title: The cost-effectiveness of surgery for trigeminal neuralgia in surgically naïve patients: a retrospective study.
abstract: OBJECTIVE
  For 75% of patients with trigeminal neuralgia (TN), the pain can be controlled with medication. For those who fail medication therapy, surgical options include microvascular decompression (MVD), percutaneous radiofrequency rhizotomy (RFR), and stereotactic radiosurgery (SRS). Few studies have explored the relative cost-effectiveness of these interventions, particularly in surgically naïve patients.
  
  
  METHODS
  A retrospective chart review performed between January 2003 and January 2013 identified a total of 89 patients who underwent surgical treatment for TN (MVD=27, RFR=23, SRS=39). Outcome measures included facial pain (excellent=no pain, no medications; good=no pain, medications required; fair=>50% decrease in pain; and poor=<50% decrease in pain/secondary surgery), numbness, cost, and the need for a subsequent procedure.
  
  
  RESULTS
  The average age of patients for each procedure was MVD=53.9±16, RFR=76.2±16, and SRS=74.5±12 (p<0.001 MVD vs. other modalities). Total charges for the procedures (US dollars) were MVD=50,100±9600, RFR=4700±2200, and SRS=39,300±6000 (p<0.001). Actual collections varied by insurance. Percentages of postoperative facial numbness were MVD=11%, RFR=52%, and SRS=28% (p<0.01). At two years, the rates of recurrence requiring a second procedure were MVD=22%, RFR=74%, and SRS=31% (p<0.01). Average times to secondary procedure in months were MVD=26±29, RFR=59±76, and SRS=35±25. Mean quality adjusted pain-free years were MVD=1.58, RFR=2.28, and SRS=0.99. Cost-effectiveness calculations in US dollars showed MVD=31,800, RFR=2100, and SRS=39,600 (p<0.001).
  
  
  CONCLUSIONS
  There are significant cost differences among the three most common surgical procedures for TN. MVD was the most expensive procedure, was more likely to be performed on younger patients, had the lowest rate of facial numbness, and had the lowest rate of recurrence requiring a secondary procedure. SRS was slightly less costly, more likely to be performed on an older population, and had a rate of recurrence similar to MVD. RFR was the least expensive procedure, provided immediate relief, but was associated with the highest rates of facial numbness and recurrence. Based on cost-effectiveness, considering both cost and outcome, RFR was the most cost-effective, followed by MVD, and finally SRS.
authors.affiliation: Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA, United States.
authors.forename: Marshall
authors.initials: M
authors.lastname: Holland
authors.affiliation: Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA, United States.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Noeller
authors.affiliation: Department of Radiation Oncology, University of Iowa Carver College of Medicine, Iowa City, IA, United States.
authors.forename: John
authors.initials: J
authors.lastname: Buatti
authors.affiliation: Department of Neurology and Neurosciences, Rutgers-New Jersey Medical School, Newark, NJ, United States.
authors.forename: Wenzhuan
authors.initials: W
authors.lastname: He
authors.affiliation: Department of Neurology, University of Iowa Carver College of Medicine, Iowa City, IA, United States.
authors.forename: E Torage
authors.initials: ET
authors.lastname: Shivapour
authors.affiliation: Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA, United States. Electronic address: patrick-hitchon@uiowa.edu.
authors.forename: Patrick W
authors.initials: PW
authors.lastname: Hitchon
mesh_terms: D000328:Adult; D000368:Aged; D003362:Cost-Benefit Analysis; D005260:Female; D006801:Humans; D008297:Male; D061145:Microvascular Decompression Surgery / Q000191:economics / Q000379:methods; D008875:Middle Aged; D010361:Patients / Q000706:statistics & numerical data; D016634:Radiosurgery / Q000191:economics*; D012189:Retrospective Studies; D016896:Treatment Outcome; D014277:Trigeminal Neuralgia / Q000191:economics* / Q000601:surgery*
keywords: Cost-effectiveness; Radiosurgery; Surgery; Trigeminal neuralgia