The investigators concluded that the 1-year outcomes were similar for patients assigned to early surgery and those assigned to conservative treatment with eventual surgery if needed, but the rates of pain relief and of perceived recovery were faster for those assigned to early surgery. A cochrane systematic review (2007) on surgical interventions for lumbar disc prolapse identified 40 randomized controlled trials and 2 quasi-randomized trials on the surgical management of lumbar disc prolapse. . However, the authors identified only 4 studies (Weber, 1983; Greenfield, 2003; Butterman, 2004; weinstein, 2006) that compared discectomy with conservative management. . The authors stated that these studies contain major design weaknesses, particularly on the issues of sample size, randomization, blinding, and duration of follow-up. . Furthermore, outcome measures in clinical studies of lbp have not been standardized making it difficult to compare the results of clinical studies of similar treatment. The first study (Weber, 1983) compared the results of surgical versus conservative treatment for lumbar disc herniation confirmed by radiculography (n 126) with 10 years of follow-up observation. . The author reported a significantly better result in the surgically treated group at the 1-year follow-up examination; however, after 4 years the difference was no longer statistically significant. .
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Dutch guidelines on the diagnosis and treatment of the lumbrosacral radicular syndrome (Stam, 1996) recommended the option of lumbar-disk surgery resume in patients who have sciatica if symptoms do not improve after 6 weeks of conservative assignments treatment. . to determine the optimal timing of surgery, investigators (Peul et al, 2007) randomly assigned patients (n 283) who had had severe sciatica for 6 to 12 weeks to early surgery or to prolonged conservative treatment with surgery if needed. . The primary outcomes were the score on the roland Disability questionnaire, the score on the visual analog scale for leg pain, and the patient's report of perceived recovery during the first year after randomization. . Repeated-measures analysis according to the intention-to-treat principle was used to estimate the outcome curves for both groups. . Of 141 patients assigned to undergo early surgery, 125 (89 ) underwent microdiskectomy after a mean.2 weeks. . Of 142 patients designated for conservative treatment, 55 (39 ) were treated surgically after a mean.7 weeks. . There was no significant overall difference in disability scores during the first year (p.13). Relief of leg pain was faster for patients assigned to early surgery (p.001). . Patients assigned to early surgery also reported a faster rate of perceived recovery (hazard ratio,.97; 95 confidence interval CI:.72.22;.001). In both groups, however, the probability of perceived recovery after 1 year of follow-up was. .
This approach is generally recommended for the treatment of slogan axial lbp in young individuals. . The usual criteria for consideration of an anterior lumbar fusion (or anterior lumbar arthroplasty) include a young person (i.e., age 20 to 40 years who on mri scan has either one or two dark discs, a concordant discogram indicating the axial pain is likely arising. However, according to ahrq (2006 the discogram remains highly controversial, and recent reports suggest that relying on the mri findings of a dark disc and limiting the discogram to just those levels may improve the definition of a "positive discorgram". . The ahrq assessment stated, "However, the high rate of false positives with normal disc spaces is problematic, as well as the high rate of prevalence of dark disc syndrome." As patients age into their 40s and 50s the disc and facet degenerative processes slowly worsen. Posterior fusion may be preferable for older individuals in order to stabilize facet joint disease. . However, the posterior approach involves significant muscle dissection, resulting in severe back pain in the post-operative period, and is avoided by some surgeons. The natural history of sciatica is favorable, with resolution of leg pain within 8 weeks from onset in the majority of patients (Peul et al, 2007). .
The addition of write fusion with or without instrumentation is considered when there are spondylolisthesis concerns about instability. . Open discectomy, performed with or without the use of an operating microscope, is the most common surgical technique applied, but there are now a number of other less invasive surgical approaches. . The surgical treatment of sciatica with discectomy is reportedly ineffective in a sizable percentage of patients, and re-herniation occurs after 5 to 15 of such procedures. . Thus, it would be ideal to define the optimal type of treatment for the specific types of prolapse (Carragee et al, 2003). Different fusion procedures, including anterior lumbar interbody fusion, posterolateral fusion, posterior lumbar interbody fusion and transforaminal lumbar interbody fusion, and anterior-posterior combined fusion, do not vary significantly in pain or disability outcomes, although there are qualitative differences in complications related to the surgical approach. . Prior to the 1980's both anterior and posterior non-insturmented lumbar fusions were commonly performed, using primarily bone graft. . As pedicle screws became more widely used, it was noted that the rate of fusion increased from 65 with bone graft alone to nearly 95 with the instrumentation to provide internal support for the bone graft. . The increased stiffness from the insertion of screws and rods has been hypothesized to lead to increased degeneration at spine segments adjacent to the fusion. Anterior spine procedures, through either the peritoneum or retroperitoneum, require no posterior muscle and ligamentous dissection and result in less post-operative axial back pain. .
Instrumented fusion is associated with enhanced fusion rates compared with non-instrumented fusion, but insufficient evidence exists to determine whether instrumented fusion improves clinical outcomes, and additional costs are substantial. . In addition, there is insufficient evidence to recommend a specific fusion method (anterior, posterolateral, or circumferential though more technically difficult procedures may be associated with higher rates of complications. In patients with persistent and disabling radiculopathy due to herniated lumbar disc or persistent and disabling leg pain due to spinal stenosis, the aps guideline recommended that clinicians discuss risks and benefits of surgery as an option (strong recommendation, high-quality evidence) (Chou et al, 2009). . It is recommended that shared decision-making regarding surgery include a specific discussion about moderate average benefits, which appear to decrease over time in patients who undergo surgery. The aps guideline explained that for persistent and disabling radiculopathy due to herniated lumbar disc, standard open discectomy and microdiscectomy are associated with moderate short-term (through 6 to 12 weeks) benefits compared to non-surgical therapy, though differences in outcomes in some trials are diminished. In addition, patients tend to improve substantially either with or without discectomy, and continued non-surgical therapy in patients who have had symptoms for at least 6 weeks does not appear to increase risk for cauda equina syndrome or paralysis. If conservative management fails to relieve symptoms of radiculopathy and there is strong evidence of dysfunction of a specific nerve root confirmed at the corresponding level by findings demonstrated by ct or mri, further evaluation and more invasive treatment, including spine surgery, may be proposed. The primary rationale of any form of surgery for disc prolapse is to provide decompression of the affected nerve root to relieve the individual's symptoms. . It involves the removal of all or part of the lamina of a lumbar vertebra. .
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It is unclear whether there is added health gain for this subgroup from either multiple or sequential use of therapies." In addition, the guidance stated that imaging is not necessary for the management of non-specific lbp. . An mri is appropriate only for people who have failed conservative care, including a combined physical and psychological treatment program, and are considering a referral for an opinion on spinal fusion. The American pain Society Clinical Practice guideline Interventional Therapies, surgery, and Interdisciplinary rehabilitation for Low Back pain (Chou et al, 2009) stated "rates of certain interventional and surgical procedures for back pain are rising. . However, it is unclear if methods for identifying specific anatomic sources of back pain are accurate, and effectiveness of some interventional therapies and surgery remains uncertain or controversial." Included in the guideline are the following recommendations. The aps guideline stated that, in patients with assignment chronic non-radicular lbp, provocative discography is not recommended as a procedure for diagnosing lbp (strong recommendation, moderate-quality evidence) (Chou et al, 2009).
In patients with non-radicular lbp who do not respond to usual, non-interdisciplinary interventions, the aps guideline recommended that clinicians consider intensive interdisciplinary rehabilitation with a cognitive/behavioral emphasis (strong recommendation, high-quality evidence) (Chou et al, 2009). In patients with non-radicular lbp, common degenerative spinal changes, and persistent and disabling symptoms, the aps guideline recommended that clinicians discuss risks and benefits of surgery as an option (weak recommendation, moderate-quality evidence) (Chou et al, 2009). The guideline recommended that shared decision-making regarding surgery for non-specific lbp include a specific discussion about intensive interdisciplinary rehabilitation as a similarly effective option, the small to moderate average benefit from surgery versus non-interdisciplinary non-surgical therapy, and the fact that the majority of such patients. The aps guideline explained that for persistent non-radicular lbp with common degenerative changes (e.g., degenerative disc disease fusion surgery is superior to non-surgical therapy without interdisciplinary rehabilitation in 1 trial, but no more effective than intensive interdisciplinary rehabilitation in 3 trials (Chou et al, 2009). . Compared with non-interdisciplinary, non-surgical therapy, average benefits are small for function (5-10 points on a 100-point scale) and moderate for improvement in pain (10-20 points on a 100-point scale). . Furthermore, more than half of the patients who undergo surgery do not experience an "excellent" or "good" outcome (i.e., no more than sporadic pain, slight restriction of function, and occasional analgesics). . Although operative deaths are uncommon, early complications occur in approximately 18 of patients who undergo fusion surgery in randomized trials. .
These include medical management (such as nsaids, etc. pain management, injections, physical therapy, exercise and various forms of cognitive rehabilitation. . Such conservative treatments are seldom applied in a comprehensive, well-organized rehabilitation program, although some such programs do exist. . Conservative treatments are usually tried for at least 6 to 12 months before surgery for any form of lumbar fusion is considered. . several reviews of these therapies noted that there is no evidence about the effectiveness of any of these therapies for low back or radicular pain beyond about 6 weeks. . In addition, the assessment stated that almost all lumbar spine surgery, including lumbar fusion, is performed to reduce the subjective individual symptoms of radiculopathy; thus, patient education to inform patients of their treatment options is considered critical.
The other indications for lumbar fusion focus on improvement in axial lumbar pain (i.e., near the midline and not involving nerve roots or leg pain). . These indications include lumbar instability, such as degenerative lumbar scoliosis, spondylolisthesis for axial pain alone, and for less common problems, such as discitis, lumbar flat back syndrome, neoplastic bone invasion and collapse, and chronic fractures, such as osteoporotic fractures which develop into burst fractures over. The assessment concluded that, "The evidence for lumbar spinal fusion does not conclusively demonstrate short-term or long-term benefits compared with non-surgical treatment, especially when considering patients over 65 years of age, for degenerative disc disease; for spondylolisthesis, considerable uncertainty exists due to lack of data. The guidance stated that one of the following treatment options should be offered to the patient: an exercise program, a course of manual therapy (i.e., spinal manipulation, spinal mobilization, massage a course of acupuncture, and pharmacological therapy. Referral to a combined physical and psychological treatment program may be appropriate for individuals who have received at least one less intensive treatment and have high disability and/or significant psychological distress. . The guidance stated "there is evidence that manual therapy, exercise and acupuncture individually are cost-effective management options compared with usual care for persistent non-specific low back pain. . The cost implications of treating people who do not respond to initial therapy and so receive multiple back care interventions are substantial. .
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Guidelines for the approach to the initial evaluation of lbp have been issued by the Agency for healthcare research and quality (1994) and similar conclusions were reached in systematic reviews (Jarvik et al, 2002; Chou et al, 2007; nice, 2009). . For adults less than 50 years of age with no signs or symptoms of systemic disease, symptomatic therapy without imaging is appropriate. For patients 50 years of age and older or those whose findings suggest slogan systemic disease, plain radiography and simple laboratory tests can almost completely rule out underlying systemic diseases. . Advanced imaging should be reserved for patients who are considering surgery or those in whom systemic disease is strongly suspected. . Conservative care without immediate imaging is also considered appropriate for patients with radiculopathy, as long as symptoms are not bilateral or associated with urinary retention. . Magnetic resonance imaging (MRI) should be performed if the latter symptoms are present or if patients do not improve with conservative therapy for 4 to 6 weeks. . Ninety percent of acute attacks of sciatica will resolve with conservative management within 4 to 6 weeks; only 5 remain disabled longer than 3 months (Gibson and Waddell, 2007; Lehrich and Sheon, 2007; ahcpr 1994). Conservative management for lbp includes: avoidance of activities that aggravate pain Chiropractic manipulation in the first 4 weeks if there is no radiculopathy cognitive support and reassurance that recovery is expected Education regarding spine biomechanics Exercise program heat/cold modalities for home use limited bed rest with gradual. For acute low back pain, the only therapy with good evidence of efficacy is superficial heat." According to a draft technology assessment prepared for the Agency for healthcare research and quality (ahrq) by the duke evidence-based Practice center on spinal fusion for treatment of degenerative.
For individuals with acute lbp, the precise etiology can be identified in only about 15 of cases (Lehrich et al, 2007). The initial evaluation of patients with lbp involves ruling out potentially serious conditions such as infection, malignancy, spinal fracture, or a rapidly progressing neurologic deficit suggestive of the cauda equina syndrome, bowel or bladder dysfunction, or weakness, which suggest the need for early diagnostic testing. . Patients without prime these conditions are initially managed with conservative therapy. The most common pathological causes of lbp are attributed to herniated lumbar discs (lumbar disc prolapse, slipped disc lumbar stenosis and lumbar spondylolisthesis (Lehrich and Sheon, 2007). Spondylolisthesis refers to the forward slippage of one vertebral body with respect to the one beneath. . This most commonly occurs at the lumbosacral junction with L5 slipping over S1, but it can occur at higher levels as well. . It is classified based on etiology into 5 types: dysplastic, defect in pars interarticularis, degenerative, traumatic, and pathologic. . The most common grading system for spondylolisthesis is the meyerding grading system for severity of slippage, which categorizes severity based upon measurements on lateral X-ray of the distance from the posterior edge of the superior vertebral body to the posterior edge of the adjacent inferior. The distance is then reported as a percentage of the total superior vertebral body length (see appendix).
should document that. The surgeon should discuss the disagreement with the provider who did the official interpretation, and there should also be a written addendum to the official report indicating agreement or disagreement with the operating surgeon. For use of mesenchymal stem cell therapy for spinal fusion, see cpb 0411 - bone and Tendon Graft Substitutes and Adjuncts. . For hybrid lumbar/cervical fusion with artificial disc replacement for the management of back and neck pain/spinal disorders, see cpb 0591 - intervertebral Disc Prostheses. . For use of evoked potentials in spinal surgery, see cpb 0181 - evoked Potential Studies. Background The lifetime incidence of low back pain (LBP) in the general population is reported to be 60 to 90 with annual incidence. . According to the national Center for health Statistics (Patel, 2007 each year,.3 of new patient visits to primary care physicians are for lbp, and nearly 13 million physician visits are related to complaints of chronic lbp. . The causes of lbp are numerous. .
Note that sagittal imbalance on standing radiographs of the spine are considered significant where there is: 1) as an offset of greater than 5 cm between the sagittal vertebral literature axis (a plumb line downward from the center of the C7 vertebral body) and the posterior superior aspect. Aetna considers lumbar spinal fusion experimental and investigational for degenerative disc disease and all other indications not listed above as medically necessary because of insufficient evidence of its effectiveness for these indications. Aetna considers spinal surgery in persons with prior spinal surgery medically necessary when any of the above criteria (i - v) is met. Aetna considers cervical and lumbar laminectomy and cervical fusion experimental and investigational for all other indications not listed above as medically necessary because of insufficient evidence of its effectiveness for these indications. Aetna considers cervical, thoracic and lumbar laminectomy and fusion experimental and investigational for all other indications not listed above as medically necessary because of insufficient evidence of its effectiveness for these indications. Medical records must document that a physical examination, including a neurologic examination, has been performed by or reviewed by the operating surgeon. For purposes of this policy, central stenosis is classified into grades: normal or mild changes (ligamentum flavum hypertrophy and/or osteophytes and/or or disk bulging without narrowing of the central spinal canal moderate stenosis (central spinal canal is narrowed but spinal fluid is still clearly visible between the. Similarly, foraminal stenosis is graded as: grade 0 refers to the absence of foraminal stenosis; mild foraminal stenosis (with some perineural fat obliteratio)n; moderate foraminal stenosis (showing perineural fat obliteration but no morphological changes and severe foraminal stenosis (showing nerve root collapse or morphological change). certain fusion procedures are considered experimental and investigational: for interlaminiar lumbar instrumented fusion (ilif coflex-f implant for lumbar fusion, and minimally invasive transforaminal lumbar interbody fusion (mitlif see cpb 16 - back pain: Invasive procedures.
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Number: 0743, policy, aetna considers cervical laminectomy (and/or an anterior cervical diskectomy, corpectomy and fusion) medically necessary for individuals with herniated discs or other causes of spinal cord or nerve root compression (osteophytic spurring, ligamentous hypertrophy) when all of the following criteria are met: All other reasonable sources of pain have been. Aetna considers thoracic laminectomy (and/or thoracic diskectomy and fusion) medically necessary for individuals with herniated discs or other causes of thoracic nerve root compression (osteophytic spurring, ligamentous hypertrophy) when all of the following criteria are met: All other reasonable sources of pain have been ruled out;. Aetna considers lumbar laminectomy medically necessary for individuals with a herniated disc when all of the following criteria are met: All other reasonable sources of pain have been ruled out; essay and, central/lateral recess or foraminal stenosis graded as moderate, moderate to severe or severe (not mild or mild. Aetna considers cervical, lumbar, or thoracic laminectomy medically necessary for any of the following: Spinal fracture, dislocation (associated with mechanical instability locked facets, or displaced fracture fragment confirmed by imaging studies (e.g., ct or mri or Spinal infection confirmed by imaging studies (e.g., ct or mri. Aetna considers lumbar decompression with or without discectomy medically necessary for rapid progression of neurological impairment (e.g., foot drop, extremity weakness, numbness or decreased sensation, saddle anesthesia, bladder dysfunction or bowel dysfunction) confirmed by imaging studies (e.g., ct or MRI). Aetna considers cervical spinal fusion medically necessary for any of the following: Cervical kyphosis associated with cord compression; or Symptomatic pseudarthrosis (non-union of prior fusion which is associated with radiological (e.g., ct or mri) evidence of mechanical instability or deformity of the cervical spine; or Spinal. Aetna considers thoracic spinal fusion medically necessary for any of the following: Scoliosis confirmed by imaging studies, with Cobb angle greater than 40 degrees in skeletally immature children and adolescents, or Cobb angle greater than 50 degrees associated with functional impairment in skeletally mature adults;. Aetna considers lumbar spinal fusion medically necessary for any of the following: Adult scoliosis, kyphosis, or pseudarthrosis (non-union of prior fusion which is associated with radiological (e.g., ct or mri) evidence of mechanical instability or deformity of the lumbar spine that has failed 3 months.