Patient Referral and Triage

The CNI population is broad and comprised of individuals with traumatic nerve injuries (e.g. brachial plexopathy), inflammatory nerve conditions (e.g. neuralgic amyotrophy), complex compression neuropathy (with secondary axonal loss), and nerve tumors. Individuals with spinal cord injury are also being evaluated through CNIPs for consideration for upper limb surgical interventions (e.g. nerve or tendon transfer), ^{Reference Fox, Miller and Curtin3} however, their care needs are different than the typical CNI patient and are outside the scope of this paper.

Functional recovery after CNI is dependent on timely evaluation and intervention. Patients with significant axon loss and limited clinical recovery are considered “urgent”, as surgery should be performed within 6 months or sooner (depending upon the distance to recipient’s muscle) to avoid irreversible muscle atrophy and degradation of motor endplates. ^{Reference Brown, Shah and Mackinnon4} Missing the window for surgical intervention can have life-long consequences to limb function; ^{Reference Jivan, Kumar, Wiberg and Kay5,Reference Kato, Htut, Taggart, Carlstedt and Birch6} therefore, expedited referral and screening are of paramount importance. The challenge in identifying and triaging CNI patients for urgent assessment, evident before the pandemic, is now compounded by healthcare provision restrictions, including reduced clinic and surgical volumes. Furthermore, reduced availability of in-person assessments could result in delayed identification of CNI, as in-person sensorimotor physical examinations are often key to identifying neurological deficits (e.g. anterior shoulder dislocation resulting in axillary nerve palsy could be missed without in-person orthopedic follow-up).

Therefore, our strongest recommendation is an immediate referral of patients with CNI by primary treating physicians to their regional CNIP, through direct physician-to-physician communication to avoid delays. CNIPs must also establish a timely and responsive system of assessing and triaging referrals, allowing for multiple physicians to participate in this process where possible.

Virtual Care

The rapid adoption of virtual care in medicine has occurred to meet the unprecedented challenges of COVID-19 ^{Reference Hollander and Carr7} and virtual visits should be implemented in the triage process to determine the requirement for, and urgency of, an in-person consultation. In addition, virtual assessments allow completion of the history and screening measures to minimize the time required in the clinic, involvement of family members who may not be permitted to attend an in-person visit, and facilitation of investigations. There are several factors specific to CNI requiring consideration: (1) video platforms are preferable to telephone, as video allows for a rudimentary physical examination to evaluate the continuity of major nerve branches and gauge recovery, (2) virtual consultations are appropriate for patients who do not have a time-sensitive nerve injury, for example, those with mild weakness, or who are rapidly improving, (3) CNI patients require close and frequent follow-up (typically every 3–6 months depending upon the stage of recovery). Many of these encounters can be performed virtually, including visits for titration of medication for pain or mood, reviewing the range of motion and strengthening exercises, and improving patient education.

However, where virtual care is not able to provide a thorough assessment of CNI, CNIPs will need to provide in-person assessments. A virtual assessment cannot substitute for the nuances of an in-person physical examination, such as evaluating for the Medical Research Council Grade 1 recovery. Therefore, if there is any concern about impediments to spontaneous or postoperative neurological recovery, or if injury characterization cannot be clearly defined virtual, we recommend that referring physicians and CNIPs have a low threshold for performing an in-person assessment. Our recommendations for those patients requiring urgent in-person assessment are presented in Table 1. For these patients, we recommend an interdisciplinary assessment where team members evaluate the patient during the same encounter, with one individual conducting the physical examination.

Table 1: Triage recommendations: patients requiring an urgent “in-person” assessment

EMG = electromyography; ROM = range of motion.

Infection Control

In order to provide safe, in-person visits, CNIPs must adhere to infection control measures according to prescribed public health recommendations with guidance from local hospital leadership. ⁸ Consideration must be given to infection control in both clinical and surgical settings, with recommendations evolving with an improved understanding of COVID-19. For example, consensus is evolving on requirements for full personal protective equipment (PPE) use during surgery and CNI surgical teams may be sufficiently protected using droplet precautions only (thereby reducing PPE usage). ^{Reference Brat, Hersey, Chhabra, Gupta and Scott9} We endorse the recent recommendations published by the American Association for Neuromuscular & Electrodiagnostic Medicine regarding general infection control measures for the resumption of routine electrodiagnostic testing. ^{Reference Desai, Kassardjian and Del Toro10} Infection control factors particularly germane to the evaluation and treatment of CNI are outlined in Table 2.

Table 2: Recommended infection control measures

PPE = personal protective equipment.

Neurophysiology and Other Testing

In order to prevent potential life-long loss of function, electrodiagnostic studies, including nerve conduction studies and needle electromyography (EMG), must be performed early in time-sensitive patients. EMG is a valuable tool in the initial diagnosis and prognostication of CNIs, as well as in helping to evaluate recovery and guide rehabilitation (Table 3).

Table 3: Role of electrodiagnosis in management of complex nerve injuries

EMG should be performed after changes are expected (~3 weeks after injury) due to Wallerian degeneration and repeated in a timeframe that allows surgical intervention before the window of recovery has started to close. EMG is also often indicated at several time points after surgery to look for evidence of reinnervation, which helps guide postoperative rehabilitation. The minimum number of key studies, including assessment of recovering muscle groups as well as possible donor nerves for nerve transfer surgery, should be performed to minimize time in the laboratory. If possible, the consultation and EMG procedure should be performed in the same clinic room to minimize points of contact for patients.

Other testing, including ultrasound and MRI, may be required in the evaluation of CNI, but should be limited to essential tests to limit exposure to the hospital environment.

Nonoperative Treatments

Many patients have suffered significant trauma and often have concomitant orthopedic and central neurological system injuries, which must be identified. ^{Reference Midha11} In addition to management of pain, range of motion and edema, psychological factors and social context need to be taken into account to optimize coping and global function. Table 4 outlines aspects of medical care that must continue despite the pandemic.

Table 4: Recommendations for early medical management of CNI

CNI = complex nerve injury; GAD-7 = Generalized Anxiety and Depression Scale-7; OT = occupational therapy; PHQ-9 = Patient Health Questionnaire-9; PT = physiotherapy; ROM = range of motion; TENS = transcutaneous electrical nerve stimulation.

Virtual care with the patient and caregivers should facilitate these interventions, wherever possible. In selective circumstances, EMG biofeedback devices and orthoses can be purchased online with home delivery with direction provided virtually by the care provider. Challenges in care delivery during the pandemic highlight the need for excellent collaboration and communication between treating clinicians.

Surgical Considerations

The goal for surgical care is to treat in a timely manner with direct repair, nerve graft, or nerve transfer where appropriate, despite the challenges of the COVID-19 pandemic. In the pandemic context, there are several systemic factors that may impact treatment, including access to surgical resources and risk of perioperative exposure of the surgical team to COVID-19. Therefore, if early reconstruction does not occur due to time delay or other factors, and irreversible loss of motor endplates occurs, secondary reconstructive options such as tendon transfers (or more elaborate reconstructions such as free functioning muscle transfers) may be required at a later time point to enhance function. However, it is strongly encouraged to manage these patients with primary nerve reconstruction, wherever possible.

Preoperative COVID-19 testing is subject to recommendations from regional public health authorities, disease prevalence within the population, and availability of testing resources. Various strategies exist including screening questionnaires and assessments to stratify risk of disease, which informs whether a test is performed. Alternatively, some advocate for testing all surgical patients due to perioperative morbidity and mortality in asymptomatic patients with COVID-19. ^{Reference Nahshon, Bitterman, Haddad, Hazzan and Lavie12,Reference Kaye, Paprottka and Escudero13} Overall, we suggest a low threshold for preoperative COVID-19 testing given the risk to patient and healthcare team. If testing positive, then patients are delayed at least 2 weeks or until asymptomatic, which is expected to have minimal impact on their nerve reconstruction.

The majority of patients requiring reconstructive nerve surgery procedures are young, with limited comorbidities and thus may be treated as outpatients. ^{Reference Karsy, Watkins, Jensen, Guan, Brock and Mahan14} Therefore, nerve surgery creates a modest impact on hospital resources. Furthermore, many procedures can be completed under regional anesthesia, which obviates the need for airway-related PPE use. ^{Reference Uppal, Sondekoppam, Landau, El-Boghdadly, Narouze and Kalagara15} It is recommended that nerve surgery be completed under regional anesthesia, where possible.

To mitigate perioperative infectious risk, we provide an example of how the surgical suite environment can be modified. This model – referred to as the surgical procedure rooms and developed at St. Paul’s Hospital, in Vancouver, British Columbia – uses an isolated site in the hospital that has adjacent operating room suites, with a neighboring patient care area that provides space for anesthetic care. This model optimizes patient flow through the surgical care pathway by increasing the number of patients being treated per day. Ideally, cases should be less than 2 hours in length. When longer cases are booked, patients who can have their surgery completed under local anesthetic (e.g. carpal tunnel release), can be treated between regional block cases to help the flow in the preoperative and postoperative area.

Pediatric Peripheral Nerve Surgery

The principles guiding the management of CNI in children during the pandemic are similar to that in adults, with a few unique considerations. The two main populations are brachial plexus birth injury (BPBI; most common) and traumatic nerve injuries.

Worldwide experience suggests that COVID-19 infection is less frequent in children, and pediatric cases requiring ICU admission or ventilatory support are rare. ^{Reference Ludvigsson16} Each pediatric patient, however, is attended by a parent which needs to be considered when configuring hospital spaces.

Assessment of CNI in young children can be difficult, and in-person assessment by an interdisciplinary team of surgeons and therapists with pediatric expertise is recommended.

For infants with BPBI, we recommend minimizing in-person assessments to the key time points within the first year of life where decisions regarding the necessity of a primary surgery are made (typically at 3, 6, and/or 9 months of age). ^{Reference Bade, Lin, Curtis and Clarke17} Virtual therapy consultations can be utilized between the in-person assessments to monitor progress and adherence to therapy regimens, as well as to continue caregiver education regarding BPBI. CNI to older children follows the same principles as that of an adult.

If the decision to operate has been made and all necessary investigations are completed, nerve reconstruction should be completed as soon as possible. For BPBI, this time window should be within 3 weeks of the decision. Other traumatic nerve injuries in children would follow similar guidelines for adults.

The risks of general anesthesia in the presence of a respiratory infection (which are common in the pediatric population) must be carefully considered against the potential detrimental effects of deferring the nerve repair; decision-making should include the surgeon, anesthetist, and patient caregivers. Given the time sensitivity of brachial plexus reconstruction in infants with BPBI, we recommend deferring the operation by a minimum of 2 weeks following a milder upper respiratory tract infection (URTI), and 6 weeks for any severe URTI or lower respiratory tract infection. The same principles would be followed in an infant or child with active COVID-19 infection. ^{Reference Tait, Malviya, Voepel-Lewis, Munro, Seiwert and Pandit18}

Rehabilitation

After nerve injury, there are immediate changes in the peripheral and central nervous system, which continue through reinnervation and recovery. ^{Reference Novak19} Extensive rehabilitation after nerve injury is required to achieve optimal outcome and function.

Postoperative rehabilitation is typically performed through “hands-on” sessions with a therapist utilizing modalities including exercises, dynamic-assist orthosis, biofeedback, and neuromuscular stimulation. Early intervention focuses on maintaining range of motion, control of edema and pain. Following nerve transfer surgery, rehabilitation is directed towards sensory and motor cortical remapping to facilitate optimal recruitment of the new neural connections. ^{Reference Kahn and Moore20} Patients are taught to activate the donor nerve in combination with recipient muscle function. Following reinnervation, rehabilitation focuses on motor re-education to learn how to correctly recruit the newly re-innervated muscle. Depending on the stage of recovery, visits (in-person or virtual) with a therapist may occur weekly to monthly. During the pandemic, this process may be compromised. We advocate for virtual therapy visits when possible, with the understanding that in-person sessions are required to fabricate resting and dynamic-assist orthoses, provide instruction on biofeedback machines and tactile reinforcement of desired motor patterns for exercise.

Research and Education

The pandemic has impacted research in the fields of nerve injury and repair, with delays affecting multiple steps of the research process. These include cancelation of grant competitions and delays in reviewers’ comments. Funding is being diverted to COVID-19-related research, reducing resources available for other areas. Carrying out research projects is hindered by the inability to obtain ethics approval and forced closure or limited operation of research labs. The pandemic has had an adverse impact on participant recruitment, protocol adherence, treatment outcomes, meeting grant deliverables, and allowing research trainees to complete thesis projects on time.

While traditional research endeavors have been interrupted, the pandemic has led to the development of innovative service delivery strategies for CNI patients, presenting novel research opportunities. These innovations now require a systematic evaluation and create novel opportunities for future scholarly activity. Described above, telehealth tools lend themselves well to remote consults, but using them to their full potential will require systematic development and validation to improve features and functionality. The creation of a standardized “virtual neurologic examination”, electronic administration of patient questionnaires, online education modules, and evaluation of patient experience with telemedicine are areas ripe for study.

Education for CNI has been affected by reduced clinic volumes which compromise trainees’ opportunity to acquire hands-on experiences and skills. The cancelation of in-person seminars further compounds the situation by reducing the opportunity for mentoring and didactic teaching. We recommend the systematic development of a coordinated program to deliver didactic teaching for trainees throughout the country. One example is the Canadian Plastic Surgery National Grand Rounds, created by the Canadian Royal College Plastic Surgery Specialty Committee, and is administered nationally to all residents and consultants each week via a virtual platform. Finally, restrictions on travel and the need for physical distancing also mean that future medical conferences may need to shift from in-person meeting to a virtual format, thereby changing how scientific knowledge is disseminated.

Future Directions

Addressing and responding to challenges experienced during the pandemic may help to guide responses to similar scenarios in the future. In the context of CNI, we recommend first tackling the most urgent issues that will have an immediate impact on quality of care for patients with CNI, including expanding and validating the capabilities of communication tools and virtual platforms. The next priority is to improve or optimize the delivery of interdisciplinary care so as to minimize the risk of exposure. In this regard, expanding the capabilities of digital tools to provide a richer array of clinical information and time /expense associated with travel for rural patients, would be worthwhile efforts. The lessons learned from the pandemic have been valuable in highlighting the need for a widespread integrated approach for future healthcare delivery.

As CNIPs start to “re-open”, they must have a plan in place to prioritize and manage the backlog of patients impacted by the sudden, unanticipated halt to clinical care. In addition, programs must be cognizant of the potential for a second wave of the pandemic, potentially necessitating a similar shutdown of services affecting peripheral nerve patients. Table 5 highlights recommendations for future planning when these services do open.

Table 5: Recommendations for future planning

CNI = complex nerve injury; PPE = personal protective equipment.