Chronic neuropathic pain after burn injury may have multiple causes, such as direct nerve injury, nerve compression, or neuroma formation, and can significantly impair quality of life and limit functional recovery. Management includes a team-based approach that involves close collaboration between occupational and physical therapists, plastic surgeons, and experts in chronic pain, from neurology, anesthesia, psychiatry, and physiatry. Carefully selected patients with an anatomic cause of chronic neuropathic pain unequivocally benefit from surgical intervention. Self-reflection and analysis yield improvement in both efficiency and effectiveness when managing patients with burns with chronic neuropathic pain.
Key points
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Chronic neuropathic pain in patients with burns may have an anatomic cause that is amenable to surgical intervention.
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History and physical examination are critical in identifying the location of potential nerve compression or injury in patients with burns.
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The surgical management of neuropathic pain can serve as a viable model for practice-based learning and improvement in the care of patients with burns.
Introduction
Can’t we give ourselves one more chance? Why can’t we give love that one more chance?
Patients with burns often develop debilitating pruritus, paresthesias, and allodynia, as well as motor dysfunction, despite medical and pharmacologic therapy. Peripheral nerve decompression has emerged as a potentially effective intervention to alleviate these symptoms, but many questions remain, regarding surgical indications, timing, and technique. For example, our own experience in abdominal wall reconstruction has shown that learning curves contain both incremental and disruptive inflection points, which can represent volatile periods of evolution in the synthesis of surgical algorithms. Phases of technical innovation versus development represent distinctly different periods of learning for surgeons, marked by contrasting periods of feasibility and proficiency.
Practice-based learning and improvement (PBLI) is an educational model that was adopted by the Accreditation Council of Graduate Medical Education in 1999 as one of 6 core competencies designed to help establish the basic skills and attributes of practicing physicians. These competencies, which also include medical knowledge, patient care, professionalism, team work and communication, and systems-based practice, were later incorporated by the American Board of Medical Specialties into their program of Maintenance of Certification, to promote and ensure self-directed, lifelong learning.
Because burn care, like all of medicine, is constantly evolving, plastic surgeons are exposed to new information and new clinical scenarios almost daily. PBLI should enable practicing physicians to become efficient, as knowledge is gained, and effective, as this knowledge is applied to real-life situations. As a formal paradigm, PBLI includes 3 components for physicians to pursue:
- •
Investigate and evaluate physicians’ own patient care practices, with rigorous comparison with standard of care, as well as the state-of-the-art care
- •
Appraise, analyze, and assimilate scientific evidence, both within physicians’ individual practices, and across the published literature of their peers
- •
Improve the practice of medicine by physicians applying new knowledge and by educating all of the stakeholders, including themselves and their colleagues, patients and their families, and other members of the health care team
This article shows the utility of PBLI in the care of patients with burns. Although there are some reports of learning-curve analyses in burn care, surprisingly little is published with regard to the application of PBLI to the care that is provided to patients with burns. As a content area for PBLI, this article discusses a complex, clinical situation that is poorly understood, the development of chronic neuropathic pain and sensorimotor dysfunction after burn injury, but that profoundly affects quality of life and both the trajectory and end points of recovery. The authors’ intuition suggested that, over the past 5 years, from 2011 to 2015, the number of procedures we were performing for neuropathic was increasing, and our outcomes were improving, compared with the first 10 years of the senior surgeon’s practice, from 2000 to 2010. Specifically, what role does the learning curve play in affecting these outcomes? Can PBLI be applied to measure disruptive versus incremental change, innovation, and subsequent development of a procedure, and attaining competency, proficiency, and ultimately mastery of a set of surgical techniques? In addition, what is the gap in what is known and what needs to be known, in order to provide the best care possible to patients?
Introduction
Can’t we give ourselves one more chance? Why can’t we give love that one more chance?
Patients with burns often develop debilitating pruritus, paresthesias, and allodynia, as well as motor dysfunction, despite medical and pharmacologic therapy. Peripheral nerve decompression has emerged as a potentially effective intervention to alleviate these symptoms, but many questions remain, regarding surgical indications, timing, and technique. For example, our own experience in abdominal wall reconstruction has shown that learning curves contain both incremental and disruptive inflection points, which can represent volatile periods of evolution in the synthesis of surgical algorithms. Phases of technical innovation versus development represent distinctly different periods of learning for surgeons, marked by contrasting periods of feasibility and proficiency.
Practice-based learning and improvement (PBLI) is an educational model that was adopted by the Accreditation Council of Graduate Medical Education in 1999 as one of 6 core competencies designed to help establish the basic skills and attributes of practicing physicians. These competencies, which also include medical knowledge, patient care, professionalism, team work and communication, and systems-based practice, were later incorporated by the American Board of Medical Specialties into their program of Maintenance of Certification, to promote and ensure self-directed, lifelong learning.
Because burn care, like all of medicine, is constantly evolving, plastic surgeons are exposed to new information and new clinical scenarios almost daily. PBLI should enable practicing physicians to become efficient, as knowledge is gained, and effective, as this knowledge is applied to real-life situations. As a formal paradigm, PBLI includes 3 components for physicians to pursue:
- •
Investigate and evaluate physicians’ own patient care practices, with rigorous comparison with standard of care, as well as the state-of-the-art care
- •
Appraise, analyze, and assimilate scientific evidence, both within physicians’ individual practices, and across the published literature of their peers
- •
Improve the practice of medicine by physicians applying new knowledge and by educating all of the stakeholders, including themselves and their colleagues, patients and their families, and other members of the health care team
This article shows the utility of PBLI in the care of patients with burns. Although there are some reports of learning-curve analyses in burn care, surprisingly little is published with regard to the application of PBLI to the care that is provided to patients with burns. As a content area for PBLI, this article discusses a complex, clinical situation that is poorly understood, the development of chronic neuropathic pain and sensorimotor dysfunction after burn injury, but that profoundly affects quality of life and both the trajectory and end points of recovery. The authors’ intuition suggested that, over the past 5 years, from 2011 to 2015, the number of procedures we were performing for neuropathic was increasing, and our outcomes were improving, compared with the first 10 years of the senior surgeon’s practice, from 2000 to 2010. Specifically, what role does the learning curve play in affecting these outcomes? Can PBLI be applied to measure disruptive versus incremental change, innovation, and subsequent development of a procedure, and attaining competency, proficiency, and ultimately mastery of a set of surgical techniques? In addition, what is the gap in what is known and what needs to be known, in order to provide the best care possible to patients?
Methods
Patients
The authors performed an Institutional Review Board–approved, retrospective, 2-stage review of all patients needing burn reconstruction who underwent elective, peripheral nerve surgery at the University of North Carolina, by a single surgeon, from 2000 to 2015. The master database was created by first querying the billing records of our practice plan for all current procedural terminology (CPT) codes involving the decompression, neurolysis, transposition, excision, and/or implantation of peripheral nerves, by the senior surgeon (CSH). Next, the authors identified the target group of patients needing burn reconstruction by cross-merging this list with patients with burns admitted to the University of North Carolina Jaycee Burn Center who had been entered prospectively into the National Burn Repository, a registry maintained by the American Burn Association. Asymptomatic patients who underwent nerve decompression, as part of contracture release or exposure of deeper structures, were excluded from this analysis (n = 51 patients).
Data Collection
In addition to using data collected from the billing and admission databases, our electronic medical record (Epic, Verona, WI) was used to obtain the following data points: age, mechanism of injury, size of burn, incidence of escharotomy and/or fasciotomy, time from injury to reconstructive nerve surgery, location and type of nerve surgery, postoperative complications, long-term sensorimotor function, and length of follow-up. Main outcome measures, in terms of efficacy of surgery on nerve dysfunction, were defined as follows: definite improvement (discontinuation of pharmacotherapy and/or nearly complete relief of symptoms), moderate improvement (reduction in pharmacotherapy and/or lessening of symptoms), no improvement, or worsening of symptoms or function. These data points were gleaned from several sources: initial consultation notes, operative notes, postoperative notes, and pharmacologic regimen.
Study Design
The patients were segregated into 2 different cohorts, based on year of surgical intervention: 2000 to 2010 and 2011 to 2015. The groups were selected, using these time points, because the first cohort was initially part of a quality improvement project, to determine baseline information on indications, complications, and outcomes. Several interventions were then introduced, after 2010, as part of a practice-based learning initiative, with the goal of improving efficiency and effectiveness: (1) moving cases from our hospital-based ambulatory surgery center to our office-based surgery facility; (2) introducing wide-awake local anesthesia no tourniquet (WALANT) into our practice; (3) favoring in-situ nerve decompression rather than transposition (especially in cubital tunnel release); (4) becoming more aggressive in neuroma exploration and resection, with intramuscular stump implantation; (5) optimizing pharmacologic regimen preoperatively (nonsteroidal antiinflammatory drugs, anticonvulsants, antihistamines, anxiolytics, and antidepressants) with limited opioid use postoperatively for incisional pain; and (6) introducing laser resurfacing, laser-assisted steroid delivery, and fat grafting as preliminary or adjuvant measures to alleviate neuropathic pain.
Statistical Analysis
The 2 cohorts, 2000 to 2010 and 2011 to 2015, were compared by Student t-test for continuous data and χ 2 analysis for categorical data. Statistical significance was assigned at P <.05. Only elective, nonemergent, symptomatic patients with burns, undergoing reconstructive nerve surgery, were included in this analysis. All patients had components of sensory or motor dysfunction, but nearly all patients had some degree of neuropathic pain.
Results
Patient Demographics
From 2000 to 2015, 223 symptomatic patients with burns underwent reconstructive nerve surgery, over the course of 284 operative sessions, involving 460 CPT codes related to nerve decompression, neurolysis, transposition, neuroma excision, and/or implantation. The trend in surgical volume, as represented by number of patient cases over time, is presented in Fig. 1 , which shows a substantial increase in procedures during the last 5 years of the study. The 2 time-based cohorts compare as follows: 2000 to 2010 included 105 patients, 141 operative sessions, and 236 CPT codes; 2011 to 2015 included 118 patients, 143 operative sessions, and 224 CPT codes. Demographic data contrasting the 2 groups are shown in Table 1 . Mechanisms of burn injury, for the 2 cohorts, are shown in Fig. 2 . Overall, 72% of the burns were thermal, 18% were electrical, 6% were chemical, 2% were mechanical, and 1% were caused by radiation.
| Cohort | Patients (N) | Sessions (N) | Nerves (N) | Age (y) | TBSA (%) | Fasciotomy or Escharotomy (%) | Time from Burn Injury to Nerve Surgery (y) |
|---|---|---|---|---|---|---|---|
| 2000–2010 | 105 | 141 | 236 | 38.2 ± SD 15.2 | 18.7 ± SD 19.7 | 25.7 | 1.67 ± SD 2.55 |
| 2011–2015 | 118 | 143 | 224 | 37.6 ± SD 18.8 | 12.5 ± SD 15.1 | 39.1 | 2.11 ± SD 3.00 |
| P value | — | — | — | NS | P <.01 | NS | NS |
Operative Considerations
Time from burn injury to surgical intervention, defined as nerve release, neurolysis, neuroma excision plus or minus implantation, is noted in Table 1 . Location of procedural site, where the reconstructive nerve surgery was performed, is listed in Table 2 . Certain procedures, such as carpal tunnel release, Guyon canal release, and cubital tunnel release, were performed with higher frequency during the early cohort, whereas superficial radial nerve release and lower extremity decompression were more commonly performed during the late cohort. From 2000 to 2010, no neuromas were excised, whereas 19 neuromas were excised from 2011 to 2015, with muscle implantation occurring in 5 patients. Regarding cubital tunnel release, only in-situ releases were performed during the 2011 to 2015 period, in contrast with anterior subfascial or submuscular transpositions in the early period of 2000 to 2011.
| Location/Procedure | 2000–2010 | 2010–2015 | Total |
|---|---|---|---|
| Digital Nerves | 41 | 62 | 103 |
| Median: CTR | 82 | 30 | 112 |
| Median: Palmar Branch | 11 | 0 | 11 |
| Median: Elbow | 1 | 0 | 1 |
| Ulnar: Guyon Canal | 40 | 20 | 60 |
| Ulnar: Dorsal Branch | 5 | 0 | 5 |
| Ulnar: Cubital Tunnel | 33 | 19 | 52 |
| Antebrachial Cutaneous | 4 | 5 | 9 |
| Radial: Superficial | 4 | 24 | 28 |
| Radial: Elbow | 1 | 0 | 1 |
| Radial: PIN | 1 | 0 | 1 |
| Intercostal | 0 | 4 | 4 |
| Intercostobrachial | 0 | 4 | 4 |
| Common Peroneal | 12 | 5 | 17 |
| Saphenous | 0 | 7 | 7 |
| Sural | 0 | 11 | 11 |
| Anterior Tibial | 0 | 2 | 2 |
| Posterior Tibial | 0 | 1 | 1 |
| Plantar/Tarsal Tunnel | 0 | 4 | 4 |
| Auricular | 0 | 2 | 2 |
| Neuroma Resection | 0 | 19 | 19 |
| Implantation: Muscle | 0 | 5 | 5 |
| Intraneural Neurolysis | 0 | 1 | 1 |
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