Nerve transfer versus muscle transfer to restore elbow flexion after pan–brachial plexus injury: a cost-effectiveness analysis

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>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 6 months of injury, transfer of spinal accessory nerve (SAN) fascicles via a sural nerve graft or intercostal nerve (ICN) fascicles to the musculocutaneous nerve can restore elbow flexion. Beyond 1 year, free-functioning muscle transplantation (FFMT) of the gracilis muscle can be used to restore elbow flexion. The authors 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 possible income recovered through restoration of elbow flexion.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>A Markov model was constructed to simulate a 25-year-old man with PBPI without signs of recovery 4.5 months after injury. The management options available to the patient were SAN transfer, ICN transfer, delayed FFMT, or no treatment. Probabilities of surgical success rates, quality of life measurements, and disability were derived from the published literature. Cost-effectiveness was defined using incremental cost-effectiveness ratios (ICERs) defined by the ratio between costs of a treatment strategy and quality-adjusted life years (QALYs) 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 (PSA) was performed to address parameter uncertainty.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>The base case model demonstrated a lifetime QALYs 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 PSA 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.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>This model demonstrates that nerve transfer surgery and muscle transplantation are cost-effective strategies in the management of PBPI. These reconstructive neurosurgical modalities can improve quality of life and lifelong earnings through decreasing disability.</jats:p></jats:sec>

Direct Cost of Surgically Treated Adult Traumatic Brachial Plexus Injuries

“…Economic models based on the US health care system showed the potential cost-effectiveness of surgical reconstruction after BPI 8 , 11 but do not provide actual payment data to contextualize their findings. Like all economic simulations, the models of Wali 12 and Khalifeh et al 11 rely on assumptions about the use of procedures, the projected occurrence of postoperative events, and estimated surgical charges. Our findings add to this body of work by providing actual payment data from patient encounters, which can help in advocating for BPI care and research among stakeholders such as health care payers and funding sources.…”

Một Số Đặc Điểm Lâm Sàng Ở Bệnh Nhân Mất Gấp Khuỷu Được Phẫu Thuật Chuyển Gân Theo Phương Pháp Steindler

“…Khớp khuỷu mất gấp là biểu hiện bệnh nhân không thể gấp chủ động cẳng tay vào cánh tay được. Đây là một tổn thương nặng nề về mặt chức năng, thẩm mỹ và tâm lý; tác động lớn đến chất lượng sống của người bệnh [1], [2]. Có nhiều nguyên nhân dẫn đến mất gấp khớp khuỷu như: Tổn thương gân cơ (đứt gân, cơ nhị đầu, cơ cánh tay trước); tổn thương tại khớp khuỷu (viêm khớp, chấn thương khớp…) gây di chứng cứng duỗi khớp khuỷu; tổn thương thần kinh cơ bì, dây thần kinh lớn của đám rối thần kinh cánh tay (TKCT) chi phối vận động cơ nhị đầu, cơ cánh tay trước gây liệt gấp khuỷu là nguyên nhân hay gặp hàng đầu.…”

Introductory Chapter: Brachial Plexus Injuries - Past, Present, and Future

“…Progressive improvement of the surgical techniques with direct nerve repair, nerve grafting, and particularly with nerve transfers has greatly improved the results in the brachial plexus injuries [47,[70][71][72]. Direct repair, when at all possible, is still the first choice, provided that there is no tension in the suture line [73].…”