Comparing Nerve Transfer Versus Tendon Transfer and Conservative Management for Restoring Finger Extension Following...

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.