Routine patient evaluation should include the usual information such as: current medications, allergies, past medical and surgical history, social and family history, and a routine review of systems. A number of other factors including patient age, occupation, hobbies, and associated preceding treatments are important to consider as their expectations and desires will significantly affect the management plan.
Patient Factors Considerations:
Age:
- Younger patients tend to have better results after reinnervation.
- Younger patients have greater ease with sensory and motor reeducation.
- Smaller patients also have a shorter distance from site of repair to end organ, which allows for faster recovery.
Occupation and Hobbies:
- Activities requiring fine motor function may lead one to choose a nerve transfer rather than a tendon transfer as the function will likely be more precise.
- On the other hand a desire for quick recovery and power lifting may suggest a tendon transfer as a better fit.
Past Medical History:
- Comorbidities, such as cardiac or cerebrovascular disease, are contraindications for lengthy surgery.
- Diabetes and renal failure predispose to compressive neuropathy. (Be careful to discriminate diabetic neuropathy from specific compressive neuropathy.)
- Other associated pathology such as fractures, joint injury, pre-existing loss of function, and old injuries may influence treatment decisions.
Past Surgical History:
- Previous vascular repair in the area of nerve injury is a contraindication for the use of a tourniquet. This might also preclude direct exploration of the area for fear of disrupting the previous vein graft which may be fragile and encased in scar tissue.
- A skin graft, flap, or other soft tissue procedures in the area may make extra-anatomic reconstruction or distal nerve transfers more visually appealing.
Medications:
- Past and present medication use for neuropathic pain management is often quite helpful to know. In particular, knowledge of the effectiveness of the medication and its course (what worked, what didn’t, length of use, etc.) might dictate future management.
Patient Stressors:
- Worker’s compensation.
- Legal issues.
- Depression.
- Post-Traumatic stress disorder.