Purpose: In the United States, more than 100,000 Americans live with the Disability of Tetraplegia. These individuals must struggle through long and complicated rehabilitations. Upper-extremity reconstructive surgery can improve use of the upper limb for appropriate candidates; however, a prior national study showed that these procedures rarely are performed. This cross-sectional survey identified the attitudes and beliefs of people with tetraplegia that may dissuade potential candidates from receiving these procedures.

Methods: An oral survey was designed to determine priorities of reconstruction in individuals with tetraplegia. This survey was administered to 50 people with tetraplegia.

Results: Among those surveyed, 13 (26%) had never heard of upper- extremity reconstructive surgery, but 22 (44%) were interested in upper-extremity reconstruction. People with tetraplegia who had a negative first impression of these procedures were far less likely to want reconstruction 0 (0%) vs. 11 (45%). Of patients who learned about these procedures from their physicians, 10 (67%) had a negative first impression after the physician consultation.

Conclusions: Although many people with tetraplegia understand the benefits of upper-extremity reconstruction, a large number of them are unaware of or have unfavorable attitudes toward these procedures. These negative attitudes may account for the marked underuse of upper-extremity reconstructive procedures in the United States. (J Hand Surg 2007;32A:483-490. Copyright 2007 by the American Society for Surgery of the Hand.)

Key words: Survey, tetraplegia, preferences.

Upper-extremity reconstructive procedures for people with tetraplegia have been well described for more than 30 years. case series have shown that these procedures can improve upper-extremity function in appropriate candidates.1-8 Experts in this field, such as Moberg9 and Hentz et al10 have estimated that at least 65% of people with tetraplegia would benefit from some type of upper- extremity surgical intervention; however, a recent analysis of national databases showed that fewer than 10% of people with tetraplegia will have these procedures.11 As the primary providers of upper-extremity reconstruction, hand surgeons must take a leadership role in addressing this profound underuse. The goal of this study was to better understand the barriers limiting use of upper-extremity reconstruction for people with tetraplegia.

Health care resource use depends on the participation of the health care system, the health care provider, and the patient. Factors causing an underuse of a procedure include a lack of health insurance, physician doubts about the efficacy of an intervention, or general patient disinterest. For upper-extremity reconstructions, the health care system does not appear to be the major barrier because most patients with a spinal cord injury have health insurance coverage and these procedures are covered by Medicare.12 Health care providers may be contributing to the underuse of upper- extremity reconstructive surgery. It has been shown that the 2 specialties involved in upper-extremity reconstruction (hand surgeons, physiatrists) have differing views about these procedures. Hand surgeons are positive about upper-extremity reconstruction, with 96% stating that they would want these procedures themselves. Physiatrists have more concerns about the efficacy of these procedures, with far fewer physiatrists (63%) wanting these procedures for themselves.13 This interdisciplinary divergence in opinion, however, does not fully explain the profound underuse of upper-extremity reconstruction in the United States. To fully grasp this marked underuse of a proven effective procedure, we must understand the patient component.