Editors' note: Surgery and risk of Guillain-Barré syndrome: A French nationwide epidemiologic study

Abstract

In their retrospective, nationwide, case-crossover study of more than 8,000 cases of Guillain-Barre syndrome (GBS) (2009–2014), Rudant et al. reported on the association between surgery and postoperative risk of GBS. The authors found a significant 53% higher odds of postoperative GBS in the 60 days following any surgery (adjusted OR 1.53, 95% CI 1.25–1.88), although this may be driven in part by orthopedic and gastrointestinal surgeries. Also interesting was the observation that (generally) longer procedures were associated with a greater probability of postoperative GBS (OR 2.22, 95% CI 1.48–3.34 for surgeries lasting ≥120 minutes vs no surgery). Although the mechanism by which surgery mediates this risk remains unclear, Dr. Steiner suggests that the type of anesthesia (epidural vs general) may play a role. Citing earlier literature, Dr. Steiner notes that a substantial proportion of patients had undergone epidural anesthesia before the onset of GBS. Dr. Steiner suggests that local damage from the anesthetic agent or reagent may have contributed to nerve root injury and/or inflammation. Unfortunately, anesthetic technique is not documented in the claims data of the present investigation. Therefore, the investigators are unable to comment on whether epidural anesthesia may have played a role in the development of GBS in their nationwide data set. In their survey of graduating adult and child neurology residents from 2017, Mahajan and colleagues reported on the subjective lack of preparation of graduating trainees as they take on fellowship or junior faculty roles. Among these findings, although more respondents in 2017 felt prepared to address managerial tasks (e.g., billing and malpractice) than in previous years, fewer than 40% felt knowledgeable about billing, coding, contract negotiations, malpractice insurance, or RVUs. Furthermore, among the adult neurology respondents, 54% felt that the fellowship application process began too early, with 46% feeling as if their limited outpatient exposure negatively affected the fellowship decision-making process. In response, Drs. Ratliff and Shanker reference similar pressures placed on orthopedic surgery residents as they embark on their own journeys into fellowship. Because 87% of neurology residents prefer fellowship applications to start in the second half of the PGY3 year or even later, it would be better to delay the application process until this time in order for residents to make the most informed decision about their future careers. As Dr. Mahajan points out, the process of mandating a single “match day” is challenging because of the differences in neurology fellowship offerings. Nonetheless, some date late in the PGY3 year could be suggested by our organizations as the earliest date a program director can make an offer. This may allow for more outpatient exposure, so our trainees can make a more informed career decision.