Nerve Transfer Versus Muscle Transfer to Restore Elbow Flexion After Pan Brachial Plexus Injury: A Cost-Effectiveness Analysis
Arvin Raj Wali, BA1; David Rafael Santiago-Dieppa, MD1; Justin M. Brown, MD2; Ross Mandeville, MD1; (1)University of California, San Diego, La Jolla, CA, (2)Department of Neurosurgery, University of California, San Diego, San Diego, CA
Pan brachial plexus injury (PBPI), involving C5-T1, disproportionately affects young males causing lifelong disability and decreased quality of life. The restoration of elbow flexion remains a surgical priority for these patients. Within the first six months of injury, transfer of spinal accessory nerve (SAN) fascicles via sural nerve graft or intercostal nerve (ICN) fascicles to the musculocutaneous nerve can restore elbow flexion. Beyond one year, free functioning muscle transplant (FFMT) of the gracilis muscle can be used to restore elbow flexion. We present the first cost-effectiveness model to directly compare the different treatment strategies available to a patient with PBPI. This model assesses the quality of life impact, surgical costs, and the possible income recovered through restoration of elbow flexion.
A Markov model was constructed to simulate a 25 year-old-male with PBPI without signs of recovery 4.5 months after injury. The management options available to the patient are SAN transfer, ICN transfer, delayed FFMT, or no treatment. Probabilities of surgical success rates, quality of life measurements, and disability were derived from published literature. Cost-effectiveness was defined using incremental cost-effectiveness ratios (ICERs) defined by the ratio between costs of a treatment strategy and the quality of adjusted life years (QALY) gained. A strategy was considered cost-effective if it yielded an ICER less than a willingness-to-pay of $50,000/QALY gained. Probabilistic sensitivity analysis was performed to address parameter uncertainty.
The base case model demonstrated a lifetime QALY of 22.45 in the SAN group, 22.0 in the ICN group, 22.3 in the FFMT group and 21.3 in the no treatment group. The lifetime costs of income lost through disability and interventional/rehabilitation costs were $683,400 in the SAN group, $727,400 in the ICN group, $704,900 in the FFMT group, and $783,700 in the no treatment group. Each of the interventional modalities was able to dramatically improve quality of life and decrease lifelong costs. A Monte Carlo probabilistic sensitivity analysis demonstrated that at a willingness-to-pay of $50,000/QALY gained, SAN transfer dominated in 88.5% of iterations, FFMT dominated in 7.5% of iterations, ICN dominated in 3.5% of iterations, and no treatment dominated in 0.5% of iterations.
Conclusion: Our model demonstrates that nerve transfer surgery and muscle transplant are cost-effective strategies in the management of PBPI. These reconstructive neurosurgical modalities can improve quality of life and lifelong earnings through decreasing disability.
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