Is Surgical Repair With Nerve Allograft More Cost-Effective Than Non-Surgical Management for Persistent Trigeminal Neuropathy? Initial Assessment With Markov Model.

PURPOSE: Persistent trigeminal neuropathy (PTN) is associated with high rates of depression, loss of work, and decreased quality of life (QoL). Nerve allograft repair can achieve functional sensory recovery in a predictable manner; however, it bears significant upfront costs. In patients suffering from PTN, is surgical repair with allogeneic nerve graft, when compared to non-surgical therapy, a more cost-effective treatment option? MATERIALS AND METHODS: A Markov model was constructed with TreeAge Pro Healthcare 2022 (TreeAge Software, Massachusetts) to estimate the direct and indirect costs for PTN. The model ran for 40 years with 1-year-cycles on a 40-year-old model patient with persistent inferior alveolar or lingual nerve injury (S0 to S2+) at 3 months without signs of improvement, and without dysesthesia or neuropathic pain (NPP). The 2 treatment arms were surgery with nerve allograft versus non-surgical management. There were 3 disease states, functional sensory recovery (S3 to S4), hypoesthesia/anesthesia (S0 to S2+), and NPP. Direct surgical costs were calculated using the 2022 Medicare Physician Fee Schedule and verified with standard institutional billing practices. Non-surgical treatment direct costs (follow-up, specialist referral, medications, imaging) and indirect costs (QoL, loss of employment) were determined from historical data and the literature. Direct surgical costs for allograft repair were $13,291. State-specific direct costs for hypoesthesia/anesthesia were $2,127.84 per year, and $3,168.24 for NPP per year. State-specific indirect costs included decreased labor force participation, absenteeism, and decreased QoL. RESULTS: Surgical treatment with nerve allograft was more effective and had a lower long-term cost. The incremental cost-effectiveness ratio was -10,751.94, indicating surgical treatment should be utilized based on efficiency and cost. With a willingness-to-pay threshold of $50,000, the net monetary benefits of surgical treatment are $1,158,339 compared to $830,654 for non-surgical treatment. With a standard threshold incremental cost-effectiveness ratio of 50,000, the sensitivity analysis shows that surgical treatment would remain the preferred choice based on efficiency even if surgical costs were doubled. CONCLUSION: Despite high initial costs of surgical treatment with nerve allograft for PTN, surgical intervention with nerve allograft is a more cost-effective treatment option when compared to non-surgical therapy.

High resolution MRI for quantitative assessment of inferior alveolar nerve impairment in course of mandible fractures: an imaging feasibility study.

The purpose of this study was to evaluate a magnetic resonance imaging (MRI) protocol for direct visualization of the inferior alveolar nerve in the setting of mandibular fractures. Fifteen patients suffering from unilateral mandible fractures involving the inferior alveolar nerve (15 affected IAN and 15 unaffected IAN from contralateral side) were examined on a 3 T scanner (Elition, Philips Healthcare, Best, the Netherlands) and compared with 15 healthy volunteers (30 IAN in total). The sequence protocol consisted of a 3D STIR, 3D DESS and 3D T1 FFE sequence. Apparent nerve-muscle contrast-to-noise ratio (aNMCNR), apparent signal-to-noise ratio (aSNR), nerve diameter and fracture dislocation were evaluated by two radiologists and correlated with nerve impairment. Furthermore, dislocation as depicted by MRI was compared to computed tomography (CT) images. Patients with clinically evident nerve impairment showed a significant increase of aNMCNR, aSNR and nerve diameter compared to healthy controls and to the contralateral side (p < 0.05). Furthermore, the T1 FFE sequence allowed dislocation depiction comparable to CT. This prospective study provides a rapid imaging protocol using the 3D STIR and 3D T1 FFE sequence that can directly assess both mandible fractures and IAN damage. In patients with hypoesthesia following mandibular fractures, increased aNMCNR, aSNR and nerve diameter on MRI imaging may help identify patients with a risk of prolonged or permanent hypoesthesia at an early time.

Laser-Assisted Indocyanine Green Imaging for Assessment of Perioperative Maxillary Perfusion During Le Fort I Osteotomy: A Pilot Study.

PURPOSE: To determine the changes in maxillary perfusion during different stages of Le Fort I osteotomies as measured by laser-assisted indocyanine green imaging (LAICGI) and to determine whether various clinical factors affect maxillary vascular perfusion. MATERIALS AND METHODS: The medical records of those who had undergone Le Fort I osteotomy with LAICGI at the University of Illinois from 2016 to 2017 were reviewed retrospectively. The maxillary perfusion levels using LAICGI were measured before induction, after induction, after down fracture, after segmentalization (for segmental osteotomies), and after wound closure. The effects of clinical variables, including gender, race, American Society of Anesthesiologists physical status, type of Le Fort I osteotomy, intraoperative status of the descending palatine vessels, maxillary movements (anteroposterior, vertical, transverse), and hemodynamic data (mean arterial blood pressure, heart rate), were analyzed. RESULTS: Compared with the preoperative baseline values, the indocyanine green (ICG) levels decreased after down fracture and mobilization, segmentalization, and wound closure; no statistically significant differences were found among these 3 points. Segmentalization did not affect the ICG levels compared with the nonsegmentalized cases. Male gender and the amount of maxillary impaction were significantly associated statistically with decreased ICG levels, although the difference was not clinically significant. CONCLUSIONS: Compared with the baseline levels, maxillary perfusion, as measured by LAICGI, decreased from down fracture to wound closure. Segmentalization did not appear to influence maxillary perfusion, although male gender and impaction were associated with decreased perfusion. Because of its safety and convenience, LAICGI shows promise as a method of assessing maxillary perfusion in future largescale prospective studies linking perioperative perfusion to the occurrence of aseptic necrosis.

Does Restriction of Public Health Care Dental Benefits Affect the Volume, Severity, or Cost of Dental-Related Hospital Visits?

PURPOSE: On July 1, 2012, the Illinois legislature passed the Save Medicaid Access and Resources Together (SMART) Act, which restricts adult public dental insurance coverage to emergency-only treatment. The purpose of this study was to measure the effect of this restriction on the volume, severity, and treatment costs of odontogenic infections in an urban hospital. MATERIALS AND METHODS: A retrospective cohort study of patients presenting for odontogenic pain or infection at the University of Illinois Hospital was performed. Data were collected using related International Classification of Diseases, Ninth Revision codes from January 1, 2011 through December 31, 2013 and divided into 2 cohorts over consecutive 18-month periods. Outcome variables included age, gender, insurance status, oral and maxillofacial surgery (OMS) consultation, imaging, treatment, treatment location, number of hospital admission days, and inpatient care level. Severity was determined by the presence of OMS consultation, incision and drainage, hospital admission, and cost per encounter. Hospital charges were used to compare the cost of care between cohorts. Between-patients statistics were used to compare risk factors and outcomes between cohorts. RESULTS: Of 5,192 encounters identified, 1,405 met the inclusion criteria. There were no significant differences between cohorts for age (P = .28) or gender (P = .43). After passage of the SMART Act, emergency department visits increased 48%, surgical intervention increased 100%, and hospital admission days increased 128%. Patients were more likely to have an OMS consult (odds ratio [OR] = 1.42; 95% confidence interval [CI], 1.11-1.81), an incision and drainage (OR = 1.48; 95% CI, 1.13-1.94), and a longer hospital admission (P = .04). The average cost per encounter increased by 20% and the total cost of care increased by $1.6 million. CONCLUSION: After limitation of dental benefits, there was an increase in the volume and severity of odontogenic infections. In addition, there was an escalated health care cost. The negative public health effects and increased economic impact of eliminating basic dental care show the importance of affordable and accessible preventative oral health care.

Subjective outcomes following sural nerve harvest.

PURPOSE: The goal of this study was to assess subjective patient recovery of donor site sensory deficit following sural nerve harvest for trigeminal nerve repair surgery. PATIENTS AND METHODS: A review of 42 consecutive sural nerve graft patient records yielded 26 patients, at least 20 months following sural nerve grafting for trigeminal nerve repair, who participated in a telephone questionnaire survey to assess subjective outcomes. The association between donor site outcome and other factors, including nerve graft recovery, age, gender, pain, cold sensitivity, scar cosmesis and tactile sensitivity, and legal involvement were analyzed, and presurgical and present levels of donor and nerve graft site sensibility were compared. RESULTS: The perceived area of donor site sensory deficit decreased significantly over time. Postoperative donor site pain and cold sensitivity at low levels were reported by few patients, and the majority have completely resolved. Most patients reported no problems with scar cosmesis or pain. There was a moderate agreement between donor site recovery and nerve graft recovery (kappa = 0.32). Few patients reported satisfaction with one site and not the other or complete dissatisfaction with both sites. Other factors such as age, gender, or legal involvement were not found to correlate with satisfaction level. CONCLUSIONS: The use of a questionnaire for subjective assessment of neurosensory recovery following nerve graft repair yields outcomes information that is generally not considered in the traditional clinical patient assessment. The majority of patients tolerate sural nerve harvest without significant donor site morbidity.