If you have a headache, you take a pain reliever pill. If you can’t sleep, you take a sleeping aid tablet. If you have essential tremor (ET), you may be prescribed pills—and you may not be happy with the results. Roughly 50% of persons with ET who try one or more medications s have unsatisfactory side effects, or their tremors eventually stop responding to the drugs (which is called medication refractory ET).
Neurosurgery to the rescue
When medication refractory tremors occur, it can be devastating. Where else can a person turn as ordinary tasks become frustrating, depressing and embarrassing hurdles? The doctor may recommend a neurosurgical procedure to bring medication-free rescue from a dire situation. The two main types are Deep Brain Stimulation (DBS) or MR-guided Focused Ultrasound (MRgFUS).
Deep Brain Stimulation (DBS)
DBS has earned a respectable history since its introduction in 1993. Since then, this hours-long surgical procedure has demonstrated long-term tremor symptom reduction of 40-80%, whether performed unilaterally or bilaterally. On the plus side, the stimulation settings can be adjusted (to balance tremor control vs side effects) and the operation can be reversed. On the minus side, DBS requires a hospital stay, and comes with risks of surgical complications, infection, need for battery replacement, displacement of electrodes in the brain, or other hardware-related issues. Any post-operative side effects requiring treatment or further surgeries add to the medical costs. In short, a lot of healthcare dollars go into DBS surgery, professional labor, recovery/follow-up, and possible future intervention.
MRI-guided Focused Ultrasound (MRgFUS)
Relatively speaking, MRgFUS is a fairly new kid on the neurosurgery block. The FDA approved MRgFUS for the treatment of ET in July, 2016. That’s nearly a quarter century after DBS, so it hasn’t had a lot of time to earn its stripes—yet it is rapidly gaining favor as an alternative to DBS. Its advantages include no cutting of skin or drilling holes in the skull because the ultrasound passes noninvasively into the targeted area; it is done as an outpatient procedure; immediate results require no further adjustment; no implants, no infection risk, and side effects (e.g. tingling) resolve quickly. As for disadvantages, some patients are claustrophobic in the MRI “tunnel”, some don’t like the idea that it’s irreversible, and it’s not yet covered universally by insurance so patients pay out-of-pocket. However, all patients who experience what feels like a miraculous transformation have no regrets over paying the bill.
Healthcare dollars: the bigger picture
The proven safety, effectiveness and comparative simplicity of MRgFUS vs. DBS for tremor control have gained it a quickly growing preference among patients who can’t have or don’t want an invasive neurosurgery. There is also another growing “fan club” among institutions, hospitals, clinics and individual doctors—as well as potential insurers—who are cost-conscious about medical costs. In fact, everyone who receives medical care should be economy-minded, because ultimately rising costs do get passed along to consumers. How do line item costs stack up for the two procedures?
|Procedure time||Neurosurgeon, nurses as needed||Neurosurgeon, MRI technician, physician assistant/other nurse|
|Procedure staff||3-6 hours (4 hr. avg)||2-4 hours|
|Medications/drugs||Anesthesiologist and drugs||Local anesthesia|
|Device costs||Stimulator leads, battery pack; CT imaging||MRI use|
|Recovery room time||Recovery room or intensive care 2-3 hours||Outpatient recovery 1 hour|
|Hospitalization||Yes 2-5 days||No|
|Possible after-effect risk management||Surgical complications, infection, brain bleeding, need for battery replacement, displacement of electrodes in the brain, or other device-related issues||Temporary after-effects generally self-resolve|
A Japanese study did a cost comparison within the Japanese healthcare system, based on a “cost-minimisation model, which assumes equal efficacy for each included procedure…comparing the costs of MRgFUS to unilateral DBS across a 12-month time horizon. The objective of conducting this economic analysis was to determine whether MRgFUS is cost saving versus unilateral DBS in the treatment of medication-refractory ET in Japan.”[i] As you are about to see the MRgFUS savings are considerable:
- In Japanese yen, MRgFUS costs 143,337 vs. DBS at 546,196 (per procedure)
- In Swedish krona, MRgFUS costs 48,000 vs DBS at 170,000 (per patient)
- In Canadian dollars, MRgFUS costs 23,507 vs DBS at 57,535 (per case)
- In U.S. dollars, MRgFUS saves $8,278 per procedure.[ii]
There are few published cost comparisons in the literature, so we are thankful that the Japanese team took the time to collect and analyze the cost data. At Sperling Neurosurgery Associates, we look forward to the day when MRgFUS is as little a financial burden on patients as it is on the healthcare system.
NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.
[i] Igarashi A, Tanaka M, Abe K, Richard L et al. Cost-minimisation model of magnetic resonance-guided focussed ultrasound therapy compared to unilateral deep brain stimulation for essential tremor treatment in Japan. PLoS One. 2019 Jul 17;14(7):e0219929.