Comparative Cost Analysis of Surgery Versus Neurotoxin Injection for Long-Term Management of Upper-Extremity...

Upper-extremity spasticity is a functionally limiting symptom of upper motor neuron syndrome that can lead to musculotendinous and joint contractures. Surgical interventions, including hyperselective and selective neurectomies, have shown sustained efficacy in treating the spastic upper limb and have recently gained notable traction. We hypothesized that, in the long-term, surgical procedures are a cost-effective option for management of upper-extremity spasticity compared with neurotoxin therapy.

Reimbursement rates were obtained from the Centers for Medicare and Medicaid Services Physician Fee Schedule using Current Procedural Terminology codes. Surgical costs incorporated both physician reimbursement and facility fees in hospital outpatient and Ambulatory Surgery Center settings, whereas neurotoxin costs included physician reimbursement and drug costs, modeled at 3-month intervals. Cost estimates were generated for each anatomic level of the upper extremity, with analyses and figures created using Python 3.13.1.

Although neurotoxin therapy incurred lower short-term expenses, cumulative costs surpassed surgical management across all anatomic levels. Cost-parity was consistently achieved around 5 years. Over 10 years, neurotoxin therapy ranged from $18,990 to $65,810, depending on the anatomic region treated, whereas average surgical management ranged from $4,009 to $24,880, with the lowest costs observed in ambulatory surgery centers. For example, repeated neurotoxin treatment for elbow spasticity reached $65,810 at 10 years versus $3,875 for hyperselective neurectomy in an Ambulatory Surgery Center.

Hyperselective neurectomy and tendon procedures provide a cost-effective treatment for the management of upper-extremity spasticity, as compared with widely accepted treatment standards of repeated neurotoxin injection. Although surgical interventions come with a high initial cost, cost-parity is reached when compared with 5 years of neurotoxin treatment. Future research should further investigate the utility, financial burden, and indirect costs of surgery and long-term neurotoxin therapy from a patient perspective.

Economic and decision analysis IV.