A Descriptive Analysis of Spinal Cord Arteriovenous Malformations: Clinical Features, Outcomes, and Trends in Management.

BACKGROUND: Spinal arteriovenous malformations (AVM) are an abnormal interconnection of vasculature in the spine than can lead to significant neurologic deficit if left untreated. OBJECTIVE: The objective of this study was to characterize how patients with spinal AVM initially presented, what treatment options were used, and their overall outcomes on a national scale. METHODS: The MarketScan database was queried to identify adult patients diagnosed with a spinal AVM from 2007 to 2015. Trends in management, postoperative complication rates, and costs were determined. RESULTS: In total, 976 patients were identified with having a diagnosis of a spinal AVM. Patients were more commonly treated with an open incision than an embolization (40.1% vs. 15.4%). The overall complication rate was 33.61%. Spinal AVM admissions have been stable over the past decade, and mean cost of hospitalization has risen from of $48,700 in 2007 to $71,292 in 2015. Patients who underwent open surgery had a greater complication rate than those treated with embolization (31.15% vs. 18.25%, P < 0.005); however, this may be strongly influenced by complexity of spinal AVM pathology and not treatment modality. CONCLUSIONS: Costs of spinal AVM management continue to rise, even when treatment modalities have reduced length of stay significantly. Open surgery may lead to more postoperative complications and a greater length of stay than endovascular approaches. Further studies should look to identify the efficacy of endovascular approaches for spinal cord AVMs, particularly in complex spinal AVM traditionally treated with open surgery and to isolate factors leading to the elevated hospitalization costs.

Cost-Effectiveness Analysis of Percutaneous Sclerotherapy for Venous Malformations.

PURPOSE: To assess cost-effectiveness of sclerotherapy for venous malformations (VMs) to improve patient quality of life (QOL). MATERIALS AND METHODS: This prospective study enrolled 28 patients with symptomatic VMs who underwent sclerotherapy. EuroQol-5 Dimension (EQ-5D) and Short-Form 36 (SF-36) Health Survey were used to measure health-related QOL. Questionnaires were collected before and 1, 3, 6, and 12 months after sclerotherapy. Quality-adjusted life years (QALYs) were calculated using EQ-5D score as a measure of health utility. Medical costs obtained from the hospital accounting system and other costs of staff, drugs, materials, and angiographic equipment were calculated for each procedure. Cost-effectiveness was analyzed using incremental cost-effectiveness ratio (ICER) as the medical cost/gain of QALYs. RESULTS: Median EQ-5D scores improved from 0.768 (range, 0.705-1) to 1 (range, 0.768-1) after 6 months (P = .023) and 1 (range, 0.768-1) after 12 months (P = .063). The gain of QALYs at 12 months was 0.043. The mean medical cost was ¥281,228 ($2,337). The pain group (baseline bodily pain scale of SF-36 score < 70) showed greater improvement in median EQ-5D score, from 0.705 (range, 0.661-0.768) to 0.768 (range, 0.705-1) after 6 months (P = .041) and 0.768 (range, 0.768-1) after 12 months (P = .049). ICER at 12 months was ¥6,600,483 ($54,840) in the overall group and decreased to ¥3,998,113 ($33,218) in the pain group, < ¥6,000,000 ($49,850), threshold for acceptance of a public health benefit in Japan, even accounting for 50% increase in costs. CONCLUSIONS: Sclerotherapy was cost-effective for improving QOL for symptomatic VMs, especially for patients with moderate to severe pain.

Evaluación comparativa de efectividad y costo/efectividad en terapias alternativas para algunas lesiones vasculares encefálicas: experiencia del autor y revisión de la literatura / Comparative assessment of effectiveness and cost/effectiveness in alternative therapies to vascular encephalic lesions: author experience and review

Las patologías vasculares encefálicas quirúrgicas (aneurismas, malformaciones arterio venosas) han experimentado uno de los avances más importantes dentro de la medicina en las últimas décadas en materias de diagnóstico y tratamiento. Técnicas de introducción relativamente reciente y contemporánea, como la micro neurocirugía, la terapia endovascular encefálica y la radiocirugía, lograron mejorar en magnitudes las posibilidades de diagnóstico y los resultados de los tratamiento en estas lesiones. En este contexto parece de suma importancia definir el rol que juega cada uno de estos tratamientos en el manejo de la patología; así como la participación de los profesionales involucrados en la toma de decisiones muchas veces complejas y no exentas de controversia. El análisis de los resultados clínicos, la efectividad y la relación costo/efectividad son fundamentales para tener claridad en nuestro enfrentamiento como neurocirujanos tratantes. Este análisis debe interpretar la experiencia internacional en estas materias y a la vez revisar la experiencia local, hecho de suma importancia, que muchas veces dejamos rezagado en nuestro medio. Este estudio revisa los tópicos mencionados, incluyendo la experiencia del autor y un análisis exhaustivo de la bibliografía universal. Los resultados y las conclusiones podrán servir como herramienta a la hora de buscar referentes locales y foráneos que avalen con solidez nuestras conductas diagnósticas y terapéuticas.

Surgical vascular brain diseases (aneurysms, arterio venous malformations) have experienced one of the most important advances in medicine in the last decades related, to diagnosis and treatment. Recently and contemporary developed techniques, like micro neurosurgery, endovascular therapy and radiosurgery, have remarkably improved the diagnostic possibilities and the treatment outcomes in this lesions. In this context, it seems to be of the most importance to define the part that each treatment plays in the management of these diseases; and the participation of the professionals linked to the decision making in issues frequently complex and controversial. The analysis of clinical outcomes, the effectiveness and the cost/effectiveness ratio are basic to be clear in our approaches like neurosurgeons. This article reviews the international literature in these topics and, at the same time, the local experience, a fact of enormous importance that we use to left behind. The previously mentioned issues are reviewed, including the author's own experience and an exhaustive bibliographic analysis. Some of the results and conclusions included article should be useful tools when searching for local and foreign references to endorse with strength our diagnostic and therapeutic behaviour.