Nerve and Reconstruction Track: Hot-off-the-press and Abstract Session
GP5b - Is surgical repair with nerve allograft more cost-effective than non-surgical management of post-traumatic trigeminal neuropathy? Initial assessment with Markov model
Friday, September 16, 2022
11:00 AM – 11:10 AM CDT
Location: Great Hall BC, New Orleans Ernest N. Morial Convention Center
This session will present current practice guidelines for the diagnosis and management of patient with trigeminal nerve injuries. Is surgical repair with nerve allograft more cost-effective than non-surgical management of post-traumatic trigeminal neuropathy? Initial assessment with Markov model
The trigeminal nerve is at risk of injury during routine dental procedures. In rare cases, these injuries will persist with the risk of developing post-traumatic trigeminal neuropathy (PTTN). (1) PTTN has a significant impact on quality of life (QoL), with 36% of patients suffering from depression (2), and minimal benefit from medical therapy. (3) Nerve allograft repair of the inferior alveolar nerve (IAN) and lingual nerve has been shown to achieve functional sensory recovery (FSR) in ~90% of patients (4,5), but the direct costs of the procedure are high.
The purpose of this study is to answer the following question: In patients suffering from PTTN following iatrogenic nerve injury, is surgical repair with allogeneic nerve graft, when compared to non-surgical therapy, a more cost-effective treatment option? We utilized a Markov model to estimate the direct and indirect costs for treatment of trigeminal nerve injuries via surgical and non-surgical methods.
The Markov model was developed with TreeAge Pro Healthcare 2022. The model ran for 40 years with 1-year-cycles on a 40-year-old subject with persistent IAN or lingual nerve injury (S0-S2+) at 3 months without signs of improvement, and without dysesthesia or neuropathic pain (NPP). There were three disease states, FSR (S3-S4), hypoesthesia/anesthesia (S0-S2+), and NPP; in addition, there were two treatments (surgical vs. non-surgical therapy). Direct surgical costs were calculated using the 2022 Physician Fee Reference (75th percentile) and verified with standard institutional billing practices. Non-surgical treatment direct costs (follow-up, specialist referral, medications, imaging) and indirect costs (quality of life, loss of employment) were determined from historical data. Direct surgical costs for allograft repair was $33,638, and direct costs of non-surgical treatment was $1,874.52 per year for hypoesthesia/anesthesia, and $2,478.00 per year for NPP. Indirect costs for non-surgical treatment included decreased labor force participation (OR 0.534), absenteeism (OR 2.471), and decreased QoL (EQ-Health 0.64).
Surgical treatment with nerve allograft was more effective and had a lower long-term cost. The incremental cost-effectiveness ratio (ICER) was -6694.87, indicating surgical treatment should be utilized based on efficiency (Table 1). With a willingness-to-pay of $50,000, the net monetary benefits of surgical treatment is $1,132,283 compared to $851,000 for non-surgical treatment. Cost-equivalency occurred at 15 years, however cost-effectiveness ratio occurs at 12 years due to the high effectiveness of surgical treatment (Table 2). With a standard threshold ICER of $50,000, the sensitivity analysis shows that surgical treatment would remain the preferred choice based on efficiency even with doubling of the direct surgical costs (Table 3).
Despite high initial costs of surgical treatment of nerve injuries with allograft repair, it is a more cost-effective treatment option when compared to non-surgical interventions by 12 to 15 years.
1. International Classification of Orofacial Pain, 1st edition (ICOP). Cephalalgia. 2020;40(2):129-221. 2. Melek LN, Smith JG, Karamat A, Renton T. Comparison of the Neuropathic Pain Symptoms and Psychosocial Impacts of Trigeminal Neuralgia and Painful Posttraumatic Trigeminal Neuropathy. J Oral Facial Pain Headache. 2019;33(1):77-88. 3. Haviv Y, Zadik Y, Sharav Y, Benoliel R. Painful traumatic trigeminal neuropathy: an open study on the pharmacotherapeutic response to stepped treatment. J Oral Facial Pain Headache. 2014;28(1):52-60. 4. Miloro M, Ruckman P, Kolokythas A. Lingual Nerve Repair: To Graft or Not to Graft? J Oral Maxillofac Surg Off J Am Assoc Oral Maxillofac Surg. 2015;73(9):1844-1850. 5. Yampolsky A, Ziccardi V, Chuang SK. Efficacy of Acellular Nerve Allografts in Trigeminal Nerve Reconstruction. J Oral Maxillofac Surg Off J Am Assoc Oral Maxillofac Surg. 2017;75(10):2230-2234.