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Evaluating the Costs of Surgery versus Neurotoxin Injection for Management of Upper Extremity Spasticity
Benjamin L. Savitz, B.S.¹, Orlane Caro, MPH², Anvith P. Reddy, M.S.¹, Mariam Saad, M.D.¹, Daniel O'Neill, MD¹; Shady Elmaraghi, MD¹
(¹)Vanderbilt University Medical Center, Nashville, TN, (²)Meharry Medical College, Nashville, TN

INTRODUCTION

Upper extremity spasticity is a functionally limiting symptom of upper motor neuron syndrome leading to musculotendinous and joint contractures. We hypothesized that, in the long-term, neurectomy and tendon lengthening procedures are a more cost-effective option for management of upper extremity spasticity compared to neurotoxin therapy, which requires repeated clinic visits over a patient's lifetime despite limited efficacy in treating contractures.

MATERIALS & METHODS

Reimbursement rates based on Current Procedural Terminology (CPT) codes were queried from the Center of Medicare and Medicaid Services using Physician Fee Schedule 2024B. The average facility price was determined for each CPT code and used to estimate procedural costs (Table 1). The costs of different tendon lengthening procedures were estimated for direct comparisons as well as the average cost of tendon procedures at each anatomical level throughout the upper extremity. Neurotoxin injections were assumed to be given every three months when calculating cost estimates. All data analyses and figures were created using Python 3.13.1.

RESULTS

While neurotoxin initially appears less costly, its cumulative expense over 10- and 20-year periods far exceeds surgical costs. Similar cost advantages for surgery were observed across all anatomical levels, with break-even points often occurring around five years. For instance, 20 years of neurotoxin therapy for intrinsic hand spasticity was estimated to be $15,850 compared to $4,699 for surgical approaches (Figure 1). For extrinsic hand, neurotoxin therapy cost $15,850 over 20 years in comparison to $5,012 based on estimates for neurectomy and tendon procedures. Likewise, the cost of surgery for the elbow, forearm, and wrist flexors was $2,811, $1,135, and $2,206, respectively, while neurotoxin therapy over 20 years was projected to cost $8,649 at each.

Conclusions

Although surgical interventions for upper extremity spasticity involve higher initial costs, procedures such as hyperselective neurectomy and tendon lengthening achieve cost parity with neurotoxin therapy by approximately five years. Importantly, this analysis under-estimates the costs of repeated neurotoxin injections as drug costs are billed separately and not accounted for in procedural billing. These single-intervention approaches offer a cost-competitive alternative from a health systems perspective. Future studies should evaluate patient-centered costs to better inform shared decision-making.

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