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.

Comparison of CT, MRI, and F-18 FDG PET/CT for initial N-staging of oral squamous cell carcinoma: a cost-effectiveness analysis.

BACKGROUND AND PURPOSE: Treatment of oral squamous cell carcinoma (OSCC) is based on clinical exam, biopsy, and a precise imaging-based TNM-evaluation. A high sensitivity and specificity for magnetic resonance imaging (MRI) and F-18 FDG PET/CT are reported for N-staging. Nevertheless, staging of oral squamous cell carcinoma is most often based on computed tomography (CT) scans. This study aims to evaluate cost-effectiveness of MRI and PET/CT compared to standard of care imaging in initial staging of OSCC within the US Healthcare System. METHODS: A decision model was constructed using quality-adjusted life years (QALYs) and overall costs of different imaging strategies including a CT of the head, neck, and the thorax, MRI of the neck with CT of the thorax, and whole body F-18 FDG PET/CT using Markov transition simulations for different disease states. Input parameters were derived from literature and willingness to pay (WTP) was set to US $100,000/QALY. Deterministic sensitivity analysis of diagnostic parameters and costs was performed. Monte Carlo modeling was used for probabilistic sensitivity analysis. RESULTS: In the base-case scenario, total costs were at US $239,628 for CT, US $240,001 for MRI, and US $239,131 for F-18 FDG PET/CT whereas the model yielded an effectiveness of 5.29 QALYs for CT, 5.30 QALYs for MRI, and 5.32 QALYs for F-18 FDG PET/CT respectively. F-18 FDG PET/CT was the most cost-effective strategy over MRI as well as CT, and MRI was the cost-effective strategy over CT. Deterministic and probabilistic sensitivity analysis showed high robustness of the model with incremental cost effectiveness ratio remaining below US $100,000/QALY for a wide range of variability of input parameters. CONCLUSION: F-18 FDG PET/CT is the most cost-effective strategy in the initial N-staging of OSCC when compared to MRI and CT. Despite less routine use, both whole body PET/CT and MRI are cost-effective modalities in the N-staging of OSCC. Based on these findings, the implementation of PET/CT for initial staging could be suggested to help reduce costs while increasing effectiveness in OSCC.

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.