3%). Patients predominantly underwent neuroplasty of major arm or leg nerves, CPT 64708 (n = 506; 45.2%), or decompression of other nerves, CPT 64722 (n = 436; 38.9%) (Table 3). Patients were predominantly healthy, with most having no comorbidities (n = 613; 54.7%) or 1 major comorbidity (n = 328; 29.3%). Patients were also generally not frail, with over half of patients having an mFI-5 score of 0 (n = 636; 56.8%) or an mCCI score of 0 (n = 373; 33.3%) or 1 (n = 208; 16.8%). The predominant comorbidities were medicated hypertension (n = 426; 38.0%), diabetes (n = 196; 17.5%), and chronic steroid use (n =33; 2.9%). One-fifth of patients were smokers (n = 239; 21.3%), had a mean BMI of 30.6 (7.0) kg/m2, and a median BMI of 29.7 kg/m2 (Table 4).
TABLE 3.
PATIENT DEMOGRAPHICS
| Mean | SD | Median | |
|---|---|---|---|
| Age | 51.3 | 15.4 | 52 |
| BMI | 30.6 | 7 | 29.6 |
| N | % | ||
| Total patients | 1120 | ||
| Sex | |||
| Male | 512 | 45.7 | |
| Female | 608 | 54.3 | |
| Race | |||
| American Indian or Alaska Native | 116 | 10.4 | |
| Asian | 26 | 2.3 | |
| Black or African American | 82 | 7.3 | |
| Native Hawaiian or Pacific Islander | 3 | 0.3 | |
| White | 728 | 65.0 | |
| Unknown/not reported | 165 | 14.7 | |
| Ethnicity | |||
| Hispanic | 51 | 4.6 | |
| Non-Hispanic | 798 | 71.3 | |
| Unknown/not reported | 271 | 24.2 | |
| Procedure | N | % | CPT |
| Neuroplasty, digit | 100 | 8.9 | 64702 |
| Neuroplasty, hand or foot | 78 | 7.0 | 64704 |
| Neuroplasty, major arm/leg | 506 | 45.2 | 64708 |
| Decompression of other nerve | 436 | 38.9 | 64722 |
| Cases, by year | N | Complications | |
| 2014 | 182 | 6 | |
| 2015 | 263 | 6 | |
| 2016 | 213 | 12 | |
| 2017 | 170 | 6 | |
| 2018 | 224 | 7 | |
| 2019 | 250 | 7 | |
BMI, body mass index; CPT, Current Procedural Terminology; SD, standard deviation.
TABLE 4.
COMORBIDITIES AND RISK FACTORS
| Comorbidities | Provided values | Calculated values | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Comorbidity | Patients, n | Patients, % | Values | Patients, n | Patients, % | Values | Patients, n | Patients, % | ||
| Hypertension, medicated | 426 | 38.0 | Class 1 | 144 | 12.9 | 0 | 636 | 56.8 | ||
| Smoking status | 239 | 21.3 | Class 2 | 637 | 56.9 | 1 | 324 | 28.9 | ||
| Diabetes | 196 | 17.5 | ASA class | Class 3 | 305 | 27.2 | mFI-5 score | 2 | 151 | 13.5 |
| Chronic steroid use | 33 | 2.9 | Class 4 | 7 | 0.6 | 3 | 9 | 0.8 | ||
| COPD | 21 | 1.9 | Class 5 | 0 | 0.0 | 4 | 0 | 0.0 | ||
| Dyspnea | 16 | 1.4 | None | 27 | 2.4 | 5 | 0 | 0.0 | ||
| Impaired function | 10 | 0.9 | ||||||||
| Bleeding dyscrasia | 9 | 0.8 | Number of major comorbidities | 0 | 613 | 54.7 | 0 | 373 | 33.3 | |
| Cancer | 4 | 0.4 | 1 | 328 | 29.3 | 1 | 208 | 18.6 | ||
| Dialysis | 2 | 0.2 | 2 | 152 | 13.6 | 2 | 170 | 15.2 | ||
| Renal failure | 1 | 0.1 | 3 | 22 | 2.0 | mCCI score | 3 | 140 | 12.5 | |
| Congestive heart failure | 0 | 0.0 | 4 | 4 | 0.4 | 4 | 108 | 9.6 | ||
| Ventilator dependency | 0 | 0.0 | 5+ | 0 | 0.0 | 5 | 74 | 6.6 | ||
| Ascites | 0 | 0.0 | 6 | 28 | 2.5 | |||||
| 7 | 12 | 1.1 | ||||||||
| 8 | 3 | 0.3 | ||||||||
| 9 | 1 | 0.1 | ||||||||
| 10 | 0 | 0.0 | ||||||||
| 11 | 0 | 0.0 | ||||||||
| 12 | 1 | 0.1 | ||||||||
| 13 | 1 | 0.1 | ||||||||
ASA, American Society of Anesthesiologists; COPD, chronic obstructive pulmonary disease; mCCI, modified Charlson Comorbidity Index; mFI-5, modified 5-Item Frailty Index.
Complications were rare, with a total complication rate of 3.4% (38 patients, 43 complications). In 1120 patients, the most common complication was superficial surgical site infection (n = 17; 1.5%). There were 11 readmissions (1.0%) and 10 unplanned returns to the operating room (0.9%). The mean ACDS for patients who suffered complications was 3.4 (2.6). ACDS included any surgical site complication, systemic complication, reoperation, and readmission as recorded in the ACS-NSQIP database. While nearly all patients were discharged the same day, 71 patients (6.3%) remained overnight and 60 patients (5.4%) were admitted for 2 or more days. The median length of stay for non-outpatient surgery was 1.0 (2.0) days (Table 5). When the mFI-5 score was analyzed within the context of postoperative complications in univariate analysis, increasing mFI-5 score was significantly associated with readmission (P = .014) and all-cause complications (P = .012), and this association approached significance for surgical site complications (P = .063) (Table 6).
TABLE 5.
COMPLICATIONS
| Complications | Patients, n | Patients, % |
|---|---|---|
| Neurologic | ||
| Stroke | 0 | 0.0 |
| Cardiac | ||
| Cardiac arrest requiring CPR | 0 | 0.0 |
| Myocardial infarction | 0 | 0.0 |
| Respiratory | ||
| Unplanned reintubation | 0 | 0.0 |
| Ventilator >48 hr | 0 | 0.0 |
| Pneumonia | 0 | 0.0 |
| Renal | ||
| Acute renal failure (needs dialysis) | 0 | 0.0 |
| Progressive renal failure (no dialysis) | 0 | 0.0 |
| Hematologic/thrombotic | ||
| Deep vein thrombosis, requiring treatment | 0 | 0.0 |
| Pulmonary embolism | 0 | 0.0 |
| Bleed, requiring transfusion | 1 | 0.1 |
| Infectious (surgical) | ||
| Superficial SSI incisional | 17 | 1.5 |
| Deep SSI incisional | 2 | 0.2 |
| Organ space SSI | 0 | 0.0 |
| Sepsis | 1 | 0.1 |
| Septic shock | 0 | 0.0 |
| Infectious (hospital) | ||
| Clostridium difficile infection | 0 | 0.0 |
| UTI | 4 | 0.4 |
| Wound | ||
| Wound dehiscence | 2 | 0.2 |
| Other | ||
| Readmission | 11 | 1.0 |
| Unplanned return to the operating room | 10 | 0.9 |
| Death | 0 | 0.0 |
CPR, cardiopulmonary resuscitation; SSI, surgical site infection; UTI, urinary tract infection.
TABLE 6.
COMPLICATIONS AND OUTCOMES BY mFI-5 SCORE
| mFI-5 = 0 | mFI-5 = 1 | mFI-5 ≥ 2 | |||||
|---|---|---|---|---|---|---|---|
| Patients, n | Patients, % | Patients, n | Patients, % | Patients, n | Patients, % | ||
| Total patients | 636 | 56.8 | 324 | 28.9 | 160 | 14.3 | |
| mFI-5 = 0 | mFI-5 = 1 | mFI-5 ≥ 2 | |||||
| Complications | Patients, n | Patients, % | Patients, n | Patients, % | Patients, n | Patients, % | P |
| Hematologic/thrombotic | |||||||
| Bleed, requiring transfusion | 0 | 0.0 | 1 | 0.3 | 0 | 0.0 | .43 |
| Infectious (surgical) | 0.0 | 0.0 | 0.0 | ||||
| Superficial SSI incisional | 6 | 0.9 | 7 | 2.2 | 4 | 2.5 | .13 |
| Deep SSI incisional | 0 | 0.0 | 2 | 0.6 | 0 | 0.0 | .19 |
| Sepsis | 1 | 0.2 | 0 | 0.0 | 0 | 0.0 | 1 |
| Infectious (hospital) | 0.0 | 0.0 | 0.0 | ||||
| UTI | 1 | 0.2 | 2 | 0.6 | 1 | 0.6 | .26 |
| Wound | 0.0 | 0.0 | 0.0 | ||||
| Wound dehiscence | 1 | 0.2 | 0 | 0.0 | 1 | 0.6 | .35 |
| Other | 0.0 | 0.0 | 0.0 | ||||
| Readmission | 2 | 0.3 | 7 | 2.2 | 2 | 1.3 | .014 |
| Unplanned return to the operating room | 6 | 0.9 | 3 | 0.9 | 1 | 0.6 | 1 |
| mFI-5 = 0 | mFI-5 = 1 | mFI-5 ≥ 2 | |||||
| Outcome aggregates | Patients, n | Patients, % | Patients, n | Patients, % | Patients, n | Patients, % | P |
| All-cause complications | 13 | 2.0 | 18 | 5.6 | 7 | 4.4 | .012 |
| Any surgical site complication | 7 | 1.1 | 9 | 2.8 | 5 | 3.1 | .063 |
| Any mild systemic complication | 2 | 0.3 | 3 | 0.9 | 1 | 0.6 | .42 |
| Any severe systemic complication | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | N/A |
| Any complication, CD >3 | 8 | 1.3 | 9 | 2.8 | 3 | 1.9 | .22 |
CD, Clavien-Dindo; mFI-5, modified 5-Item Frailty Index; N/A, not available; SSI, surgical site infection; UTI, urinary tract infection.
On univariate analysis, several risk factors and indices were predictive of complications. The strongest predictor of all-cause 30-day complications was ≥ 3 major comorbidities (odds ratio [OR], 95% CI: 6.26, 1.36-21.32; P = .007), while mFI-5 score, mCCI score, and fewer major comorbidities were also predictive of all-cause complications. Complication severity was associated with number of major comorbidities and mFI-5 score, while length of stay was most strongly predicted by age ≥ 65 years (OR, 95% CI: 2.17, 1.37-3.42; P = .0008) and mCCI score of 3 (OR, 95% CI: 1.77, 1.01-3.05; P = .041). The only factor predictive of surgical site complications was ≥ 3 major comorbidities (OR, 95% CI: 6.94, 1.00-30.44; P = .019); age, diabetes, obesity, smoking status, and frailty were not associated with an increased risk. The only risk factor associated with reoperation rates was smoking status (OR, 95% CI: 3.74, 1.03-13.56; P = 0.038), and the only risk factor associated with readmission rates was an mFI-5 score of 1 (OR, 95% CI: 7.00, 1.68-47.16; P = 0.016) (Table 7).
TABLE 7.
RISK INDICES VERSUS OUTCOMES MEASURES
| All complications | Surgical site event | Complication severity | Clavien-Dindo ≥3 | Length of stay | Readmission | Reoperation | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Risk index | Stratification | N | OR | P | OR | P | Coefficient | P | OR | P | OR | P | OR | P | OR | P |
| Age | 18-49 y (ref) | 499 | ||||||||||||||
| 50-65 y | 394 | 0.71 | .41 | 0.69 | .46 | -0.03 | .62 | 0.79 | .68 | 1.24 | .34 | 1.27 | .77 | 0.5 | .41 | |
| ≥65 y | 227 | 1.83 | .11 | 0.8 | .7 | 0.1 | .09 | 1.98 | .2 | 2.17 | .0008 | 3.72 | .07 | 1.32 | .7 | |
| BMI | <25.0 (ref) | 242 | ||||||||||||||
| 25.0-29.9 | 333 | 1.38 | .47 | 1.71 | .44 | 0.12 | .07 | 2.47 | .17 | 0.89 | .64 | 6.69 | .07 | Unable to calculate | ||
| ≥30.0 | 520 | 0.17 | .53 | 1.4 | .61 | 0.01 | .89 | 1.09 | .9 | 0.72 | .16 | 0.46 | .59 | |||
| # of major comorbidities | 0 (ref) | 613 | ||||||||||||||
| 1 | 328 | 2.91 | .005 | 2.44 | .08 | 0.11 | .038 | 2.44 | .08 | 1.23 | .32 | 15.3 | .09 | Unable to calculate | ||
| 2 | 152 | 1.7 | .32 | 1.74 | .42 | 0.03 | .68 | 1.74 | .42 | 1.03 | .93 | 8.16 | .09 | |||
| ≥3 | 27 | 6.26 | .007 | 6.93 | .019 | 0.33 | .027 | 3.33 | .27 | 1.42 | .53 | N/A | N/A | |||
| History of diabetes | No diabetes (ref) | 924 | ||||||||||||||
| Diabetic | 196 | 1.98 | .06 | 2.41 | .06 | 0.06 | .33 | 1.59 | .38 | 0.58 | .06 | 1073 | .11 | 0.52 | .54 | |
| Chronic steroid use | No steroids (ref) | 1087 | Unable to calculate | |||||||||||||
| Steroid use | 33 | 1.88 | .4 | 1.67 | .62 | 0.04 | .78 | 1.76 | .59 | 1.36 | .53 | 3.37 | .25 | |||
| Smoking status | Nonsmoker (ref) | 881 | ||||||||||||||
| Smoker | 239 | 1.53 | .25 | 1.87 | .18 | 0.11 | .052 | 2.01 | .14 | 1.11 | .64 | 0.82 | .8 | 3.74 | .038 | |
| ASA class | 1 (ref) | 144 | Unable to calculate; no overnight stays for ASA Class 1 | Unable to calculate; no readmissions for ASA Class 1 | Unable to calculate | |||||||||||
| 2 | 637 | 1.13 | .82 | 1.13 | .87 | 0.05 | .53 | 2.51 | .38 | |||||||
| 3 | 305 | 1.43 | .54 | 1.91 | .42 | 0.11 | .16 | 3.36 | .26 | |||||||
| ≥4 | 7 | 5.83 | .14 | 11.83 | .056 | 0.09 | .77 | <0.01 | .99 | |||||||
| mFI-5 score | 0 (ref) | 636 | ||||||||||||||
| 1 | 324 | 2.82 | .005 | 2.57 | .06 | 0.11 | .041 | 2.24 | .1 | 1.09 | .93 | 7 | .016 | 0.98 | .98 | |
| ≥2 | 160 | 2.19 | .1 | 2.9 | .07 | 0.06 | .35 | 1.5 | .55 | 0.98 | .94 | 4.01 | .17 | 0.66 | .7 | |
| mCCI score | 0 (ref) | 373 | Unable to calculate | |||||||||||||
| 1 | 208 | 0.71 | .57 | 0.9 | .88 | 0.07 | .31 | 0.29 | .26 | 0.61 | .14 | 1.8 | .68 | |||
| 2 | 170 | 0.87 | .82 | 1.1 | .89 | 0.01 | .89 | 1.1 | .89 | 1.34 | .3 | 2.2 | .58 | |||
| 3 | 140 | 1.63 | .36 | 1.8 | .37 | 0.06 | .47 | 1.34 | .68 | 1.77 | .041 | 8.15 | .07 | |||
| ≥4 | 229 | 2.36 | .041 | 1.37 | .61 | 0.08 | .21 | 1.93 | .24 | 1.34 | .25 | 8.3 | .054 | |||
ASA, American Society of Anesthesiologists; BMI, body mass index; mCCI, modified Charlson Comorbidity Index; mFI-5, modified 5-Item Frailty Index; N/A, not applicable; OR, odds ratio.
In multivariate analysis, mFI-5 score (P = .022) and mCCI score (P = .038) were the only predictors of any complication; age, BMI, smoking status, diabetes status, ASA class, and steroid use were not significantly associated with postoperative complications.
Discussion
Current Literature
There are sparse data regarding postsurgical non-nerve outcomes and complications after PND, particularly outside of the distal arm and hand. As such, the present literature review was supplemented with soft tissue hand surgery and PND of the distal arm and hand as proxies for general decompression of superficial peripheral nerves. These studies are only partially applicable, especially given that the present study seeks to examine atypical nerve decompressions in patients who are potentially substantially less healthy than their counterparts undergoing PND in the hand. However, given the limits of the current state of the literature, the authors feel this proxy relationship and the current study are a reasonable first step.
Some studies relating to common PNDs can contextualize risks associated with PNDs at less common sites and in less healthy patients. A study of approximately 850,000 carpal tunnel release patients in the United Kingdom using National Health Service (NHS) data showed an all-cause 90-day complication rate of 0.082%, with even lower rates of dehiscence and infection.1 This extremely low complication profile may be partially generalizable to PNDs with limited incisions, and it suggests that the number of patients needed to identify true risk factors would be prohibitively high. The use of a procedure room,9 WALANT (wide awake, local anesthesia, no tourniquet) techniques,10 or foregoing postoperative antibiotics11 do not increase risk. Some risk factors still remain uncertain—diabetics may have worse recovery,12 similar recovery,13 or a mixed recovery,14 although hemoglobin A1c values do appear to accurately reflect risk.15 On the other hand, some risk factors are extremely clear: steroid injection within 30 days of nerve decompression increases risk of infection, wound complications, and 1-year reoperation needs.16,17
Studies that examine other PNDs, or all nerve surgery in aggregate, may not be completely applicable because some of these studies include traumatic injury repair, nerve grafting, or brachial plexus and lumbosacral plexus/sciatic nerve surgery. However, these studies suggest an increased risk with prolonged surgery, high ASA status, bleeding disorders, and higher BMI.18,19 Studies of isolated cubital tunnel release suggest increasing risk with male sex, obesity, smoking status, and such comorbidities as lung and kidney disease.20
Contextualized Results
At first glance, PND in diabetic patients with peripheral vascular disease and diabetic neuropathy may seem to be a much higher-risk proposition than nerve decompression in the hand. However, the opposite case appears to be true. There is strong Level 1 and 2 evidence21 from prospective and randomized controlled trials that suggests that PND in the lower extremity improves protective sensation22 and pain23,24; improves wound healing; decreases the risk of diabetic foot wounds4 or accelerates healing of existing diabetic foot ulcers2,25 in patients with prior wounds26; and significantly reduces hospitalization length of stay, duration of wound care, and the need for amputation.6,27 Compared with medical management, preliminary simulation studies of PND in diabetic patients suggest the procedure may yield higher quality-adjusted life-years, reduced need for amputation, improved survival, and higher net monetary benefits and cost savings.5
The present study showed a complication rate of 3.4%, which is substantially higher than the NHS-reported 0.082% in carpal tunnel surgery. However, the NSQIP database reflects a generally more ill and more complex patient distribution. These patients undergo surgery in the hospital setting; typically, patients who require hospital services for PND are those who are considered too high-risk for procedure rooms or ambulatory surgery centers. While the strongest predictor of all-cause complications was 3 or more major comorbidities, mFI-5 and mCCI were also predictive of multiple outcomes and approached significance for multiple additional outcomes that did not otherwise have strong predictors. An appropriately powered study could potentially identify if these are statistically significant.
Limitations
This study has several key limitations. While the use of NSQIP data is widely accepted in plastic surgery, orthopedic surgery, and hand surgery, the NSQIP database is designed for much more invasive procedures and does not measure many outcomes that would be relevant to nerve decompression.10 Patient selection bias is strong, as NSQIP excludes WALANT procedures performed outside of an operating room, patients seen in a private practice, and low-risk patients who do not undergo surgery at participating hospitals. The data within NSQIP does not provide adequate granularity; for example, NSQIP does not stratify diabetes control by hemoglobin A1c or by insulin needs,21 nor does it quantify the amount and recency of smoking.28 Outside of the limits of NSQIP, surgeons may have different policies regarding canceling surgery for patients who have recently smoked, and some surgeons may have cutoff points for BMI or hemoglobin A1c above which they do not offer surgery to patients. The Clavien-Dindo complication grade, in particular, is designed to allow cross-comparison of complications, not to create a total score of aggregate complication severity; furthermore, the literature does not describe ACDS as reported in this paper.
Conclusions
Frailty measures, such as the mFI-5 and mCCI, are able to predict increased risk of 30-day all-cause complications, complication severity, length of stay, and readmission. However, the risk profile of PND outside of the distal arm and wrist remain poorly described in the literature. Further work is needed to clarify specific frailty components and to adequately power a determination of other related risk factors.
Acknowledgments
Ethics: Investigational Review Board approval was obtained for this study (study number STUDY-21-01655).
Disclosures: The authors disclose no relevant conflict of interest or financial disclosures for this study.
References
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