Steps towards cost-benefit analysis of regional neurosurgical care.

OBJECTIVE: To determine the cost of averting death or severe disability by neurosurgical intervention. DESIGN: Retrospective analysis of one year's admissions for neurosurgery; comparison of outcome with expected outcome in the absence of neurosurgical intervention and with the cost of neurosurgery. SETTING: Wessex Neurological Centre. PATIENTS: 1026 Patients were admitted to the neurosurgical service in 1984. Of 1185 admissions, 978 case records were available and outcome was known in 919. MAIN OUTCOME MEASURES: Outcome was assessed with the Glasgow outcome scale, modified as necessary, from the case notes, or by letter follow up to the general practitioner. Expected outcomes for each of the 54 diagnoses were derived from both published reports where available and an expert panel of 18 consultant neurosurgeons. The cost of the neurosurgical service for 1983-4 was known from a separate study and the cost per patient was calculated using the length of stay. RESULTS: The cost of neurosurgery in 1983-4 was 1.8 million pounds. In all, 243 deaths or severe disabilities were estimated to have been averted at an average cost of 7325 pounds (range 5000 pounds to 70,000 pounds). The overall cost per quality adjusted life year (QALY) was 350 pounds (range 34 pounds to greater than 400,000 pounds). The cost of long term care for severely disabled survivors is at least 18-fold greater than the cost of neurosurgical intervention to avert such disability. CONCLUSIONS: In Britain neurosurgery is not expensive in comparison with the costs and benefits of other areas of medicine, and the cost per QALY is unexpectedly low except for severe diffuse head injury, malignant brain tumors, and cerebral metastases. The neurosurgical budget should be assessed in the context of managing a patient in hospital and subsequently in the community.

Spinal cord stimulation in peripheral vascular disease.

The results of ten patients with severe, intractable symptoms of arterial disease receiving spinal cord stimulation are reported. Six out of ten patients showed clinical improvement. Three of five patients with severe rest pain obtained complete or very marked relief and one of two patients with moderate rest pain in the legs obtained complete relief. The mean claudication distance in the ten patients increased from 65 to 212 metres during epidural stimulation of the spinal cord. Exercise tolerance as measured on a bicycle ergometer increased by 61%. These changes were associated with small increases in cutaneous and muscle blood flow. In those patients who responded clinically, the improvements seen were maintained as long as spinal cord stimulation was continued. There was no clinical response to transcutaneous (placebo) stimulation and four patients did not respond in any way to spinal cord stimulation. The improvements seen are unlikely to be due to either the natural history of the disease or to a placebo effect. The effect is probably due to antidromic stimulation of the central processes of the first order sensory neurons. It is suggested on the basis of animal studies that this effect may be mediated by release of prostaglandins as well as indirectly via pain relief.

Management of intracranial metastases.

Of 223 patients with intracranial metastases, 161 underwent removal of a presumed solitary lesion and 29 were treated by burr-hole biopsy. Results of radical surgery were better than those of biopsy alone in terms of survival. Quality and duration of survival were poorer in patients who had infratentorial metastases removed than in those who underwent surgery for supratentorial metastases. In this second group only patients with breast cancer benefited from surgery, though a few women with bronchial carcinoma also did well. The interval removal of a primary tumour and development of intracranial symptoms did not influence outcome. Evidence of a previous primary tumour should not lead to the assumption that intracranial symptoms are caused by a metastasis.

The place of ganglion or root alcohol injection in trigeminal neuralgia.

Of 157 patients with trigeminal neuralgia, referred for neurosurgery, 81 underwent 85 ganglion or root injections. The results, which are analysed with regard to pain relief and sensory loss, compare favourably with results from the literature of other forms of surgery, particularly open temporal root section.

Epidemiology of primary tumours of the brain and spinal cord: a regional survey in southern England.

This survey is based upon 894 patients presenting with primary tumours of the brain, spinal cord, and meninges, over a nine year period in the Wessex population of about 1 1/2 million. All patients were 15 years of age or over. Each tumour type is characterized by age, sex, district, social class, and by rural or urban distribution. Standardized morbidity ratios for each tumour type are calculated for each health district. Gliomas are the commonest tumour with an average annual incidence of 3.94 per 100,000; they occur with a lower frequency in large urban areas. Grade 3-4 astrocytomas (glioblastoma multiforme) have a peak annual incidence of 7.53 per 100,000 in the 50-59 years age group and are more common in males. The peak incidence for oligodendrogliomas is also 50-59 years but for grade 1-2 astrocytomas it is 30-39 years. Meningiomas have an average annual incidence of 1.23 per 100,000 with a peak incidence of 2.48 per 100,000 at 60-69 years; they have a female predominance (female 1.76 per 100,000; male of 0.64 per 100,000). Rural districts have a lower incidence of meningiomas than urban areas. There is some variation in the distribution of gliomas, meningiomas, and Schwannomas throughout the Wessex region and there is a suggestion of geographical clustering of ependymomas, acoustic neuromas, and meningiomas. An excess of patients with grade 1-2 astrocytomas and oligodendrogliomas is seen in social classes 1 and 2 and a deficit in classes 4-5; a similar, but less marked, preponderance is seen with meningiomas.

Lumbar spondylosis and neuropathic bladder: investigation of 73 patients with chronic urinary symptoms.

Seventy-three patients presented with either chronic urinary symptoms such as incontinence, retention, and recurrent urinary infection or chronic low back pain and neurogenic claudication. Lumbar spondylosis was considered to be the major cause of the urological and skeletal symptoms; the diagnosis of a neuropathic bladder depended as much on features in the history as on the results of urological and neurological investigations. The preoperative demonstration of significant lumbar spondylosis was often difficult, but decompressive laminectomy in 34 patients produced relief of urinary symptoms and improvement in bladder function in 75%.