Comparing Nerve Transfer Versus Tendon Transfer and Conservative Management for Restoring Finger Extension Following Tetraplegia: A Cost-Effectiveness Analysis
4 affiliations
- 1Department of Neurosurgery, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA 02118, USA
- 2School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
- 3Department of Orthopedic Surgery, University Medical Center, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
- 4Department of Hand and Microvascular Surgery, University Medical Center, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
Abstract
Background/Objectives: Cervical spinal cord injury (SCI) frequently causes tetraplegia and severe upper-limb dysfunction with substantial societal cost. Restoring finger extension is a priority, since even modest gains improve independence. Tendon transfer and supinator-to-posterior interosseous nerve transfer (SUP–PIN) both restore hand function, but their relative economic value is unclear. We assessed the lifetime cost-effectiveness of SUP–PIN versus tendon transfer and conservative management for finger extension in patients with mid-cervical SCIs who are candidates for both reconstructive strategies. Methods: A decision-analytic model combining a decision-tree front end with a lifetime Markov state-transition structure (one-year cycles, 3% annual discounting, half-cycle correction) compared SUP–PIN, tendon transfer, and conservative (nonoperative) care over a lifetime horizon, incorporating direct medical costs and indirect productivity losses. The outcomes were quality-adjusted life years (QALYs) accumulated over the horizon, using a willingness-to-pay threshold of $100,000/QALY. Success, complication, recovery, and return-to-work probabilities were drawn from the published literature. Deterministic, probabilistic, and two-way sensitivity analyses assessed robustness. Results: From the healthcare-sector perspective, conservative management was the least costly ($630.48; 14.84 QALYs) but least effective; nerve transfer was the most effective (18.55 QALYs) at $6485.84 and dominated tendon transfer, with an ICER versus conservative management of $1579/QALY, well below the $100,000/QALY threshold. From the societal perspective, nerve transfer was dominant, with the lowest lifetime cost ($903,937) and the highest effectiveness. Across the sensitivity analyses, nerve transfer was preferred under nearly all assumptions; tendon transfer was preferred only with ≥90% tendon success combined with ≤40% nerve-transfer success. Conclusions: In this decision-analytic model, SUP–PIN nerve transfer was projected to be economically favorable, yielding greater modeled effectiveness and lower lifetime costs than tendon transfer and conservative care under the stated assumptions. These modeled findings support further evaluation of nerve transfer in post-SCI rehabilitation algorithms and timely surgical referrals but do not, by themselves, establish clinical superiority, which requires a prospective comparative study.
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BibTeX
@article{sakthiyendran2026comparing,
title = {{Comparing Nerve Transfer Versus Tendon Transfer and Conservative Management for Restoring Finger Extension Following Tetraplegia: A Cost-Effectiveness Analysis}},
author = {Naveen Arunachalam Sakthiyendran and Caroline J. Cushman and Evan J. Hernandez and Brendan J. Mackay},
journal = {Journal of Clinical Medicine},
year = {2026},
month = oct,
doi = {10.3390/jcm15207849},
url = {https://www.mdpi.com/2077-0383/15/20/7849},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Comparing Nerve Transfer Versus Tendon Transfer and Conservative Management for Restoring Finger Extension Following Tetraplegia: A Cost-Effectiveness Analysis
AU - Naveen Arunachalam Sakthiyendran
AU - Caroline J. Cushman
AU - Evan J. Hernandez
AU - Brendan J. Mackay
PY - 2026
DA - 2026/10/01
JO - Journal of Clinical Medicine
DO - 10.3390/jcm15207849
UR - https://www.mdpi.com/2077-0383/15/20/7849
AB - Background/Objectives: Cervical spinal cord injury (SCI) frequently causes tetraplegia and severe upper-limb dysfunction with substantial societal cost. Restoring finger extension is a priority, since even modest gains improve independence. Tendon transfer and supinator-to-posterior interosseous nerve transfer (SUP–PIN) both restore hand function, but their relative economic value is unclear. We assessed the lifetime cost-effectiveness of SUP–PIN versus tendon transfer and conservative management for finger extension in patients with mid-cervical SCIs who are candidates for both reconstructive strategies. Methods: A decision-analytic model combining a decision-tree front end with a lifetime Markov state-transition structure (one-year cycles, 3% annual discounting, half-cycle correction) compared SUP–PIN, tendon transfer, and conservative (nonoperative) care over a lifetime horizon, incorporating direct medical costs and indirect productivity losses. The outcomes were quality-adjusted life years (QALYs) accumulated over the horizon, using a willingness-to-pay threshold of $100,000/QALY. Success, complication, recovery, and return-to-work probabilities were drawn from the published literature. Deterministic, probabilistic, and two-way sensitivity analyses assessed robustness. Results: From the healthcare-sector perspective, conservative management was the least costly ($630.48; 14.84 QALYs) but least effective; nerve transfer was the most effective (18.55 QALYs) at $6485.84 and dominated tendon transfer, with an ICER versus conservative management of $1579/QALY, well below the $100,000/QALY threshold. From the societal perspective, nerve transfer was dominant, with the lowest lifetime cost ($903,937) and the highest effectiveness. Across the sensitivity analyses, nerve transfer was preferred under nearly all assumptions; tendon transfer was preferred only with ≥90% tendon success combined with ≤40% nerve-transfer success. Conclusions: In this decision-analytic model, SUP–PIN nerve transfer was projected to be economically favorable, yielding greater modeled effectiveness and lower lifetime costs than tendon transfer and conservative care under the stated assumptions. These modeled findings support further evaluation of nerve transfer in post-SCI rehabilitation algorithms and timely surgical referrals but do not, by themselves, establish clinical superiority, which requires a prospective comparative study.
SN - 2077-0383
ER -