Cost Effectiveness of Dural Sealants in Endoscopic Cerebrospinal Fluid Leak Repair

Objectives Various synthetic and autologous grafting materials are utilized for endoscopic repair of cerebrospinal fluid (CSF) leak repairs. These include fat or pericranium, dural grafts, such as collagen matrices, fibrin glue, fibrin sealant, and polyethylene glycol hydrogel dural sealants. The objective of our study was to use a cost effectiveness model to look at the efficacy of dural sealants, DuraSeal and Tisseel, in preventing CSF leak recurrence after repair.

Methods A decision tree was constructed to determine the incremental cost effectiveness ratio (ICER) of nasal septal flap with versus without the use of dural sealants. We performed a sensitivity analysis to calculate what the minimum cost of dural sealants would have to be to justify their effectiveness.

Results The results show that the overall cost of endoscopic CSF repair is $15,397 with average addition of $621 for use of dural sealants that lead to a 2.5% decrease in CSF leak recurrence. ICER of using sealants was $25,540, which is above acceptable WTP threshold of $20,000. Furthermore, the cost of dural sealants would have to be below $500 to justify the incremental gain in effectiveness in preventing CSF leaks postoperatively.

Conclusion In the current climate where medical costs are continuously rising, the need for cost effective medical techniques and practices is paramount. Results show the use of dural sealants is not a cost-effective measure to prevent recurrence of CSF leak repairs when simultaneously accounting for the cost and decrease in recurrence rate postoperatively. Given the current cost of commercially available dural sealants, majority of which are above $500, their cost does not justify their effectiveness based on our study. Some limitations to our study include lack of randomized controlled trials with a large sample size to better elucidate the long-term effectiveness of dural sealants. In addition, experience, familiarity, and technical skills play a significant role in closure of skull base and dural defects. Nonetheless, this is the first cost-effective study looking at dural sealants in preventing recurrence of CSF leak repairs.