Patient- and Provider-Perceived Barriers to Reconstructive Surgery for Patients With Upper Limb Spasticity.

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The benefits of upper-extremity reconstructive surgery for patients with spastic deformities are well documented, but a small portion of eligible patients undergo surgery. We sought to determine perceptions of upper-extremity reconstructive surgery among brain injury patients and nonsurgical providers to identify potential barriers to surgical evaluation. Electronic medical records at a referral center were reviewed for patients diagnosed with upper limb spasticity following brain injury. A patient-specific survey was distributed by email to all eligible patients. An anonymous provider-specific electronic survey was distributed to the members of United States-based professional societies that routinely provide nonsurgical medical care to patients with spasticity. Forty-three of 143 patients (30%) responded to the survey. All subjects underwent initial nonsurgical management for their spastic upper limbs, but only 19% (n= 8) underwent subsequent reconstructive upper-extremity surgery. Hesitancy to undergo surgery was primarily related to "uncertainty regarding its benefits" and "fear of worsened postoperative function." Thirty-seven medical providers responded to the survey. Seventy-six percent (n= 28) saw more than 10 patients afflicted with spasticity annually, but 83% referred fewer than 10 patients for surgical evaluation. Barriers to referral included "uncertainty regarding procedure effectiveness" (58%), "concerns regarding insurance approval" (56%), "uncertainty whether a patient is a surgical candidate" (53%), and "no relationship with an upper extremity surgeon" (39%) for referral. Surgery is infrequently performed among brain injury patients with spastic upper limb deformities. Patients report unfamiliarity with surgical options and concerns regarding surgical risks and benefits. Nonsurgical providers describe uncertainty regarding surgical efficacy and candidacy and underdeveloped referral networks. Surgical treatment of upper-extremity spasticity following brain injury is infrequently provided to eligible patients. Patient and provider perceptions of upper-extremity reconstructive surgery may help identify the factors that underlie the relative infrequency of surgical treatment and suggest opportunities to optimize the delivery of surgical care.