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Comparative Cost-Effectiveness Analysis of Sacral Anterior Root Stimulation for Rehabilitation of Bladder Dysfunction in Spinal Cord Injured Patients

Bénard, Antoine MD, PhD*; Verpillot, Elise PhD; Grandoulier, Anne-Sophie Msc*; Perrouin-Verbe, Brigitte MD, PhD§; Chêne, Geneviève MD, PhD*; Vignes, Jean-Rodolphe MD, PhD; the French study group on SARS

doi: 10.1227/NEU.0000000000000033
Research-Human-Clinical Studies

BACKGROUND: Urinary disorders account for 10% of deaths in patients with complete spinal cord injury. Sacral anterior root stimulation (SARS) may be a valuable therapeutic option to restore complete and voluntary micturition (CVM), but questions on its cost-effectiveness remain.

OBJECTIVE: To evaluate the cost-effectiveness of SARS to restore CVM in patients with complete spinal cord injury.

METHODS: We conducted a nonrandomized, multicenter, parallel-group cohort study comparing SARS vs current medical treatments with catheterization or reflex micturition. CVM was assessed at 12 months (end of follow-up) by urodynamic examination. Medical and nonmedical costs were measured in the perspective of the French national health insurance. Linear regression models were used to estimate the incremental net benefit (

; λ = willingness-to-pay) adjusted for potential confounders, and P (INB >0) (ie, probability of SARS being cost-effective vs medical treatment) for different values of λ.

RESULTS: Twenty-five patients were included in each group in 2005 to 2009. At inclusion, mean age was 41 years; 45 (90%) patients were male, and 29 (59%) patients were paraplegic. At 12 months, 15 (60%) patients with SARS had a CVM vs 3 (12%) patients with medical treatment (P < .001). The total mean cost was 42 803€ and 8762€, respectively (P < .001). After adjustment for CVM and voiding methods at inclusion, P (INB >0) was 74% at λ = 100 000€. This probability was 94% in a sensitivity analysis excluding 6 patients presenting a CVM at inclusion.

CONCLUSION: The effectiveness and cost of SARS are much higher than for medical treatment. Our results inform decision makers of the opportunity to reimburse SARS in this vulnerable population.

ABBREVIATIONS: BoNT-A, botulinum toxin A

CI, confidence interval

CVM, complete and voluntary micturition

ICER, incremental cost-effectiveness ratio

INB, incremental net monetary benefit

IQR, interquartile range

QALY, quality-adjusted life year

SARS, sacral anterior root stimulation

Author Information

*CHU Bordeaux, Pôle de Santé Publique, USMR et CIC-EC 7, Bordeaux, France;

Univ Bordeaux, Bordeaux School of Public Health, Groupe de Recherche Economie et Gestion en Santé Publique (GREGSAP), Bordeaux, France;

§CHU Nantes, Service de Médecine Physique et Réadaptation Neurologique, Nantes, France;

CHU Bordeaux, Service de Neurochirurgie A, Bordeaux, France; Université Bordeaux, Bordeaux, France

Correspondence: Antoine Bénard, MD, PhD, Pôle de Santé Publique du CHU de Bordeaux. Isped, Université Bordeaux Segalen, case 75. 146, rue Léo Saignat, 33076 Bordeaux, France. E-mail: and Jean-Rodolphe Vignes, MD, PHD, CHU de Bordeaux, hôpital Pellegrin, Service de Neurochirurgie A, Place Amélie Raba-Léon 33000 Bordeaux, France. E-mail:

Received January 3, 2013

Accepted June 4, 2013

Copyright © by the Congress of Neurological Surgeons