Treatment of ulnar neuropathy at the elbow: cost-utility analysis.

PURPOSE: The choice of surgical treatment for ulnar neuropathy at the elbow (UNE) remains controversial. A cost-utility analysis was performed for 4 surgical UNE treatment options. We hypothesized that simple decompression would emerge as the most cost-effective strategy. METHODS: A cost-utility analysis was performed from the societal perspective. A decision analytic model was designed comparing 4 strategies: (1) simple decompression followed by a salvage surgery (anterior submuscular transposition) for a poor outcome, (2) anterior subcutaneous transposition followed by a salvage surgery for a poor outcome, (3) medial epicondylectomy followed by a salvage surgery for a poor outcome, and (4) anterior submuscular transposition. A poor outcome when anterior submuscular transposition was the initial surgery was considered an end point in the model. Preference values for temporary health states for UNE, the surgical procedures, and the complications were obtained through a time trade-off survey administered to family members and friends who accompanied patients to physician visits. Probabilities of clinical outcomes were derived from a Cochrane Collaboration meta-analysis and a systematic MEDLINE and EMBASE search of the literature. Medical care costs (in 2009 U.S. dollars) were derived from Medicare reimbursement rates. The model estimated quality-adjusted life-years and costs for a 3-year time horizon. A 3% annual discount rate was applied to costs and quality-adjusted life-years. Incremental cost-effectiveness ratios were calculated, and sensitivity analyses performed. RESULTS: Simple decompression as an initial procedure was the most cost-effective treatment strategy. A multi-way sensitivity analysis varying the preference values for the surgeries and a model structure sensitivity analysis varying the model assumptions did not change the conclusion. Under all evaluated scenarios, simple decompression yielded incremental cost-effectiveness ratios less than US$2,027 per quality-adjusted life-year. CONCLUSIONS: Simple decompression as an initial treatment option is cost-effective for UNE according to commonly used cost-effectiveness thresholds. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and Decision Analysis III.

Diagnosis and Treatment of Work-Related Ulnar Neuropathy at the Elbow.

Ulnar neuropathy at the elbow (UNE) is the second most common entrapment neuropathy after carpal tunnel syndrome and occurs most commonly at the elbow due to mechanical forces that produce traction or ischemia to the nerve. The primary symptom associated with UNE is diminished sensation or dysesthesias in the fourth or fifth digits, often coupled with pain in the proximal medial aspect of the elbow. Treatment may be conservative or surgical, but optimal management remains controversial. Surgery should include exploration of the ulnar nerve throughout its course around the elbow and release of all compressive structures.