Median nerve fascicle transfer versus ULNAR nerve fascicle transfer to the biceps motor branch in C5‐C6 and C5‐C7 brachial plexus injuries: Nonrandomized prospective study of 23 consecutive patients

Cho, Álvaro Baik; Paulos, Renata Gregorio; Resende, Marcelo Rosa de; Kiyohara, Leandro Yoshinobu; Sorrenti, Luiz; Wei, Teng Hsiang; Neto, Raul Bölliger; Júnior, Rames Mattar

doi:10.1002/micr.22263

Cited by 25 publications

(19 citation statements)

References 29 publications

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“…Importantly, the result of this study demonstrates the cost-effectiveness of the Oberlin nerve transfer and comparable procedures utilizing the median nerve, ulnar nerve, or a combination of both. 8,16,19 There are several limitations to our model. This model is based on assumptions and values obtained from prior studies, many of which are retrospective single-center studies that have not been externally validated in prospective, randomized trial settings.…”

Section: Discussionmentioning

confidence: 99%

“…This model used carefully selected data from our literature review that included studies on health-related QOL and quality-adjusted life years (QALYs). The base scenario involved a 28-year-old male patient, with 50 years of life expectancy, 8 with loss of C-5 and C-6 function without spontaneous recovery 4.5 months after injury. Using a Markov model, each "patient" underwent 50 cycles (1 year per cycle) to model the lifetime QOL impact of each functional state.…”

Section: Decision Modelmentioning

confidence: 99%

“…8,14,19 Loss of elbow flexion due to upper brachial plexus injury leads to disability and dramatic reduction in quality of life (QOL) over a patient's remaining lifespan. 11,[20][21][22] Moreover, financial burdens on the individual and society are enormous.…”

mentioning

confidence: 99%

“…Similarly, a fascicle of the median nerve transferred to the biceps branch of the musculocutaneous nerve is also effective in improving elbow flexion. 1,8,19 A double fascicular transfer that uses both ulnar and median nerve fascicles to reinnervate musculocutaneous branches to both biceps and brachialis muscles has been argued to provide additional strength. 16 Although prior studies have investigated the comparative efficacy of these nerve transfer procedures, 3 a cost-effectiveness study of surgical management compared with conservative management has not yet been conducted.…”

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confidence: 99%

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Analyzing cost-effectiveness of ulnar and median nerve transfers to regain forearm flexion

Wali¹,

Park

Brown³

et al. 2017

FOC

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OBJECTIVE Peripheral nerve transfers to regain elbow flexion via the ulnar nerve (Oberlin nerve transfer) and median nerves are surgical options that benefit patients. Prior studies have assessed the comparative effectiveness of ulnar and median nerve transfers for upper trunk brachial plexus injury, yet no study has examined the cost-effectiveness of this surgery to improve quality-adjusted life years (QALYs). The authors present a cost-effectiveness model of the Oberlin nerve transfer and median nerve transfer to restore elbow flexion in the adult population with upper brachial plexus injury. METHODS Using a Markov model, the authors simulated ulnar and median nerve transfers and conservative measures in terms of neurological recovery and improvements in quality of life (QOL) for patients with upper brachial plexus injury. Transition probabilities were collected from previous studies that assessed the surgical efficacy of ulnar and median nerve transfers, complication rates associated with comparable surgical interventions, and the natural history of conservative measures. Incremental cost-effectiveness ratios (ICERs), defined as cost in dollars per QALY, were calculated. Incremental cost-effectiveness ratios less than $50,000/QALY were considered cost-effective. One-way and 2-way sensitivity analyses were used to assess parameter uncertainty. Probabilistic sampling was used to assess ranges of outcomes across 100,000 trials. RESULTS The authors' base-case model demonstrated that ulnar and median nerve transfers, with an estimated cost of $5066.19, improved effectiveness by 0.79 QALY over a lifetime compared with conservative management. Without modeling the indirect cost due to loss of income over lifetime associated with elbow function loss, surgical treatment had an ICER of $6453.41/QALY gained. Factoring in the loss of income as indirect cost, surgical treatment had an ICER of −$96,755.42/QALY gained, demonstrating an overall lifetime cost savings due to increased probability of returning to work. One-way sensitivity analysis demonstrated that the model was most sensitive to assumptions about cost of surgery, probability of good surgical outcome, and spontaneous recovery of neurological function with conservative treatment. Two-way sensitivity analysis demonstrated that surgical intervention was cost-effective with an ICER of $18,828.06/QALY even with the authors' most conservative parameters with surgical costs at $50,000 and probability of success of 50% when considering the potential income recovered through returning to work. Probabilistic sampling demonstrated that surgical intervention was cost-effective in 76% of cases at a willingness-to-pay threshold of $50,000/QALY gained. CONCLUSIONS The authors' model demonstrates that ulnar and median nerve transfers for upper brachial plexus injury improves QALY in a cost-effective manner.

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Section: Discussionmentioning

confidence: 99%

Section: Decision Modelmentioning

confidence: 99%

mentioning

confidence: 99%

mentioning

confidence: 99%

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Analyzing cost-effectiveness of ulnar and median nerve transfers to regain forearm flexion

Wali¹,

Park

Brown³

et al. 2017

FOC

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“…A Markov model was used to investigate the base scenario of a 25-year-old patient with 78 years of life expectancy 6 with PBPI.…”

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confidence: 99%

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

Wali

Santiago-Dieppa

Brown

et al. 2017

Neurosurgical Focus

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OBJECTIVEPan–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.METHODSA 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.RESULTSThe 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.CONCLUSIONSThis 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.

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Comparison of objective muscle strength in c5‐c6 and c5‐c7 brachial plexus injury patients after double nerve transfer

Tsai

Hsiao

et al. 2014

Microsurgery

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Median nerve fascicle transfer versus ULNAR nerve fascicle transfer to the biceps motor branch in C5‐C6 and C5‐C7 brachial plexus injuries: Nonrandomized prospective study of 23 consecutive patients

Cited by 25 publications

References 29 publications

Analyzing cost-effectiveness of ulnar and median nerve transfers to regain forearm flexion

Analyzing cost-effectiveness of ulnar and median nerve transfers to regain forearm flexion

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

Comparison of objective muscle strength in c5‐c6 and c5‐c7 brachial plexus injury patients after double nerve transfer

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