ESTABLISHMENT OF PERIPHERAL NERVE INJURY DATA REPOSITORY TO MONITOR AND SUPPORT POPULATION HEALTH DECISIONS

Approach: We propose to carry out epidemiologic chart reviews of approximately 400 patients with Combat-Related Peripheral Nerve Injuries (CR-PNI) who were referred to Walter Reed National Military Medical Center (WRNMMC) or San Antonio Military Medical Center (SAMMC) for tertiary care. A data registry will be established at the Uniformed Services University for the Health Services (USUHS) and algorithms developed by the Surgical Critical Care Initiative (SC2i) to improve and support health decisions related to peripheral nerve injuries, leading to better standard of care practices and improved quality of life.

Background: Combat-related injuries to the peripheral nervous system represent an exceedingly complex challenge for the treating physicians and surgeons. These injuries often result from penetrating mechanisms such as gunshot wounds or blast fragments, or bone fractures associated with high-energy skeletal insult. CR-PNIs are a major source of functional disability and lost duty hours for the active duty population and particularly combat casualties. Civilian trauma data on peripheral nerve injury has demonstrated the highest rate of injury to the radial nerve; however, the characteristics of military-related trauma likely differ. By contrast, nerve injuries in the recent conflicts in Iraq and Afghanistan have demonstrated a high rate of injury to the ulnar nerve as well as a higher likelihood of multiple nerve injuries. The rate of nerve injury in military trauma may be higher than civilian trauma, with higher severity and poorer outcomes. In a study of Army Physical Evaluation Board records of 464 wounded Service members injured between 2001-2005, Cross et al. found that loss of nerve function was the second most frequent unfitting condition, resulting in an average 31% disability, with 131/464 (28%) of individuals having loss of nerve function and/or sensation as a final diagnosis. One outcomes study of warfare-related nerve injuries graded 66% of cases as 'good'; however, only 9 of 100 patients returned to full military duties with the majority of patients requiring discharge form the military or sedentary/restricted duties. The current state of managing PNI is not satisfactory and demands further investigation to identify the best practices in the care of our beneficiaries.

Specific Aim 1: Establish a database registry of CR-PNI mechanisms, management, and outcomes using both retrospective chart review and prospective patient enrollment.

Specific Aim 2: Develop algorithms based upon evaluation of the CR-PNI registry to establish clinical decision support systems to correlate clinical history, management, and outcomes in order to provide recommendations for clinical care that will improve outcomes for peripheral nerve injury patients.

Study Design: Our group intends to do a retrospective study to catalogue and describe CR-PNI seen at WRNMMC and SAMMC between 2003 and present. During our medical records review, we plan to extract information such as patient demographics; mechanism of injury; location, severity and extent of PNI, other injuries; diagnostic findings (EMG, Ultrasound, and Imaging); surgical and rehabilitative management; and outcomes (when available). This robust dataset will allow our team to have a more complete understanding of the injuries patterns observed in modern military conflict as well as serve as a foundation to follow-up prospective studies to evaluate outcomes of certain select patient populations identified within this database. SC2i will help to develop algorithms based upon the data registry to help improve health outcomes leading to better quality of life.

Relevance: The years following Operation Iraqi Freedom/Operation Enduring Freedom provide a unique opportunity to advance the study of CR-PNIs. Due to improvements in body armor, Warriors are now surviving injuries that were previously lethal, but with increased incidence of injuries to the peripheral nerves. The findings of this study will help us to characterize both combat and non-combat PNIs of this particular war and delineate which management techniques, both surgical and conservative, have the best outcome for each type of injury. This information potentially can have widespread applications to both the civilian and military communities, including the development of treatment algorithms for various PNIs, prevention of various iatrogenic or non-traumatic neuropathies, and improvements in body armor designed to prevent the most common or most severe PNIs.