Spinal Surgery: Laminectomy and Fusion

Spinal Surgery: Laminectomy and Fusion 5/2/17, 9:17 AM
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Spinal Surgery: Laminectomy and

Fusion
Number:(0743
Policy History
Policy
I.# Aetna#considers#cervical#laminectomy#(and/or Last(Review #03/29/2017#
an#anterior#cervical#diskectomy,#corpectomy#and Eec=ve:#12/14/2007
fusion)#medically#necessary#for#individuals#with#herniated Next#Review:#09/23/2018
discs#or#other#causes#of#spinal#cord#or#nerve#root
compression#(osteophy=c#spurring,#ligamentous Review(History #
hypertrophy)#when#all#of#the#following#criteria#are#met:
A.# All#other#reasonable#sources#of#pain#have#been#ruled Deni>ons
out;#and
B.# Presence#of#neck#or#cervicoDbrachial#pain#with#ndings
of#weakness,#myelopathy,#or#sensory#decit;#and
C.# Central,#lateral#or#recess#stenosis#graded#as#moderate, Additional
moderate#to#severe#or#severe#(not#mild#or#mild#to Information
moderate);#and%
D.# Imaging#studies#(e.g.,#CT#or#MRI)#indicate#nerve#root Clinical(Policy(Bulle>n
or#spinal#cord#compression,#at#the#level#corresponding Notes
with#the#clinical#ndings;#and#
E.# Member#has#failed#at#least#6#weeks#of#conserva=ve
http://www.aetna.com/cpb/medical/data/700_799/0743.html?TLAE0026956c4d00000000000000000000000000005908361200c03b28ac Page 1 of 92
therapy*#(unless#there#is#evidence#of#cervical#cord
compression,#which#requires#urgent#interven=on);#and
F.# Member#has#physical#and#neurological#abnormali=es
conrming#the#historical#ndings#of#nerve#root#or
spinal#cord#compression#(e.g.,#reex#change,#sensory
loss,#weakness)#at#or#below#the#level#of#the#lesion#and
may#have#gait#or#sphincter#disturbance#(evidence#of
cervical#radiculopathy#or#myelopathy);#and
G.# Member's#ac=vi=es#of#daily#living#are#limited#by
persistent#neck#or#cervicoDbrachial#pain.
II.# 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#(osteophy=c#spurring,
ligamentous#hypertrophy)#when#all#of#the#following
criteria#are#met:
A.# All#other#reasonable#sources#of#pain#have#been#ruled
out;#and
B.# Presence#of#thoracic#pain#secondary#to#nerve#root#or
spinal#cord#compression#with#ndings#of#weakness,
myelopathy,#or#sensory#decit;#and
C.# Central,#lateral#or#recess#stenosis#graded#as#moderate,
moderate#to#severe#or#severe#(not#mild#or#mild#to
moderate);#and%
D.# Imaging#studies#(e.g.,#CT#or#MRI)#indicate#nerve#root
or#spinal#cord#compression,#at#the#level#corresponding
with#the#clinical#ndings;#and
E.# Member#has#failed#at#least#6#weeks#of#conserva=ve
therapy*#(unless#there#is#evidence#of#thoracic#cord
compression#with#progression,#which#requires#urgent
interven=on);#and
F.# Member#has#physical#and#neurological#abnormali=es
conrming#the#historical#ndings#of#nerve#root#or
spinal#cord#compression#(e.g.,#reex#change,#sensory
loss,#weakness)#at#or#below#the#level#of#the#lesion#and
may#have#gait#or#sphincter#disturbance#(evidence#of
thoracic#radiculopathy#or#myelopathy);#and
G.# Member's#ac=vi=es#of#daily#living#are#limited#by
persistent#pain.
#
III.# Aetna#considers#lumbar#laminectomy#medically#necessary
for#individuals#with#a#herniated#disc#when#all#of#the
following#criteria#are#met:
#
A.# All#other!reasonable#sources#of#pain#have#been#ruled
out;#and#
B.# Central,#lateral#or#recess#stenosis#graded#as#moderate,
moderate#to#severe#or#severe#(not#mild#or#mild#to
moderate);#and%
C.# Imaging#studies#(e.g.,#CT#or#MRI)#indicate#nerve#root
compression,#that#corresponds#to#the#clinical#ndings
of#the#specic#aected#nerve#root;#and
D.# Member#has#failed#at#least#6#weeks#of#conserva=ve
therapy*;#and
E.# Member's#ac=vi=es#of#daily#living#are#limited#by
persistent#pain#radia=ng#from#the#back#down#to#the
lower#extremity;#and
F.# Presence#of#neurological#abnormali=es#(e.g.,#reex
change,#posi=ve#straight#leg#raising,#sensory#loss,
weakness)#persist#on#examina=on#and#correspond#to
the#specic#aected#nerve#root.
#
IV.# Aetna#considers#cervical,#lumbar,#or#thoracic
laminectomy#medically#necessary#for#any#of#the
following:
A.# Spinal#fracture,#disloca=on#(associated#with
mechanical#instability),#locked#facets,#or#displaced
fracture#fragment#conrmed#by#imaging#studies#(e.g.,
CT#or#MRI);#or
B.# Spinal#infec=on#conrmed#by#imaging#studies#(e.g.,#CT
or#MRI);#or
C.# Spinal#tumor#conrmed#by#imaging#studies#(e.g.,#CT#or
MRI);#or
D.# Epidural#hematomas#conrmed#by#imaging#studies
(e.g.,#CT#or#MRI);#or
E.# Synovial#cysts,#or#arachnoid#cysts#causing#spinal#cord
or#nerve#root#compression#with#unremi`ng#pain,
conrmed#by#imaging#studies#(e.g.,#CT#or#MRI)
and#with#corresponding#neurological#decit,#where
symptoms#have#failed#to#respond#to#six#weeks#of
conserva=ve#therapy*#(unless#there#is#evidence#of
cord#compression,#or#progressive#neurological#decit,
which#requires#urgent#interven=on)#or
F.# Spinal#stenosis#(recess,#foraminal,#central
stenosis)#graded#as#moderate,#moderate#to#severe#or
severe#(not#mild#or#mild#to#moderate)#with
unremi`ng#pain,#with#stenosis#conrmed#by#imaging
studies#(e.g.,#CT#or#MRI)#at#the#level#corresponding
to#neurological#ndings,#where#symptoms#have#failed
to#respond#to#three#months#of#conserva=ve#therapy*
(unless#there#is#evidence#of#cord#compression,#or
progressive#neurological#decit,#which#requires#urgent
interven=on);#or
G.# Other#mass#lesions#conrmed#by#imaging#studies#(e.g.,
CT#or#MRI),#upon#individual#case#review.
#
V.# 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#sensa=on,#saddle
anesthesia,#bladder#dysfunc=on#or#bowel#dysfunc=on)
conrmed#by#imaging#studies#(e.g.,#CT#or##MRI).
VI.# Aetna#considers#cervical#spinal#fusion#medically
necessary#for#any#of#the#following:
A.# Cervical#kyphosis#associated#with#cord#compression;
or
B.# Symptoma=c#pseudarthrosis#(nonDunion#of#prior
fusion),#which#is#associated#with#radiological#(e.g.,#CT
or#MRI)#evidence#of#mechanical#instability#or
deformity#of#the#cervical#spine;#or
C.# Spinal#fracture,#disloca=on#(associated#with
CT#or#MRI),#which#may#be#combined#with#a
laminectomy;#or
D.# Spinal#infec=on#conrmed#by#imaging#studies#(e.g.,#CT
or#MRI)#and/or#other#studies#(e.g.,#biopsy),#which#may
be#combined#with#a#laminectomy;#or
E.# Spinal#tumor,#primary#or#metasta=c#to#spine,
conrmed#by#imaging#studies#(e.g.,#CT#or#MRI),#which
may#be#combined#with#a#laminectomy;#or
F.# Atlantoaxial#(C1DC2)#subluxa=on#(e.g.,#associated
with#congenital#anomaly,#os#odontoideum,#or
rheumatoid#arthri=s)#noted#as#widening#of#the
atlantodens#interval#greater#than#3#mm#conrmed#by
imaging#studies#(e.g.,#CT#or#MRI);#or
G.# Basilar#invagina=on#of#the#odontoid#process#into#the
foramen#magnum;#or
H.# Subaxial#(C2DT1)#instability#conrmed#by#imaging
studies,#when#both%of#the#following#are#met:
1.# Signicant#instability#(sagical#plane#transla=on#of
at#least#3#mm#on#exion#and#extension#views#or
rela=ve#sagical#plane#angula=on#greater#than#11
degrees);#and
2.# Symptoma=c#unremi`ng#pain#that#has#failed#3
months#of#conserva=ve#management*;#or
I.# Adjunct#to#excision#of#synovial#cysts#causing#spinal
cord#or#nerve#root#compression#with#unremi`ng#pain,
conrmed#by#imaging#studies#(e.g.,#CT#or#MRI)
and#with#corresponding#neurological#decit,#where
symptoms#have#failed#to#respond#to#six#weeks#of
conserva=ve#therapy*#(unless#there#is#evidence#of
cord#compression,#or#progressive#neurological#decit,
which#requires#urgent#interven=on)#or
J.# Clinically#signicant#deformity#of#the#spine#(kyphosis,
headDdrop#syndrome,#postDlaminectomy#deformity)
that#meets#any#of#the#following#criteria:
1.# The#deformity#prohibits#forward#gaze;#or
2.# The#deformity#is#associated#with#severe#neck#pain,
diculty#ambula=ng,#and#interference#with
ac=vi=es#of#daily#living;#or
3.# Documented#progression#of#the#deformity.
VII.# Aetna#considers#thoracic#spinal#fusion#medically
necessary#for#any#of#the#following:
A.# Scoliosis#conrmed#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#func=onal#impairment#in
skeletally#mature#adults;#or
B.# Thoracic#kyphosis#resul=ng#in#spinal#cord#compression,
or#kypho=c#curve#greater#than#75#degrees#that#is
refractory#to#bracing;#or
C.# Symptoma=c#pseudarthrosis#(nonDunion#of#prior
fusion),#which#is#associated#with#radiological#(e.g.,#CT
or#MRI)#evidence#of#mechanical#instability#or
deformity#of#the#thoracic#spine#that#has#failed#3
D.# Spinal#fracture,#disloca=on#(associated#with
laminectomy;#or
E.# Spinal#infec=on#conrmed#by#imaging#studies#(e.g.,#CT
F.# Spinal#tumor,#primary#or#metasta=c#to#spine,
conrmed#by#imaging#studies#(e.g.,#CT#or#MRI),#which
may#be#combined#with#a#laminectomy;#or
G.# Spondylolisthesis#with#segmental#instability#conrmed
by#imaging#studies#(e.g.,#CT#or#MRI),#when#both#of#the
following#criteria#are#met:#
##
1.# Signicant#spondylolisthesis,#grades#II,#III,#IV,#or#V
(see#appendix);#and
2.# Symptoma=c#unremi`ng#pain#that#has#failed#6
months#of#conserva=ve#management*;##or
#
H.# Spinal#stenosis#graded#as#moderate,#moderate#to
severe,#or#severe#(not#mild#or#mild#to#moderate)#with
unremi`ng#pain#conrmed#by#imaging#studies#(e.g.,
CT#or#MRI)#that#has#failed#3#months#of#conserva=ve
management*#when#any#of#the#following#is#met:#
#
1.# Decompression#is#performed#in#an#area#of
segmental#instability#as#manifested#by#gross
movement#on#exionDextension#radiographs;#or
2.# Decompression#coincides#with#an#area#of
signicant#degenera=ve#instability#(e.g.,#scoliosis#or
any#degree#of#spondylolisthesis#(grades#I,#II,#III,#IV
or#V);#or
3.# Decompression#creates#an#iatrogenic#instability#by
the#disrup=on#of#the#posterior#elements#where
facet#joint#excision#exceeds#50%#bilaterally#or
complete#excision#of#one#facet#is#performed.
#
VIII.# Aetna#considers#lumbar#spinal#fusion#medically#necessary
for#any#of#the#following:
A.# Adult#scoliosis,#kyphosis,#or#pseudarthrosis#(nonDunion
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
B.# Iatrogenic#or#degenera=ve#atback#syndrome#with
signicant#sagical#imbalance,#when#fusion#is
performed#with#spinal#osteotomy;#or
C.# Spinal#fracture,#disloca=on#(associated#with
laminectomy;#or
D.# Spinal#infec=on#conrmed#by#imaging#studies#(e.g.,#CT
E.# Spinal#tumor#conrmed#by#imaging#studies#(e.g.,#CT#or
MRI),#which#may#be#combined#with#a#laminectomy;#or
F.# Spondylolisthesis#with#segmental#instability#conrmed
by#imaging#studies#(e.g.,#CT#or#MRI),#when#both#of#the
following#criteria#are#met:
#
1.# Signicant#spondylolisthesis,#grades#II,#III,#IV,#or#V
(see#appendix);#and#
2.# Symptoma=c#unremi`ng#low#back#pain,
radiculopathy#or#neurogenic#claudica=on#that#has
failed#6#months#of#conserva=ve#management*;##or
G.# Spinal#stenosis#graded#as#moderate,#moderate#to
severe#or#severe#(not#mild#or#mild#to#moderate)#with
unremi`ng#pain#conrmed#by#imaging#studies#(e.g.,
CT#or#MRI)#that#has#failed#3#months#of#conserva=ve
management*#when#any#of#the#following#is#met:
1.# Decompression#is#performed#in#an#area#of
segmental#instability#as#manifested#by#gross
movement#on#exionDextension#radiographs;#or#
2.# Decompression#coincides#with#an#area#of
signicant#degenera=ve#instability#(e.g.,#scoliosis#or
any#degree#of#spondylolisthesis#(grades#I,#II,#III,#IV
or#V);#or#
3.# Decompression#creates#an#iatrogenic#instability#by
the#disrup=on#of#the#posterior#elements#where
facet#joint#excision#exceed#50%#bilaterally#or
complete#excision#of#one#facet#is#performed.
IX.# Aetna#considers#lumbar#spinal#fusion#experimental#and
inves=ga=onal#for#degenera=ve#disc#disease#and#all#other
indica=ons#not#listed#above#as#medically
necessary#because#of#insucient#evidence#of#its
eec=veness#for#these#indica=ons.
X.# Aetna#considers#spinal#surgery#in#persons#with#prior
spinal#surgery#medically#necessary#when#any#of#the
above#criteria#(I#D#V)#is#met.
#
XI.# Aetna#considers#cervical#and#lumbar#laminectomy#and
cervical#fusion#experimental#and#inves=ga=onal#for#all
other#indica=ons#not#listed#above#as#medically#necessary
because#of#insucient#evidence#of#its#eec=veness#for
these#indica=ons.
XII.# Aetna#considers#cervical,#thoracic#and#lumbar
laminectomy#and#fusion#experimental#and#inves=ga=onal
for#all#other#indica=ons#not#listed#above#as#medically
necessary#because#of#insucient#evidence#of#its
eec=veness#for#these#indica=ons.
*#Conserva=ve#measures#must#include#the#following#nonD
surgical#measures#and#medica=ons#unless#neurologic#signs
are#severe#or#rapidly#progressive:#pa=ent#educa=on;#ac=ve
physical#therapy;#medica=ons#(NSAIDS,#acetaminophen,#or
tricyclic#an=depressants),#and#(where
appropriate)#iden=ca=on#and#management#of#associated
anxiety#and#depression.
**#Medical#records#must#document#that#a#physical
examina=on,#including#a#neurologic#examina=on,#has#been
performed#by#or#reviewed#by#the#opera=ng#surgeon.
#For#purposes#of#this#policy,#central#stenosis#is#classied
into#grades:#normal#or#mild#changes#(ligamentum#avum
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#uid#is
s=ll#clearly#visible#between#the#nerve#roots#in#the#dural#sac);
severe#stenosis#(central#spinal#canal#is#narrowed#and#there#is
only#a#faint#amount#of#spinal#uid#or#no#uid#between#the
nerve#roots#in#the#dural#sac).#Similarly,#foraminal#stenosis#is
graded#as:#grade#0#refers#to#the#absence#of#foraminal
stenosis;#mild#foraminal#stenosis#(with#some#perineural#fat
oblitera=o)n;#moderate#foraminal#stenosis#(showing
perineural#fat#oblitera=on#but#no#morphological#changes);
and#severe#foraminal#stenosis#(showing#nerve#root#collapse
or#morphological#change).
#Certain#fusion#procedures#are#considered#experimental
and#inves=ga=onal:#for#interlaminiar#lumbar#instrumented
fusion#(ILIF),#CoexDF#implant#for#lumbar#fusion,#and
minimally#invasive#transforaminal#lumbar#interbody#fusion
(MITLIF),#see#CPB(16(J(Back(Pain:(Invasive(Procedures
(../1_99/0016.html).#Also#see#CPB(772(J(Axial(Lumbar
Interbody(Fusion((AxiaLIF)((0772.html).
Notes:#For#purposes#of#this#policy,#Aetna#will#consider#the
ocial#wricen#report#of#complex#imaging#studies#(e.g.,#CT,
MRI,#myelogram).#If#the#opera=ng#surgeon#disagrees#with
the#ocial#wricen#report,#the#surgeon#should#document
that.disagreement.#The#surgeon#should#discuss#the
disagreement#with#the#provider#who#did#the#ocial
interpreta=on,#and#there#should#also#be#a
wricen#addendum#to#the#ocial#report#indica=ng
agreement#or#disagreement#with#the#opera=ng#surgeon.#
For#use#of#mesenchymal#stem#cell#therapy#for#spinal#fusion,
see#CPB(0411(J(Bone(and(Tendon(GraV(Subs>tutes(and
Adjuncts((../400_499/0411.html).##For#hybrid
lumbar/cervical#fusion#with#ar=cial#disc#replacement#for
the#management#of#back#and#neck#pain/spinal#disorders,#see
CPB(0591(J(Intervertebral(Disc(Prostheses
(../500_599/0591.html).##For#use#of#evoked#poten=als#in
spinal#surgery,#see#CPB(0181(J(Evoked(Poten>al(Studies
(../100_199/0181.html).
Background
The#life=me#incidence#of#low#back#pain#(LBP)#in#the#general
popula=on#is#reported#to#be#60#%#to#90#%#with#annual
incidence#of#5#%.##According#to#the#Na=onal#Center#for
Health#Sta=s=cs#(Patel,#2007),#each#year,#14.3#%#of#new
pa=ent#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.##For
individuals#with#acute#LBP,#the#precise#e=ology#can#be
iden=ed#in#only#about#15#%#of#cases#(Lehrich#et#al,#2007).
The#ini=al#evalua=on#of#pa=ents#with#LBP#involves#ruling#out
poten=ally#serious#condi=ons#such#as#infec=on,#malignancy,
spinal#fracture,#or#a#rapidly#progressing#neurologic#decit
sugges=ve#of#the#cauda#equina#syndrome,#bowel#or#bladder
dysfunc=on,#or#weakness,#which#suggest#the#need#for#early
diagnos=c#tes=ng.##Pa=ents#without#these#condi=ons#are
ini=ally#managed#with#conserva=ve#therapy.##The#most
common#pathological#causes#of#LBP#are#acributed
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#it.##This#most
commonly#occurs#at#the#lumbosacral#junc=on#with#L5
slipping#over#S1,#but#it#can#occur#at#higher#levels#as#well.##It#is
classied#based#on#e=ology#into#5#types:#dysplas=c,#defect#in
pars#interar=cularis,#degenera=ve,#trauma=c,#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#XDray#of#the#distance#from#the
posterior#edge#of#the#superior#vertebral#body#to#the
posterior#edge#of#the#adjacent#inferior#vertebral#body.##The
distance#is#then#reported#as#a#percentage#of#the#total
superior#vertebral#body#length#(see#appendix).#
Guidelines#for#the#approach#to#the#ini=al#evalua=on#of#LBP
have#been#issued#by#the#Agency#for#Healthcare#Research#and
Quality#(1994)#and#similar#conclusions#were#reached
in#systema=c#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,#symptoma=c#therapy
without#imaging#is#appropriate.##For#pa=ents#50#years#of#age
and#older#or#those#whose#ndings#suggest#systemic#disease,
plain#radiography#and#simple#laboratory#tests#can#almost
completely#rule#out#underlying#systemic#diseases.##Advanced
imaging#should#be#reserved#for#pa=ents#who#are#considering
surgery#or#those#in#whom#systemic#disease#is#strongly
suspected.##Conserva=ve#care#without#immediate#imaging#is
also#considered#appropriate#for#pa=ents#with#radiculopathy,
as#long#as#symptoms#are#not#bilateral#or#associated#with
urinary#reten=on.##Magne=c#resonance#imaging#(MRI)
should#be#performed#if#the#lacer#symptoms#are#present#or#if
pa=ents#do#not#improve#with#conserva=ve#therapy#for#4#to#6
weeks.##Ninety#percent#of#acute#acacks#of#scia=ca#will
resolve#with#conserva=ve#management#within#4#to#6
weeks;#only#5#%#remain#disabled#longer#than#3#months
(Gibson#and#Waddell,#2007;##Lehrich#and#Sheon,
2007;#AHCPR#1994).#
Conserva=ve#management#for#LBP#includes:
Avoidance#of#ac=vi=es#that#aggravate#pain
Chiroprac=c#manipula=on#in#the#rst#4#weeks#if#there#is
no#radiculopathy
Cogni=ve#support#and#reassurance#that#recovery#is
expected
Educa=on#regarding#spine#biomechanics
Exercise#program
Heat/cold#modali=es#for#home#use
Limited#bed#rest#with#gradual#return#to#normal#ac=vi=es
Low#impact#exercise#as#tolerated#(e.g.,#sta=onary#bike,
swimming,#walking)
Pharmacotherapy#(e.g.,#nonDnarco=c#analgesics,#NSAIDs
(as#secondDline#choices),#avoid#muscle#relaxants,#or#only
use#during#the#rst#week,#avoid#narco=cs)
In#the#American#Pain#Society/American#College#of#Physicians
Clinical#Prac=ce#Guideline#on#"Nonpharmacologic#Therapies
for#Acute#and#Chronic#Low#Back#Pain,"#Chou#and
Human#(2007)#reached#the#following#conclusions:
"Therapies#with#good#evidence#of#moderate#ecacy#for
chronic#or#subacute#low#back#pain#are#cogni=veDbehavioral
therapy,#exercise,#spinal#manipula=on,#and#interdisciplinary
rehabilita=on.##For#acute#low#back#pain,#the#only#therapy
with#good#evidence#of#ecacy#is#supercial#heat."
According#to#a#draq#technology#assessment#prepared#for#the
Agency#for#Healthcare#Research#and#Quality#(AHRQ)#by#the
Duke#EvidenceDbased#Prac=ce#Center#on#spinal#fusion#for
treatment#of#degenera=ve#disease#aec=ng#the#lumbar
spine#(AHRQ,#2006),##conserva=ve#treatments#are#generally
performed#rou=nely#before#any#surgery#is#considered#in#axial
back#pain.##These#include#medical#management#(such#as
NSAIDs,#etc.),#pain#management,#injec=ons,#physical
therapy,#exercise#and#various#forms#of#cogni=ve
rehabilita=on.##Such#conserva=ve#treatments#are#seldom
applied#in#a#comprehensive,#wellDorganized#rehabilita=on
program,#although#some#such#programs#do#exist.#
Conserva=ve#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#eec=veness#of#any#of#these
therapies#for#low#back#or#radicular#pain#beyond#about#6
weeks.##In#addi=on,#the#assessment#stated#that#almost#all
lumbar#spine#surgery,#including#lumbar#fusion,#is#performed
to#reduce#the#subjec=ve#individual#symptoms#of
radiculopathy;#thus,#pa=ent#educa=on#to#inform#pa=ents#of
their#treatment#op=ons#is#considered#cri=cal.##The#other
indica=ons#for#lumbar#fusion#focus#on#improvement#in#axial
lumbar#pain#(i.e.,#near#the#midline#and#not#involving#nerve
roots#or#leg#pain).##These#indica=ons#include#lumbar
instability,#such#as#degenera=ve#lumbar#scoliosis,
spondylolisthesis#for#axial#pain#alone,#and#for#less#common
problems,#such#as#disci=s,#lumbar#at#back#syndrome,
neoplas=c#bone#invasion#and#collapse,#and#chronic#fractures,
such#as#osteoporo=c#fractures#which#develop#into#burst
fractures#over#=me.##The#assessment#concluded#that,#"The
evidence#for#lumbar#spinal#fusion#does#not#conclusively
demonstrate#shortDterm#or#longDterm#benets#compared
with#nonDsurgical#treatment,#especially#when#considering
pa=ents#over#65#years#of#age,#for#degenera=ve#disc#disease;
for#spondylolisthesis,#considerable#uncertainty#exists#due#to
lack#of#data,#par=cularly#for#older#pa=ents."#
The#Na=onal#Ins=tute#for#Clinical#Excellence's#(NICE,#2009)
guidance#on#early#management#of#people#with#nonDspecic
LBP#stated#that#it#is#important#to#help#people#with#persistent
nonDspecic#LBP#selfDmanage#their#condi=on.##The#guidance
stated#that#one#of#the#following#treatment#op=ons#should#be
oered#to#the#pa=ent:#(i)#an#exercise#program,#(ii)#a#course
of#manual#therapy#(i.e.,#spinal#manipula=on,#spinal
mobiliza=on,#massage),#(iii)#a#course#of#acupuncture,#and#(iv)
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#signicant
psychological#distress.##The#guidance#stated#"[t]here#is
evidence#that#manual#therapy,#exercise#and#acupuncture
individually#are#costDeec=ve#management#op=ons
compared#with#usual#care#for#persistent#nonDspecic#low
back#pain.##The#cost#implica=ons#of#trea=ng#people#who#do
not#respond#to#ini=al#therapy#and#so#receive#mul=ple#back
care#interven=ons#are#substan=al.##It#is#unclear#whether
there#is#added#health#gain#for#this#subgroup#from#either
mul=ple#or#sequen=al#use#of#therapies."##In#addi=on,#the
guidance#stated#that#imaging#is#not#necessary#for#the
management#of#nonDspecic#LBP.##An#MRI#is#appropriate#only
for#people#who#have#failed#conserva=ve#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#Prac=ce#Guideline
Interven/onal%Therapies,%Surgery,%and%Interdisciplinary
Rehabilita/on%for%Low%Back%Pain#(Chou#et#al,#2009)#stated#"
[r]ates#of#certain#interven=onal#and#surgical#procedures#for
back#pain#are#rising.##However,#it#is#unclear#if#methods#for
iden=fying#specic#anatomic#sources#of#back#pain#are
accurate,#and#eec=veness#of#some#interven=onal#therapies
and#surgery#remains#uncertain#or#controversial."##Included#in
the#guideline#are#the#following#recommenda=ons.
The#APS#guideline#stated#that,#in#pa=ents#with#chronic#nonD
radicular#LBP,#provoca=ve#discography#is#not#recommended
as#a#procedure#for#diagnosing#LBP#(strong#recommenda=on,
moderateDquality#evidence)#(Chou#et#al,#2009).#
In#pa=ents#with#nonDradicular#LBP#who#do#not#respond#to
usual,#nonDinterdisciplinary#interven=ons,#the#APS
guideline#recommended#that#clinicians#consider#intensive
interdisciplinary#rehabilita=on#with#a#cogni=ve/behavioral
emphasis#(strong#recommenda=on,#highDquality#evidence)
(Chou#et#al,#2009).
In#pa=ents#with#nonDradicular#LBP,#common#degenera=ve
spinal#changes,#and#persistent#and#disabling#symptoms,#the
APS#guideline#recommended#that#clinicians#discuss#risks#and
benets#of#surgery#as#an#op=on#(weak#recommenda=on,
moderateDquality#evidence)#(Chou#et#al,#2009).
The#guideline#recommended#that#shared#decisionDmaking
regarding#surgery#for#nonDspecic#LBP#include#a#specic
discussion#about#intensive#interdisciplinary#rehabilita=on#as
a#similarly#eec=ve#op=on,#the#small#to#moderate#average
benet#from#surgery#versus#nonDinterdisciplinary#nonD
surgical#therapy,#and#the#fact#that#the#majority#of#such
pa=ents#who#undergo#surgery#do#not#experience#an#op=mal
outcome#(dened#as#minimum#or#no#pain,#discon=nua=on#of
or#occasional#pain#medica=on#use,#and#return#of#highDlevel
func=on)#(Chou#et#al,#2009).#
The#APS#guideline#explained#that#for#persistent#nonDradicular
LBP#with#common#degenera=ve#changes#(e.g.,#degenera=ve
disc#disease),#fusion#surgery#is#superior#to#nonDsurgical
therapy#without#interdisciplinary#rehabilita=on#in#1#trial,#but
no#more#eec=ve#than#intensive#interdisciplinary
rehabilita=on#in#3#trials#(Chou#et#al,#2009).##Compared#with
nonDinterdisciplinary,#nonDsurgical#therapy,#average#benets
are#small#for#func=on#(5D10#points#on#a#100Dpoint#scale)#and
moderate#for#improvement#in#pain#(10D20#points#on#a#100D
point#scale).##Furthermore,#more#than#half#of#the#pa=ents
who#undergo#surgery#do#not#experience#an#"excellent"#or
"good"#outcome#(i.e.,#no#more#than#sporadic#pain,#slight
restric=on#of#func=on,#and#occasional#analgesics).##Although
opera=ve#deaths#are#uncommon,#early#complica=ons#occur
in#approximately#18#%#of#pa=ents#who#undergo#fusion
surgery#in#randomized#trials.##Instrumented#fusion#is
associated#with#enhanced#fusion#rates#compared#with#nonD
instrumented#fusion,#but#insucient#evidence#exists#to
determine#whether#instrumented#fusion#improves#clinical
outcomes,#and#addi=onal#costs#are#substan=al.##In#addi=on,
there#is#insucient#evidence#to#recommend#a#specic#fusion
method#(anterior,#posterolateral,#or#circumferen=al),#though
more#technically#dicult#procedures#may#be#associated#with
higher#rates#of#complica=ons.
In#pa=ents#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#benets#of#surgery#as#an#op=on
(strong#recommenda=on,#highDquality#evidence)#(Chou#et#al,
2009).##It#is#recommended#that#shared#decisionDmaking
regarding#surgery#include#a#specic#discussion#about
moderate#average#benets,#which#appear#to#decrease#over
=me#in#pa=ents#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#shortDterm#(through#6#to#12#weeks)#benets
compared#to#nonDsurgical#therapy,#though#dierences#in
outcomes#in#some#trials#are#diminished#or#no#longer#present
aqer#1#to#2#years#(Chou#et#al,#2009).##In#addi=on,#pa=ents
tend#to#improve#substan=ally#either#with#or#without
discectomy,#and#con=nued#nonDsurgical#therapy#in#pa=ents
who#have#had#symptoms#for#at#least#6#weeks#does#not
appear#to#increase#risk#for#cauda#equina#syndrome#or
paralysis.
If#conserva=ve#management#fails#to#relieve#symptoms#of
radiculopathy#and#there#is#strong#evidence#of#dysfunc=on#of
a#specic#nerve#root#conrmed#at#the#corresponding#level#by
ndings#demonstrated#by#CT#or#MRI,#further#evalua=on#and
more#invasive#treatment,#including#spine#surgery,#may#be
proposed#as#a#treatment#op=on.##The#primary#ra=onale#of
any#form#of#surgery#for#disc#prolapse#is#to#provide
decompression#of#the#aected#nerve#root#to#relieve#the
individual's#symptoms.##It#involves#the#removal#of#all#or#part
of#the#lamina#of#a#lumbar#vertebra.##The#addi=on#of#fusion
with#or#without#instrumenta=on#is#considered#when#there
are#concerns#about#instability.##Open#discectomy,#performed
with#or#without#the#use#of#an#opera=ng#microscope,#is#the
most#common#surgical#technique#applied,#but#there#are#now
a#number#of#other#less#invasive#surgical#approaches.##The
surgical#treatment#of#scia=ca#with#discectomy#is#reportedly
ineec=ve#in#a#sizable#percentage#of#pa=ents,#and#reD
hernia=on#occurs#aqer#5#%#to#15#%#of#such#procedures.#
Thus,#it#would#be#ideal#to#dene#the#op=mal#type#of
treatment#for#the#specic#types#of#prolapse#(Carragee#et#al,
2003).###
Dierent#fusion#procedures,#including#anterior#lumbar
interbody#fusion,#posterolateral#fusion,#posterior#lumbar
interbody#fusion#and#transforaminal#lumbar#interbody
fusion,#and#anteriorDposterior#combined#fusion,#do#not#vary
signicantly#in#pain#or#disability#outcomes,#although#there
are#qualita=ve#dierences#in#complica=ons#related#to#the
surgical#approach.##Prior#to#the#1980's#both#anterior#and
posterior#nonDinsturmented#lumbar#fusions#were#commonly
performed,#using#primarily#bone#graq.##As#pedicle#screws
became#more#widely#used,#it#was#noted#that#the#rate#of
fusion#increased#from#65#%#with#bone#graq#alone#to#nearly
95#%#with#the#instrumenta=on#to#provide#internal#support
for#the#bone#graq.##The#increased#s=ness#from#the#inser=on
of#screws#and#rods#has#been#hypothesized#to#lead#to
increased#degenera=on#at#spine#segments#adjacent#to#the
fusion.
Anterior#spine#procedures,#through#either#the#peritoneum#or
retroperitoneum,#require#no#posterior#muscle#and
ligamentous#dissec=on#and#result#in#less#postDopera=ve#axial
back#pain.##This#approach#is#generally#recommended#for#the
treatment#of#axial#LBP#in#young#individuals.##The#usual
criteria#for#considera=on#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#indica=ng#the#axial#pain
is#likely#arising#from#the#degenerated#joints,#and#failure#of
previous#conserva=ve#measures#to#improve#the#back#pain
over#a#period#of#=me,#with#a#minimum#of#6#month
conserva=ve#treatment.##However,#according#to#AHRQ
(2006),#the#discogram#remains#highly#controversial,#and
recent#reports#suggest#that#relying#on#the#MRI#ndings#of#a
dark#disc#and#limi=ng#the#discogram#to#just#those#levels#may
improve#the#deni=on#of#a#"posi=ve#discorgram".##The#AHRQ
assessment#stated,#"However,#the#high#rate#of#false#posi=ves
with#normal#disc#spaces#is#problema=c,#as#well#as#the#high
rate#of#prevalence#of#dark#disc#syndrome."###As#pa=ents#age
into#their#40s#and#50s#the#disc#and#facet#degenera=ve
processes#slowly#worsen,#and#it#is#less#likely#to#nd#pa=ents
with#isolated#arthri=s,#thus,#anterior#fusion#is#less#oqen
recommended#for#older#pa=ents.##Posterior#fusion#may#be
preferable#for#older#individuals#in#order#to#stabilize#facet
joint#disease.##However,#the#posterior#approach#involves
signicant#muscle#dissec=on,#resul=ng#in#severe#back#pain#in
the#postDopera=ve#period,#and#is#avoided#by#some#surgeons.
The#natural#history#of#scia=ca#is#favorable,#with#resolu=on#of
leg#pain#within#8#weeks#from#onset#in#the#majority#of
pa=ents#(Peul#et#al,#2007).##Dutch#guidelines#on#the
diagnosis#and#treatment#of#the#lumbrosacral#radicular
syndrome#(Stam,#1996)#recommended#the#op=on#of#lumbarD
disk#surgery#in#pa=ents#who#have#scia=ca#if#symptoms#do
not#improve#aqer#6#weeks#of#conserva=ve#treatment.##To
determine#the#op=mal#=ming#of#surgery,#inves=gators#(Peul
et#al,#2007)#randomly#assigned#pa=ents#(n#=#283)#who#had
had#severe#scia=ca#for#6#to#12#weeks#to#early#surgery#or#to
prolonged#conserva=ve#treatment#with#surgery#if#needed.#
The#primary#outcomes#were#the#score#on#the#Roland
Disability#Ques=onnaire,#the#score#on#the#visual#analog#scale
for#leg#pain,#and#the#pa=ent's#report#of#perceived#recovery
during#the#rst#year#aqer#randomiza=on.##RepeatedD
measures#analysis#according#to#the#inten=onDtoDtreat
principle#was#used#to#es=mate#the#outcome#curves#for#both
groups.##Of#141#pa=ents#assigned#to#undergo#early#surgery,
125#(89#%)#underwent#microdiskectomy#aqer#a#mean#of#2.2
weeks.##Of#142#pa=ents#designated#for#conserva=ve
treatment,#55#(39#%)#were#treated#surgically#aqer#a#mean#of
18.7#weeks.##There#was#no#signicant#overall#dierence#in
disability#scores#during#the#rst#year#(p#=#0.13).##Relief#of#leg
pain#was#faster#for#pa=ents#assigned#to#early#surgery#(p#<
0.001).##Pa=ents#assigned#to#early#surgery#also#reported#a
faster#rate#of#perceived#recovery#(hazard#ra=o,#1.97;#95#%
condence#interval#[CI]:#1.72#to#2.22;#p#<#0.001).##In#both
groups,#however,#the#probability#of#perceived#recovery#aqer
1#year#of#followDup#was#95#%.##The#inves=gators#concluded
that#the#1Dyear#outcomes#were#similar#for#pa=ents#assigned
to#early#surgery#and#those#assigned#to#conserva=ve
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#systema=c#review#(2007)#on#surgical
interven=ons#for#lumbar#disc#prolapse#iden=ed#40
randomized#controlled#trials#and#2#quasiDrandomized#trials
on#the#surgical#management#of#lumbar#disc#prolapse.#
However,#the#authors#iden=ed#only#4#studies#(Weber,#1983;
Greeneld,#2003;#Bucerman,#2004;#Weinstein,#2006)#that
compared#discectomy#with#conserva=ve#management.##The
authors#stated#that#these#studies#contain#major#design
weaknesses,#par=cularly#on#the#issues#of#sample#size,
randomiza=on,#blinding,#and#dura=on#of#followDup.#
Furthermore,#outcome#measures#in#clinical#studies#of#LBP
have#not#been#standardized#making#it#dicult#to#compare
the#results#of#clinical#studies#of#similar#treatment.####
The#rst#study#(Weber,#1983)#compared#the#results#of
surgical#versus#conserva=ve#treatment#for#lumbar#disc
hernia=on#conrmed#by#radiculography#(n#=#126)#with#10
years#of#followDup#observa=on.##The#author#reported#a
signicantly#becer#result#in#the#surgically#treated#group#at
the#1Dyear#followDup#examina=on;#however,#aqer#4#years#the
dierence#was#no#longer#sta=s=cally#signicant.##Only#minor
changes#took#place#during#the#last#6#years#of#observa=on.#
The#trial#was#not#blinded#and#26#%#of#the#conserva=ve#group
crossedDover#to#surgery.#
In#a#prospec=ve,#randomized#study,#Bucermann
(2004),#evaluated#the#ecacy#of#epidural#steroid
injec=on#versus#discectomy#in#the#treatment#of#pa=ents#with
a#large,#symptoma=c#lumbar#herniated#nucleus#pulposus#(n
=#100).##The#discectomy#pa=ents#had#the#most#rapid
decrease#in#symptoms,#with#92#%#to#98#%#of#the#pa=ents
repor=ng#that#the#treatment#had#been#successful#over#the
various#followDup#periods.##Of#the#50#pa=ents#who#had
undergone#epidural#steroid#injec=on,#42#%#to#56#%#reported
the#treatment#had#been#eec=ve.##Those#who#did#not#obtain
relief#from#the#injec=on#had#a#subsequent#discectomy#(27#of
50#pa=ents).##The#epidural#steroid#injec=on#trial#group#did
not#appear#to#have#any#adverse#outcomes#as#a#result#of#their
delay#in#receiving#surgery.##The#author#concluded#that
discectomy#was#more#eec=ve#in#reducing#symptoms#and
disability#associated#with#a#large#herniated#lumbar#disc#than
epidural#steroid#injec=on;#however,#the#epidural#steroid
injec=on#was#found#to#be#eec=ve#for#the#followDup#period
of#3#years#by#nearly#50#%#of#the#pa=ents#who#had#not#had
improvement#with#6#or#more#weeks#of#nonDinvasive#care.#
The#Spine#Pa=ent#Outcomes#Research#Trial#(SPORT)#was
designed#to#compare#the#eec=veness#of#surgical#and#nonD
surgical#treatment#among#par=cipants#with#conrmed
diagnoses#of#intervertebral#disk#hernia=on,#spinal#stenosis,
and#degenera=ve#spondylolisthesis.##The#SPORT#included#13
mul=Ddisciplinary#spine#centers#across#the#United#States.##To
assess#the#ecacy#of#standard#open#diskectomy#versus#nonD
opera=ve#treatment#individualized#to#the#pa=ent#for#lumbar
intervertebral#disk#hernia=on,#the#SPORT#observa=onal
cohort#(Weinstein#et#al,#2006)#conducted#a#randomized
clinical#trial#(n#=#501)#with#imageDconrmed#lumbar
intervertebral#disk#hernia=on#and#persistent#signs#and
symptoms#of#radiculopathy#for#at#least#6#weeks.##The#authors
reported#limited#adherence#to#the#assigned#treatment:#50#%
of#pa=ents#assigned#to#surgery#received#surgery#within#3
months#of#enrollment,#while#30#%#of#those#assigned#to#nonD
opera=ve#treatment#received#surgery#in#the#same#period.#
IntentDtoDtreat#analyses#demonstrated#substan=al
improvements#for#all#primary#and#secondary#outcomes#in
both#treatment#groups.##BetweenDgroup#dierences#in
improvements#were#consistently#in#favor#of#surgery#for#all
periods#but#were#small#and#not#sta=s=cally#signicant#for#the
primary#outcomes.##The#authors#reported#that#both#surgical
and#nonDopera=ve#treatment#groups#improved#substan=ally
over#a#2Dyear#period.##However,#the#large#numbers#of
pa=ents#who#crossed#over#between#assigned#groups
precluded#any#conclusions#about#the#compara=ve
eec=veness#of#opera=ve#therapy#versus#usual#care.#
The#fourth#study#(Greeneld,#2003),#available#only#as#an
abstract,#compared#microdiscectomy#with#a#lowDtech
physical#therapy#regime#and#educa=onal#approach#in
pa=ents#with#LBP#and#scia=ca#with#a#small#or#moderate#disc
prolapse.##At#12#and#18#months#there#were#sta=s=cally
signicant#dierences#in#pain#and#disability#favoring#the
surgical#group;#however,#by#24#months#there#was#no
dierence#between#the#2#groups.#
The#Cochrane#systema=c#review#(2007)#concluded:#(i)#most
lumbar#disc#prolapses#resolve#naturally#with#conserva=ve
management#and#the#passage#of#=me;#(ii)#there#is
considerable#evidence#that#surgical#discectomy#provides
eec=ve#clinical#relief#for#carefully#selected#pa=ents#with
scia=ca#due#to#lumbar#disc#prolapse#that#fails#to#resolve#with
conserva=ve#management.##It#provides#faster#relief#from#the
acute#acack#of#scia=ca,#although#any#posi=ve#or#nega=ve
eects#on#the#longDterm#natural#history#of#the#underlying
disc#disease#are#unclear.#There#is#s=ll#a#lack#of#scien=c
evidence#on#the#op=mal#=ming#of#surgery.##The#amount#of
crossDover#in#these#trials#makes#it#likely#that#the#intentDtoD
treat#analysis#underes=mates#the#true#eect#of#surgery;#but
the#resul=ng#confounding#also#makes#it#impossible#to#draw
any#rm#conclusions#about#the#ecacy#of#surgery.#
In#a#randomized#controlled#study,#Brox#et#al#(2006)
compared#the#eec=veness#of#lumbar#fusion#with#posterior
transpedicular#screws#and#cogni=ve#interven=on#and
exercises#on#60#pa=ents#aged#25#to#60#years#with#LBP#las=ng
longer#than#1#year#aqer#previous#surgery#for#disc#hernia=on.
#Cogni=ve#interven=on#consisted#of#a#lecture#intended#to
give#the#pa=ent#an#understanding#that#ordinary#physical
ac=vity#would#not#harm#the#disc#and#a#recommenda=on#to
use#the#back#and#bend#it.##This#was#reinforced#by#3#daily
physical#exercise#sessions#for#3#weeks.##The#primary#outcome
measure#was#the#Oswestry#Disability#Index#(ODI).##The
success#rate#was#50#%#in#the#fusion#group#and#48#%#in#the
cogni=ve#interven=on/exercise#group.##The#authors
concluded#that#for#pa=ents#with#chronic#LBP#aqer#previous
surgery#for#disc#hernia=on,#lumbar#fusion#failed#to#show#any
benet#over#cogni=ve#interven=on#and#exercise.
The#American#Associa=on#of#Neurological
Surgeons/Congress#of#Neurological#Surgeons#(AANS/CNS)
Guideline's#for#the#Performance#of#Fusion#Procedures#for
Degenera=ve#Disease#of#the#Lumbar#Spine#(Resnick,#2005),#is
a#series#of#guidelines#that#deal#with#the#methodology#of
guideline#forma=on,#the#assessment#of#outcomes#following
lumbar#fusion,#recommenda=ons#that#involve#the#diagnos=c
modali=es#helpful#for#the#preD#and#postDopera=ve#evalua=on
of#pa=ents#considered#candidates#for#or#treated#with#lumbar
fusion,#followed#by#recommenda=ons#dealing#with#specic
pa=ent#popula=ons.##Finally,#several#surgical#adjuncts,
including#pedicle#screws,#intraDopera=ve#monitoring,#and
bone#graq#subs=tutes#are#discussed,#and#recommenda=ons
are#made#for#their#use.
In#their#review#of#the#literature,#the#AANS/CNS#commicee
found#that#several#authors#published#their#experience#in#the
surgical#management#of#pa=ents#with#stenosis#and
spondylolisthesis#treated#with#decompression#with#or
without#fusion.##These#results#are#variable#and#all#studies
involved#nonvalidated#outcome#measures.##Many#of#the
published#reviews#presented#awed#results#due#to#poorly
dened#outcome#measures,#inadequate#numbers#of
pa=ents,#and#comparison#of#dissimilar#treatment#groups.##As
a#result,#most#of#the#published#studies#on#lumbar#fusion
were#not#included#in#their#review.##However,#the#commicee
stated#that,#"The#aforemen=oned#results#do#not#detract
from#the#importance#of#this#document;#rather,#we#can#now
clearly#see#the#need#for#the#neurosurgical#community#to
design#and#complete#prospec=ve#randomized#controlled
studies#to#answer#the#many#lingering#clinical#ques=ons#with
rigorous#scien=c#power."##The#guidelines#concluded#that
"The#precise#deni=on#of#instability#or#kyphosis#has#varied
among#researchers#and#requires#further#study."
Inves=gators#from#the#SPORT#trial#(Weinstein#et#al,#2007)
compared#surgical#versus#nonDsurgical#treatment#for#lumbar
degenera=ve#spondylolisthesis.##Candidates#who#had#at#least
12#weeks#of#symptoms#and#imageDconrmed#degenera=ve
spondylolisthesis#were#oered#enrollment#in#a#randomized
cohort#(n#=#304)#or#an#observa=onal#cohort#(n#=#303).#
EightyDsix#percent#of#pa=ents#had#grade#1#slippage#and#14#%
had#grade#2.##However,#all#pa=ents#had#neurogenic
claudica=on#or#radicular#leg#pain#with#associated#neurologic
signs,#spinal#stenosis#shown#on#crossDsec=onal#imaging,#and
degenera=ve#spondylolisthesis.##Treatment#was#standard
decompressive#laminectomy#(with#or#without#fusion)#or
usual#nonDsurgical#care.##The#primary#outcome#measures
were#the#36DItem#ShortDForm#General#Health#Survey#(SF#D#36)
bodily#pain#and#physical#func=on#scores#(100Dpoint#scales,
with#higher#scores#indica=ng#less#severe#symptoms)#and#the
modied#ODI#(100Dpoint#scale,#with#lower#scores#indica=ng
less#severe#symptoms)#at#6#weeks,#3#months,#6#months,#1
year,#and#2#years.##The#inves=gators#reported#high#1#year
crossDover#rates#in#the#randomized#cohort#(approximately#40
%#in#each#direc=on)#but#moderate#in#the#observa=onal
cohort#(17#%#crossDover#to#surgery#and#3#%#crossDover#to
nonDsurgical#care).##The#inten=onDtoDtreat#analysis#for#the
randomized#cohort#showed#no#sta=s=cally#signicant#eects
for#the#primary#outcomes.##The#asDtreated#analysis#for#both
cohorts#combined#showed#a#signicant#advantage#for
surgery#at#3#months#that#increased#at#1#year#and#diminished
only#slightly#at#2#years.##The#treatment#eects#at#2#years
were#18.1#for#bodily#pain#(95#%#CI:#14.5#to#21.7),#18.3#for
physical#func=on#(95#%#CI:#14.6#to#21.9),#and#D16.7#for#the
ODI#(95#%#CI:#D19.5#to#D13.9).##The#inves=gators#concluded
that#pa=ents#with#degenera=ve#spondylolisthesis#and#spinal
stenosis#treated#surgically#showed#substan=ally#greater
improvement#in#pain#and#func=on#during#a#period#of#2#years
than#pa=ents#treated#nonDsurgically.##However,#the
inves=gators#stated,#"Oqen#pa=ents#fear#they#will#get#worse
without#surgery,#but#the#pa=ents#receiving#nonsurgical
treatment,#on#average,#showed#moderate#improvement#in
all#outcomes."##No#conclusion#is#drawn#regarding#selec=on
criteria#for#percentage#of#vertebral#slippage#in#individuals
with#spondylolisthesis#considered#for#fusion.
Vokshoor#(2004)#stated#that#before#surgery#is#considered#for
adult#pa=ents#with#degenera=ve#spondylolisthesis,#minimal
neurologic#signs,#or#mechanical#back#pain#alone,
conserva=ve#measures#should#be#exhausted,#and#a#thorough
evalua=on#of#social#and#psychological#factors#should#be
undertaken.##Indica=ons#for#surgical#interven=on#(fusion)
include:
Any#highDgrade#slip#(greater#than#50#%)
Iatrogenic#spondylolisthesis
Neurologic#signs#DD#Radiculopathy#(unresponsive#to
conserva=ve#measures),#myelopathy,#neurogenic
claudica=on
Trauma=c#spondylolisthesis
Type#1#and#type#2#slips,#with#evidence#of#instability#and
progression#of#listhesis
Type#3#(degenera=ve)#listhesis#with#gross#instability#and
incapacita=ng#pain
This#is#consistent#with#Wheeless#(2008)#who#stated#that#for
spondylolisthesis,#posterior#spine#fusion#should#be#limited#to
those#pa=ents#who#do#not#respond#to#conserva=ve
measures#and#whose#slips#are#greater#than#50#%.
Matsudaira#and#colleagues#(2005)#compared#outcomes
following#decompression#laminectomy#combined#with
posterolateral#fusion#and#pedicle#screw#instrumenta=on#(n#=
19)#versus#a#laminoplasty#technique#without#fusion#(n#=#18)
in#pa=ents#with#grade#I#lumbar#degenera=ve
spondylolisthesis#and#reported#no#signicant#dierence#in
the#degree#of#clinical#improvement#between#the#2#groups#at
the#2#year#followDup.
Randomized#controlled#trials#have#shown#results#of#fusion#to
be#equivalent#to#those#of#structured#exercise#and#cogni=ve
interven=on.##In#a#retrospec=ve#study#on#lumbar#fusion
outcomes#among#Washington#State#compensated#workers
with#chronic#back#pain#(n#=#1,950),#Maghout#et#al#(2006)
reported#that#fusions#with#cages#increased#from#3.6#%#in
1996#to#58.1#%#in#2001.##Overall#disability#rate#at#2#years
aqer#fusion#was#63.9#%,#the#reDopera=on#rate#was#22.1#%,
and#the#rate#for#other#complica=ons#was#11.8#%.##The#use#of
cages#or#instrumenta=on#was#associated#with#an#increased
complica=on#risk#compared#with#boneDonly#fusions#without
improving#disability#or#reopera=on#rates.##Legal,#workD
related,#and#psychologic#factors#predicted#worse#disability.#
Discography#and#mul=Dlevel#fusions#predicted#greater
reopera=on#risk.##The#authors#concluded#that#the#use#of
intervertebral#fusion#devices#rose#rapidly#aqer#their
introduc=on#in#1996#and#that#this#increased#use#was
associated#with#an#increased#complica=on#risk#without
improving#disability#or#reopera=on#rates.
In#a#systema=c#review#of#randomized#trials#comparing
lumbar#fusion#surgery#to#nonDsurgical#treatment#of#chronic
back#pain#associated#with#lumbar#disc#degenera=on,#Mirza
et#al#(2007)#compared#outcomes#in#4#trials#that#focused#on
nonDspecic#chronic#back.##One#study#suggested#greater
improvement#in#backDspecic#disability#for#fusion#compared
to#unstructured#nonopera=ve#care#at#2#years,#but#the#trial
did#not#report#data#according#to#intentDtoDtreat#principles.
#Three#trials#suggested#no#substan=al#dierence#in#disability
scores#at#1Dyear#and#2Dyears#when#fusion#was#compared#to#a
3Dweek#cogni=veDbehavior#treatment#addressing#fears#about
back#injury.##However,#2#of#these#trials#were#underDpowered
to#iden=fy#clinically#important#dierences.##The#third#trial
had#high#rates#of#crossDover#(greater#than#20#%#for#each
treatment)#and#loss#to#followDup#(20#%);#it#is#unclear#how
these#aected#results.##The#authors#concluded#that#surgery
may#not#be#more#ecacious#than#structured#cogni=veD
behavior#therapy,#however,#methodological#limita=ons#of
the#randomized#trials#prevent#rm#conclusions.
According#to#the#American#College#of#Physicians/American
Pain#Society#Clinical#Prac=ce#Guideline,#Diagnosis%and
Treatment%of%Low%Back%Pain#(2007),#studies#on#LBP
show#large#varia=ons#in#prac=ce#pacerns#on#diagnos=c#tests
and#treatments,#although#costs#of#care#can#dier
substan=ally,#pa=ents#seem#to#experience#similar
outcomes.##The#guideline#makes#the#following
recommenda=ons:
Recommenda/on%1:#A#focused#history#and#physical#should
be#conducted#to#determine#whether#the#back#pain#is:#(i)
nonDspecic;#(ii)#associated#with#radiculopathy#or#spinal
stenosis;#or#(iii)#due#to#another#specic#spinal#cause.##The
history#should#include#an#assessment#of#psychosocial#risk
factors,#which#predict#risk#of#chronic#disabling#back#pain
(strong#recommenda=on,#moderateDquality#evidence).
Recommenda/on%2:#For#pa=ents#with#nonDspecic#LBP,
imaging#or#other#diagnos=c#tests#should#not#be#rou=nely
obtained#(strong#recommenda=on,#moderateDquality
evidence).
Recommenda/on%3:#For#pa=ents#with#LBP#when#severe#or
progressive#neurologic#decits#are#present#or#when#serious
underlying#condi=ons#are#suspected#on#the#basis#of#history
and#physical#examina=on,#diagnos=c#imaging#and#tes=ng
should#be#obtained#(strong#recommenda=on,#moderateD
quality#evidence).
Recommenda/on%4:#For#pa=ents#with#persistent#LBP#and
signs#or#symptoms#of#radiculopathy#or#spinal#stenosis#who
are#also#considered#candidates#for#surgery#or#epidural
steroid#injec=on#(for#suspected#radiculopathy),#MRI
(preferred)#or#CT#should#be#performed#(strong
recommenda=on,#moderateDquality#evidence).
Recommenda/on%5:#Pa=ents#with#LBP#should#be#advised#to
remain#ac=ve,#and#informa=on#about#eec=ve#selfDcare
op=ons,#including#evidenceDbased#informa=on#on#the
expected#course#of#LBP,#should#be#provided#(strong
recommenda=on,#moderateDquality#evidence).
Recommenda/on%6:##For#pa=ents#with#LBP,#the#use#of
medica=ons#with#proven#benets#should#be#considered#in
conjunc=on#with#back#care#informa=on#and#selfDcare.#
Severity#of#baseline#pain,#func=onal#decits,#poten=al
benets,#risks,#and#rela=ve#lack#of#longDterm#ecacy#and
safety#data#should#be#considered#before#ini=a=ng#therapy
(strong#recommenda=on,#moderateDquality#evidence).##FirstD
line#medica=on#op=ons#for#most#pa=ents#are
acetaminophen#or#nonDsteroidal#an=Dinammatory#drugs.
Recommenda/on%7:#For#pa=ents#with#LBP#who#do#not
improve#with#selfDcare#op=ons,#nonDpharmacologic#therapy
with#proven##benets#should#be#considered.##For#acute#LBP,
spinal#manipula=on#may#be#considered.##For#chronic#or
subacute#LBP,#intensive#interDdisciplinary#rehabilita=on,
exercise#therapy,#acupuncture,#massage#therapy,#spinal
manipula=on,#yoga,#cogni=veDbehavioral#therapy,#or
progressive#relaxa=on#may#be#considered#(weak
recommenda=on,#moderateDquality#evidence).#
The#Washington#State#Health#Technology#Assessment
Program#commissioned#the#ECRI#Ins=tute,#an#independent,
nonDprot#health#services#research#agency,#to#conduct#an
assessment#of#lumbar#fusion#and#discography#in#pa=ents
with#chronic#uncomplicated#degenera=ve#disc#disease#(DDD)
associated#with#chronic#LBP.##In#a#draq#assessment#(2007),
the#ECRI#Ins=tute#stated#that#they#did#not#nd#sucient
evidence#that#lumbar#fusion#surgery#is#more#eec=ve#to#a
clinically#meaningful#degree#than#nonDsurgical#treatments
for#any#of#the#following#pa=ent#popula=ons,#comparisons
and#outcomes:
MetaDanalysis#of#postDopera=ve#changes#in#Oswestry
disability#scores#from#2#moderate#quality#randomized
controlled#trials#(RCTs)#(n#=#413)#revealed#no#clinically
meaningful#dierence#between#fusion#and#intensive
exercise/rehabilita=on#plus#cogni=ve#behavioral#therapy
(CBT)#in#pa=ents#without#prior#back#surgery,#although#the
dierence#slightly#favored#fusion.##Strength#of#evidence:
Weak.
The#evidence#was#insucient#to#determine#whether
lumbar#fusion#provides#a#greater#improvement#in#back
pain#(1#moderateDquality#RCT,#n#=#64)#or#quality#of#life#(no
acceptable#evidence)#compared#to#intensive
exercise/rehabilita=on#plus#CBT#in#pa=ents#without#prior
back#surgery.
The#evidence#from#1#moderate#quality#RCT#(n#=#60)#was
insucient#to#determine#the#rela=ve#benets#of#lumbar
fusion#compared#to#intensive#exercise/rehabilita=on#in
pa=ents#with#prior#back#surgery.
The#evidence#from#1#moderate#quality#RCT#(n#=#294)#was
insucient#to#determine#the#rela=ve#benets#of#lumbar
fusion#compared#to#conven=onal#physical#therapy#in
pa=ents#with#or#without#prior#back#surgery.
The#ECRI#Ins=tute#assessed#the#rates#of#adverse#events#(periD
opera=ve,#longDterm#events,#and#reopera=ons)#for#lumbar
fusion#surgery#and#nonDsurgical#treatments#and#reported#the
following:
Categories#of#adverse#events#most#frequently#reported#in
fusion#studies#include#reopera=on#(0#D#46#%),#infec=on#(0
D#9#%),#various#deviceDrelated#complica=on#(0#D#17.8#%),
neurologic#complica=ons#(0.7#D#26#%),#thrombosis#(0#D#4
%),#bleeding/vascular#complica=ons#(0#D#13#%),#and#dural
injury#(0.5#D#29#%)
Lumbar#fusion#leads#to#signicantly#higher#rates#of#early
adverse#events#compared#to#nonDintensive#physical
therapy#or#intensive#exercise/rehabilita=on#plus#CBT.
Lumbar#fusion#leads#to#signicantly#higher#rates#of#late
adverse#events#at#2Dyear#followDup#compared#to#nonD
intensive#physical#therapy#or#intensive
exercise/rehabilita=on#plus#CBT.
None#of#the#4#RCTs#comparing#fusion#to#nonDintensive
physical#therapy#or#intensive#exercise/rehabilita=on#plus
CBT#reported#any#adverse#events#occurring#in#pa=ents
who#only#received#nonDopera=ve#care.##Most#of#the
reported#adverse#events#could#not#have#occurred#in
pa=ents#who#did#not#undergo#surgery.
The#ECRI#assessment#stated#that#there#is#insucient
evidence#to#determine#what#pa=ent#characteris=cs#are
associated#with#dierences#in#the#benets#and#adverse
events#of#lumbar#fusion#surgery.
Contraindica/ons:
The#ECRI#assessment#iden=ed#one#guideline#ci=ng#absolute
contraindica=ons#for#lumbar#fusion#and#3#guidelines
repor=ng#rela=ve#contraindica=ons.
The#Washington#State#Department#of#Labor#and#Industries
(2004)#cited#the#following#as#an#absolute#contraindica=on
for#lumbar#fusion:
Ini=al#laminectomy/discectomy#related#to#unilateral
compression#of#a#lumbar#nerve#root
The#Washington#State#Department#of#Labor#and#Industries
(2004)#cited#the#following#as#rela=ve#contraindica=ons#for
lumbar#fusion:
Current#evidence#of#a#fac==ous#disorder
Current#smoking
Greater#than#12#months#of#disability#(=meDloss
compensa=on#benets)#prior#to#considera=on#of#fusion
High#degrees#of#soma=za=on#on#clinical#or#psychological
evalua=on
Mul=ple#level#degenera=ve#disease#of#the#lumbar#spine
No#evidence#of#func=onal#recovery#(return#to#work)#for#at
least#6#months#following#the#most#recent#spine#surgery
Presence#of#a#personality#disorder#or#major#psychiatric
illness
Psychosocial#factors#that#are#correlated#with#poor
outcome,#such#as#history#of#drug#or#alcohol#abuse
Severe#physical#decondi=oning.
The#American#Associa=on#of#Neurological#Surgeons
reviewed#evidence#on#lumbar#fusion#for#the#treatment#of
disc#hernia=on#and#radiculopathy,#and#concluded:#"There#is
insucient#evidence#to#recommend#a#treatment#guideline."
#However,#they#did#comment#that#lumbar#spinal#fusion#is#not
recommended#as#a#rou=ne#treatment#following#primary#disc
excision#in#pa=ents#with#a#herniated#lumbar#disc#causing
radiculopathy,#though#it#may#be#of#use#for#pa=ents#with
herniated#discs#and#evidence#of#preopera=ve#lumbar#spinal
disability#or#deformity,#for#pa=ents#with#signicant#chronic
axial#LBP#and#radiculopathy#due#to#disc#hernia=on,#or#for
pa=ents#with#recurrent#lumbar#disc#hernia=on.
For#pa=ents#with#low#back#complaints#in#general,#the
American#College#of#Occupa=onal#and#Environmental
Medicine#(2005)#stated#that#pa=ents#with#coDmorbidi=es
including#cardiac#or#respiratory#disease,#diabetes,#or#mental
illness,#are#poor#candidates#for#back#surgery#in#general.
A#cervical#laminectomy#(may#be#combined#with#an#anterior
approach)#is#some=mes#performed#when#acute#cervical#disc
hernia=on#causes#cord#compression#or#in#cervical#disc
hernia=ons#refractory#to#conserva=ve#measures.##Studies
have#shown#that#an#anterior#discectomy#with#fusion#is#the
recommended#procedure#for#central#or#anterolateral#soq
disc#hernia=on,#while#a#posterior#laminotomyDforaminotomy
may#be#considered#when#technical#limita=ons#for#anterior
access#exist#(e.g.,#short#thick#neck)#or#when#the#individual
has#had#prior#surgery#at#the#same#level#(Windsor,#2006).
Discectomy#alone#is#regarded#as#a#technique#that#most
frequently#results#in#spontaneous#fusion#(70#%#to#80#%).#
Addi=onal#fusion#techniques#include#the#use#of#bone#graqs
(autograq,#allograq#or#ar=cial)#with#or#without#cages
and/or#the#use#of#an#anterior#plate.##A#Cochrane#systema=c
review#(2004)#reported#the#results#of#14#studies#(n#=#939)
that#evaluated#three#comparisons#of#dierent#fusion
techniques#for#cervical#degenera=ve#disc#disease#and
concluded#that#discectomy#alone#has#a#shorter#opera=on
=me,#hospital#stay,#and#postDopera=ve#absence#from#work
than#discectomy#with#fusion#with#no#sta=s=cal#dierence#for
pain#relief#and#rate#of#fusion.##The#authors#concluded#that
more#conserva=ve#techniques#(discectomy#alone,#autograq)
perform#as#well#or#becer#than#allograq,#ar=cial#bone,#and
addi=onal#instrumenta=on;#however,#the#low#quality#of#the
trials#reviewed#prohibited#extensive#conclusions#and#more
studies#with#becer#methodology#and#repor=ng#are#needed.#
To#iden=fy#whether#there#is#an#advantage#to#instrumented
or#nonDinstrumented#spinal#fusion#over#decompression
alone#for#pa=ents#with#degenera=ve#lumbar
spondylolisthesis#on#the#surgical#management#of
degenera=ve#lumbar#spondylolisthesis,#Mar=n#et#al
(2007)#reported#the#results#of#13#studies#in#a#systema=c
review;#however,#the#studies#were#generally#of#low
methodologic#quality.##Abstracted#outcomes#included#clinical
outcome,#reopera=on#rate,#and#solid#fusion#status.##Analyses
were#separated#into:#(i)#fusion#versus#decompression#alone,
and#(ii)#instrumented#fusion#versus#nonDinstrumented
fusion.##A#sa=sfactory#clinical#outcome#was#signicantly
more#likely#with#fusion#than#with#decompression#alone;
however,#the#clinical#benet#favoring#fusion#decreased#when
analysis#was#limited#to#studies#where#the#majority#of
the#pa=ents#reported#neurologic#symptoms#(e.g.,
intermicent#claudica=on#and/or#leg#pain).##The#use#of
adjunc=ve#instrumenta=on#signicantly#increased#the
probability#of#acaining#solid#fusion,#but#no#signicant
improvement#in#clinical#outcome#was#reported.##There#was#a
nonDsignicant#trend#toward#lower#repeat#opera=ons#with
fusion#compared#with#both#decompression#alone#and
instrumented#fusion.##The#authors#concluded#that#spinal
fusion#may#lead#to#a#becer#clinical#outcome#than
decompression#alone.##No#conclusion#about#the#clinical
benet#of#instrumen=ng#a#spinal#fusion#could#be
made;#however,#there#is#moderate#evidence#that#the#use#of
instrumenta=on#improves#the#chance#of#achieving#solid
fusion.
Tsutsumimoto#and#collegues#(2008)#retrospec=vely
examined#the#surgical#outcomes#of#unDinstrumented
posterolateral#lumbar#fusion#for#a#minimum#of#8#years
(average#of#9.5#years),#by#comparing#cases#exhibi=ng#union
with#those#exhibi=ng#nonDunion.##UnDinstrumented
posterolateral#lumbar#fusion#was#performed#for#the
treatment#of#lumbar#canal#stenosis#(LCS)#with#degenera=ve
spondylolisthesis.##The#study#included#42#pa=ents,#and#the
followDup#rate#was#82.4#%.##The#mean#age#of#the#pa=ents
was#64.1#years#(range#of#46#to#77#years).##Eight#pa=ents
exhibited#fusion#at#the#L3DL4#level#and#34#pa=ents,#at#the#L4D
L5#level.##The#fusion#status#was#assessed#using#plain
radiographs.##The#clinical#outcomes#were#evaluated#using#the
Japanese#Orthopaedic#Associa=on#(JOA)#scores.##NonDunion
was#noted#in#26#%#(11/42)#of#the#pa=ents.##There#were#no
sta=s=cally#signicant#dierences#between#the#groups
exhibi=ng#union#and#nonDunion#with#respect#to#age,#sex,#preD
opera=ve#JOA#score,#or#preDopera=ve#lumbar#instability.##The
union#group#achieved#becer#opera=ve#results#than#the#nonD
union#group#at#the#5Dyear#and#nal#followDup#(p#=#0.006#and
0.008,#respec=vely),#although#there#was#no#signicant
dierence#in#the#percent#recovery#at#1#and#3#D#year#followDup
(p#=#0.515#and#0.506,#respec=vely).##A#stepwise#regression
analysis#revealed#that#the#best#combina=on#of#predictors#for
recovery#at#the#=me#of#nal#followDup#included#the#fusion
status#and#the#presence#of#coDmorbid#disease.
A#BlueCross#BlueShield#Associa=on#Technology#Evalua=on
Center#(BCBSA,#2007)#assessment#on#the#ar=cial#lumbar
disc#commented#on#the#evidence#for#spinal#fusion#for
degenera=ve#disc#disease.##The#assessment#stated#that#"The
eec=veness#of#fusion#for#chronic#degenera=ve#disc#disease
is#not#well#established.##There#are#few#clinical#trials#and
results#are#inconsistent."##One#of#the#reasons#the
assessment#concluded#that#the#ar=cial#disc#is#unproven#is
that#the#clinical#studies#compared#it#to#spinal#fusion,#which#is
itself#an#unproven#treatment#for#degenera=ve#disc#disease.#
The#assessment#stated#that#"Surgical#arthrodesis,#or#fusion,
is#considered#the#current#standard#surgical#treatment#for
degenera=ve#disc#disease#which#is#not#responsive#to#other
treatments.##Elimina=on#of#mo=on#across#the#disc#space#and
reduc=on#of#loads#on#disc#=ssues#theore=cally#result#in#pain
relief.##Evidence#suppor=ng#the#ecacy#of#fusion#is#rela=vely
sparse."
Na=onal#survey#data#showed#a#rapid#increase#in#the#use#of
spinal#fusion#(i.e.,#annual#numbers#of#procedures#increased
by#77#%#from#1996#to#2001)#as#a#result#of#new#technological
advances#(e.g.,#bone#morphogene=c#protein),#nancial
incen=ves,#and#controversial#expansion#of#indica=ons#(e.g.,
discogenic#back#pain#without#evidence#of#scia=ca),#and#a
high#rate#of#reDopera=ons.##These#increases#were#not
associated#with#reports#of#claried#indica=ons#or#improved
ecacy#of#various#fusion#techniques#for#various#indica=ons
(Deyo#et#al,#2004,#2005).##The#review#of#spinal#fusion#surgery
by#Deyo#et#al#(2004)#stated#that,#"Fundamental#problems
plague#the#study#of#spinal#fusion,#including#the#lack#of
deni=ve#methods#to#conrm#a#solid#fusion,#a#weak
associa=on#between#solid#fusion#and#pain#relief,#and#the
placebo#eect#of#surgery#for#pain#relief."##They#further#stated
that,#"EvidenceDbased#prac=ce#for#degenera=ve#spine
disorders#might#reserve#the#use#of#spinal#fusions#for
spondylolisthesis#and#only#rare#cases#of#disk#hernia=on#or
spinal#stenosis#without#spondylolisthesis,"#and#that#"More
evidence#from#clinical#trials#should#be#required#for
degenera=ve#disk#disease#to#be#an#accepted#indica=on."#
Regarding#the#use#of#"emerging#spinal#implants,"#such#as
ar=cial#discs,#the#review#states#that,#"If#ongoing#trials
suggest#results#equivalent#to#those#of#spinal#fusion,#it#may
be#faint#praise,#given#the#paucity#of#evidence#that#spinal
fusion#is#safe#and#eec=ve#for#common#indica=ons."
A#review#of#the#literature#by#Turner#et#al#(1992)#found#no
randomized#trials#of#fusion.##Combining#many#studies#of
fusion#performed#for#many#dierent#clinical#indica=ons,#the
authors#found#an#average#of#68#%#of#pa=ents#reported#a
sa=sfactory#outcome.##A#1999#Cochrane#review#(Gibson#et
al)#concluded#that#at#that#=me#there#was#no#acceptable
evidence#of#any#form#of#fusion#for#degenera=ve#lumbar
spondylosis,#back#pain,#or#"instability."##The#authors#could
nd#no#randomized#clinical#trials#comparing#fusion#to#a
nonsurgical#alterna=ve,#only#trials#which#compared#surgical
techniques#of#fusion#to#each#other.
Two#published#clinical#trials#comparing#lumbar#fusion#to#a
nonDsurgical#alterna=ve#treatment#for#pa=ents#with#chronic
back#pain#due#to#degenera=ve#disc#disease#have#been
published#since#the#Cochrane#review.##Fritzell#et#al#(2001)
conducted#a#mul=Dcenter#randomized#controlled#trial
comparing#3#techniques#of#lumbar#fusion#to#nonDsurgical
treatment.##Enrollment#criteria#included#pa=ents#(n#=#294)
with#chronic#pain,#severe#disability,#pain#acributed#to
degenera=ve#disc#disease,#and#no#neurologic#compromise
due#to#herniated#disc,#spondylolisthesis,#or#spinal#stenosis.#
There#was#no#specied#nonDsurgical#treatment,#but#it#was
described#as#commonly#used#physical#therapies.##In#terms#of
pa=ents'#overall#assessment,#63#%#of#pa=ents#receiving
fusion#reported#being#becer#or#much#becer,#compared#to#29
%#of#control#pa=ents.##Cri=cs#of#the#study#have#pointed#to
the#modest#eect#of#surgery#(up#to#30#%#mean#score
change),#and#the#fact#that#control#pa=ents#may#not#have
received#op=mal#nonsurgical#treatment#(Deyo#et#al,#2004).
The#other#randomized#trial,#by#Brox#et#al#(2003),#assigned#a
specic#cogni=ve#and#exercise#regimen#to#the#nonDsurgical
pa=ents.##Enrollment#criteria#for#this#study#were#roughly
similar#to#the#other#clinical#trial,#and#outcomes#were
assessed#at#1#year.##In#this#study,#pa=ents#receiving#fusion
reported#improvements#ranging#from#36#to#49#%#on#pain#and
disability#scales,#but#pa=ents#in#the#control#arm#also
reported#similar#improvements#in#these#scores,#resul=ng#in
dierences#which#were#not#sta=s=cally#signicant#for#most
outcomes.##Although#this#trial#was#much#smaller#(n#=#64)
than#the#study#by#Fritzell#et#al#(2001),#the#point#es=mates#of
eect#for#each#arm#are#very#similar#to#each#other,#and
condence#intervals#suciently#narrow#to#rule#out#a#large
clinical#benet#of#surgery.##The#authors#believed#that#the
dierence#in#results#between#the#2#studies#was#caused#by
the#specic#interven=on#used#in#the#nonDsurgical#group,
which#produced#improvements#similar#to#the#surgical#fusion
group.
The#rela=ve#sparseness#of#controlled#clinical#trial#data
regarding#the#eec=veness#of#fusion#for#degenera=ve#disc
disease#makes#the#validity#of#it#as#a#valid#comparator#to#total
disc#replacement#uncertain.##It#can#not#be#ruled#out#that
some#of#the#improvements#associated#with#lumbar#fusion
are#due#to#natural#history,#placebo#eects,#or#coD
interven=ons#such#as#rehabilita=on#and#exercise#programs.#
It#would#be#dicult#to#compare#retrospec=ve#studies#of
fusion#with#case#series#results#of#ar=cial#disc#because#of#the
very#restric=ve#selec=on#criteria#for#the#ar=cial#disc.#
Complica=ng#the#evalua=on#of#fusion#is#the#variety#of
techniques#and#devices#used#to#perform#the#procedure.#
Pedicle#screws#and#intervertebral#fusion#cages#are#2#types#of
devices#implanted#during#some#procedures.##Clinical#trial
results#comparing#use#of#these#devices#have#not#produced
consistent#results#(BCBSA,#2007).
Common#complica=ons#of#fusion#reported#by#Deyo#et#al
(2004)#include#instrument#failure#(7#%),#complica=ons#at#the
bone#donor#site#(11#%),#neural#injuries#(3#%),#and#failure#to
achieve#a#solid#fusion#or#pseudarthrosis#(15#%).##In#addi=on,
fusion#is#thought#to#cause#increased#rate#of#disc
degenera=on#in#spinal#segments#adjacent#to#the#fusion.
The#Washington#State#Health#Technology#Assessment
Program#commissioned#Spectrum#Research#Inc.,#an
independent,#clinical#research#organiza=on,#to#conduct#a
systema=c#review#of#the#evidence#on#the#safety,#ecacy,#and
costDeec=veness#of#ar=cial#disc#replacement#(Decori#et#al,
2008).##One#of#the#ques=ons#posed#to#the#reviewers#was
whether#there#is#evidence#of#the#ecacy/eec=veness#of
ar=cial#disc#replacement#compared#with#compara=ve
therapies,#including#spinal#fusion.##The#assessment#reviewed
the#eec=veness#of#ar=cial#disc#replacement#compared
with#spinal#fusion#in#pa=ents#with#degenera=ve#disc#disease
and#concluded#that#there#is#moderate#evidence#that#the
ecacy/eec=veness#of#lumbar#ar=cial#disc#replacement#is
comparable#with#anterior#lumbar#interbody#fusion#or
circumferen=al#fusion#up#to#2#years#following#surgery;
however,#the#authors#stated#that#a#nonDinferiority#trial
requires#that#the#reference#treatment#have#an#established
ecacy#or#that#it#is#in#widespread#use.##For#the#lumbar#spine,
the#authors#noted#that#the#ecacy#of#lumbar#fusion#for
degeneratvie#disc#disease#remains#uncertain,#especially
when#it#is#compared#with#nonDopera=ve#care;#thus,#this
limits#the#ability#to#fully#answer#the#ecacy/eec=veness
ques=on#of#ar=cial#disc#replacement.
Four#randomized#controlled#trials#comparing#lumbar#fusion
to#nonDsurgical#treatments#found#that#nearly#15#%#(58/399)
of#pa=ents#receiving#lumbar#fusion#experienced
complica=ons.##The#most#frequent#complica=ons#reported
included#reDopera=on#(with#rates#ranging#from#0#%#D#46.1#%),
infec=on#(0#%#D#9#%),#deviceDrelated#complica=ons#(0#%#D
17.8#%),#neurologic#complica=ons#(0.7#%#D#25.8#%),
thrombosis#(0#%#D#4#%),#bleeding/vascular#complica=ons#(0#%
D#12.8#%),#and#dural#injury#(0.5#%#D#29#%).##In#another#study,#a
12#%#2Dyear#incidence#rate#of#major#complica=ons#following
lumbar#spinal#fusion#was#reported,#with#a#reDopera=on#rate
of#14.6#%#for#that#popula=on.##Other#complica=ons#reported
in#the#literature#include#the#poten=al#for#adjacent#segment
degenera=on#(development#of#disc#degenera=on,
hypertrophic#facets,#dynamic#instability,#and/or#spinal
stenosis#in#adjacent#levels),#pseudoarthrosis,#bone#graq
donor#site#pain#and#infec=on,#instrumenta=on#prominence
or#failure,#neural#injuries,#and#failure#to#relieve#pain#(Decori
et#al,#2008).
Failed#back#surgery#syndrome#(FBSS),#a#condi=on#in#which
there#is#failure#to#improve#sa=sfactorily#aqer#back#surgery,#is
characterized#by#intractable#pain#and#various#degrees#of
func=onal#disability#aqer#lumbar#spine#surgery.##A#review#of
the#literature#on#failed#degenera=ve#lumbar#spine#surgery
(Diwan#et#al,#2003)#es=mated#that#10#%#to#15#%#of#pa=ents
who#have#undergone#a#spinal#decompression#procedure#and
15#%#to#20#%#of#pa=ents#who#have#had#a#spinal#fusion
procedure#for#degenera=ve#disease#of#the#lumbar#spine
undergo#revision#lumbar#surgery#within#3#to#5#years#due#to
signicant#back#and#leg#symptoms.##However,#most#studies
do#not#give#the#=me#to#reopera=on#from#the#ini=al#surgery.#
AHRQ#(2006)#reviewed#studies#that#reported#the#incidence
of#adjacent#segment#disease#requiring#reopera=on#following
lumbar#or#lombosacral#fusion#and#reported#that#annualized
reopera=on#rates#ranged#from#0#%#to#3.7#%#and#1.7#%#to#3.4
%#for#nonDfusion#lumbar#surgery#based#on#the#overDall
reopear=on#rates#of#the#studies#and#the#average#=me#to
followDup.
The#major#causes#for#reopera=on#include#brosis#and
adhesions,#spinal#instability,#recurrent#herniated#disk,#and
inadequate#decompression#(Skaf#et#al,#2005).##Over#=me,
recurrent#lumbar#stenosis#may#occur#at#the#same#level#(due
to#persistent#or#even#enhanced#mo=on#at#that#level)#or#at
adjacent#levels#due#to#the#natural#course#of#disease
progression.##It#is#hypothesized#that#fusion#at#one#level
increases#stress#on#joints#at#adjacent#levels#during#ordinary
spine#mo=on,#hence#leading#to#accelerated#degenera=ve
joint#disease#at#these#adjacent#levels,#as#compared#to#the
natural#history#of#disease#progression.##Whether#an
instrumented#fusion#may#increase#adjacent#segment#disease
is#another#controversial#point,#but#without#much#evidence
(AHRQ,#2006).
The#e=ology#of#FBSS#can#be#poor#pa=ent#selec=on,#incorrect
diagnosis,#subDop=mal#selec=on#of#surgery,#poor#technique,
failure#to#achieve#surgical#goals,#and/or#recurrent#pathology.#
Successful#interven=on#in#this#dicult#pa=ent#popula=on
requires#a#detailed#history#to#accurately#iden=fy#symptoms,
rule#out#extraDspinal#causes,#iden=fy#a#specic#spinal
e=ology,#and#assess#the#psychological#state#of#the#pa=ent.#
Only#aqer#these#factors#have#been#assessed#can#further
treatment#be#planned#(Guyer#et#al,#2006).
Relevant#outcome#studies#are#rarely#diagnosis#specic,#and
high#level#research#studies#comparing#surgical#and#nonD
surgical#approaches#to#FBSS#studies#have#not#been#published
to#date.##Surgical#strategies#focus#on#decompressing#neural
impingement#or#fusing#unstable#or#puta=vely#painful
intervertebral#discs.##NonDsurgical#interven=ons#range#from
nerve#root#specic#blocks#for#pain#relief#to#mul=Ddisciplinary
rehabilita=on#programs#geared#toward#improving#func=on
(Hazard,#2006).
Herron#(1994)#reported#the#results#of#recurrent#disc
hernia=on#treated#by#repeat#laminectomy#and#discectomy.#
Fiqy#recurrences#were#treated#in#46#pa=ents,#an#average#of#7
years#and#1#month#aqer#the#previous#laminectomy.##ThirtyD
four#pa=ents#were#treated#for#37#recurrences#at#the#same
level,#with#3#undergoing#a#third#laminectomy#and
discectomy.##Twelve#pa=ents#were#treated#for#13
recurrences#at#a#dierent#level.##Four#pa=ents#underwent#a
third#laminectomy#and#discectomy#for#recurrent#disc
hernia=on.##FortyDone#pa=ents#had#followDup#of#at#least#1
year#and#average#followDup#was#4#years#and#6#months.#
There#were#28#good#(69#%),#10#fair#(24#%),#and#3#poor#(7#%)
results.##Pa=ents#with#pending#li=ga=on#or#workDrelated
injuries#(5#good,#5#fair,#and#3#poor)#did#less#well#overall#than
those#without#these#issues#(23#good,#5#fair,#and#0#poor).#
Heron#stated#that,#"Fusion#is#not#rou=nely#required#in
pa=ents#undergoing#repeat#laminectomy#and#discectomy#for
recurrent#disc#hernia=on.##In#the#absence#of#objec=ve
evidence#of#spinal#instability,#recurrent#disc#hernia=on#may
be#adequately#treated#by#repeat#lumbar#laminectomy#and
discectomy#alone".
Fritsch#et#al#(1996)#conducted#a#retrospec=ve#review#of#182
revisions#on#FBSS#from#the#years#1965#to#1990#and#analyzed
the#reasons#for#failure#of#primary#discectomy,#the#outcome
of#the#revisions,#and#factors#that#inuenced#those
outcomes.##The#reported#reDinterven=on#rates#aqer#lumbar
discectomy#ranged#from#5#%#to#33#%#depending#on#the#type
of#surgical#procedure.##The#authors'#former#inves=ga=ons
reported#a#revision#rate#of#10.8#%#in#evalua=ng#1,500#lumbar
discectomies.##A#total#of#182#revisions#were#performed#on
136#pa=ents;#44#pa=ents#(34#%)#were#revised#mul=ple
=mes.##Recurrent#or#unDinuenced#scia=c#pain#and
neurologic#deciency#or#lumbar#instability#led#to#reD
interven=on.##Recurrent#lumbar#disc#hernia=on#was#mainly
found#at#the#rst#reDinterven=on.##In#mul=ple#revision
pa=ents#the#rate#of#epidural#brosis#and#instability#increased
to#greater#than#60#%.##In#80#%#of#the#pa=ents#the#results
were#sa=sfactory#in#shortDterm#evalua=on,#decreasing#to#22
%#in#longDterm#follow#up#(2##to#27#years).##Laminectomy
performed#in#primary#surgery#could#be#detected#as#the#only
factor#leading#to#a#higher#rate#of#revisions.##The#authors
noted#a#trend#toward#poor#results#aqer#recurrent#disc
surgery#due#to#the#development#of#epidural#brosis#and
instability.##In#severe#discotomy#syndrome,#a#spinal#fusion
appeared#to#be#more#successful#than#mul=ple#brinolyses.
Phillips#and#Cunningham#(2002)#conducted#a#review#of#the
peerDreviewed#publica=ons#that#inves=gated#e=ologies#and
treatments#for#neurogenic#pain#in#pa=ents#who#have
undergone#previous#spinal#surgery.##The#authors
recommended#that#in#the#absence#of#profound#or
progressive#neurologic#decits,#most#pa=ents#with#chronic
back#and#leg#pain#who#have#undergone#previous#spinal
surgery#be#treated#nonDopera=vely,#however,#addi=onal
decompressive#surgical#interven=on#may#be#jus=ed#in
pa=ents#with#wellDdened,#discrete#pathology#amenable#to
surgical#correc=on#who#have#been#refractory#to#conserva=ve
care.
During#a#2Dyear#period,#Duggal#et#al#(2004)#treated#pa=ents
diagnosed#with#FBSS#with#anterior#lumbar#interbody#fusion.#
Clinical#and#radiological#outcomes#were#recorded#in#a
prospec=ve,#nonDrandomized,#longitudinal#manner.#
Neurological,#pain,#and#func=onal#outcomes#were#measured
preDopera=vely#and#12#months#aqer#surgery.##Opera=ve
data,#periDopera=ve#complica=ons,#and#radiological#and
clinical#outcomes#were#recorded.##ThirtyDthree#pa=ents#with
a#preDopera=ve#diagnosis#of#FBSS,#with#degenera=ve#disc
disease#(n#=#17),#postDsurgical#spondylolisthesis#(n#=#13),#or
pseudarthrosis#(n#=#3),#underwent#anterior#lumbar#interbody
fusion.##Back#pain,#leg#pain,#and#func=onal#status#improved
signicantly,#by#76#%#(p#<#0.01),#80#%#(p#<#0.01),#and#67#%#(p
<#0.01),#respec=vely.##The#authors#found#anterior#lumbar
interbody#fusion#to#be#a#safe#and#eec=ve#procedure#for#the
treatment#of#FBSS#for#selected#pa=ents.
Skaf#et#al#(2005)#prospec=vely#studied#50#pa=ents#with
FBSS.##The#underlying#pathology#was#iden=ed#and#all#the
pa=ents#were#treated#surgically.##Redo#surgery#was#targeted
at#correc=ng#the#underlying#pathology:#removal#of#recurrent
or#residual#disk,#release#of#adhesions#with#neural
decompression,#and#fusion#with#or#without
instrumenta=on.##The#postDsurgical#outcome#was#studied
using#the#ODQ.##The#average#preDopera=ve#ODQ#mean#score
was#80.8;#the#average#postDopera=ve#ODQ#mean#score#was
36.6#at#1#month#and#24.2#at#1#year.##Best#scores#were
obtained#at#3#months#of#followDup#in#most#cases.##Successful
outcome#(greater#than#50#%#pain#relief)#was#achieved#in#92
%#of#the#pa=ents#at#1#year.##The#authors#concluded#that
successful#management#of#pa=ents#with#FBSS#could#be
achieved#with#proper#pa=ent#selec=on,#correct#preD
opera=ve#diagnosis,#and#adequate#surgical#procedure
targe=ng#the#underlying#pathology.
Fu#et#al#(2005)#evaluated#the#longDterm#outcomes#of#repeat
surgery#for#recurrent#lumbar#disc#hernia=on#and#compared
the#results#of#disc#excision#with#and#without#posterolateral
fusion#in#a#retrospec=ve#study.##The#sample#included#41
pa=ents#who#underwent#disc#excision#with#or#without
posterolateral#fusion,#with#an#average#followDup#of#88.7
months#(range#of#60#to#134#months).##Clinical#symptoms
were#assessed#based#on#the#Japanese#Orthopedic
Associa=on#Back#Scores.##All#medical#and#surgical#records
were#examined#and#analyzed,#including#painDfree#interval,
intraDopera=ve#blood#loss,#length#of#surgery,#and#postD
surgery#hospital#stay.##Clinical#outcome#was#excellent#or
good#in#80.5#%#of#pa=ents,#including#78.3#%#of#pa=ents
undergoing#a#discectomy#alone,#and#83.3#%#of#pa=ents#with
posterolateral#fusion.##The#recovery#rate#was#82.2#%,#and#the
dierence#between#the#fusion#and#nonDfusion#groups#was
insignicant#(p#=#0.799).##The#dierence#in#the#postD
opera=ve#back#pain#score#was#also#insignicant#(p#=#0.461).#
These#2#groups#were#not#dierent#in#terms#of#age,#painDfree
interval,#and#followDup#dura=on.##IntraDopera=ve#blood#loss,
length#of#surgery,#and#length#of#hospitaliza=on#were
signicantly#less#in#pa=ents#undergoing#discectomy#alone
than#in#pa=ents#with#fusion.##The#authors#concluded#that
repeat#surgery#for#recurrent#scia=ca#is#eec=ve#in#cases#of
true#recurrent#disc#hernia=on.
Papadopoulos#et#al#(2006)#retrospec=vely#reviewed#a#total
of#27#pa=ents#who#had#undergone#revision#discectomies#for
recurrent#lumbar#disc#hernia=ons#to#assess#their#clinical
outcomes.##Pa=ents#were#compared#with#a#control#group#of
30#matched#pa=ents#who#had#undergone#only#a#primary
discectomy.##The#spine#module#of#the#MODEMS#outcome
instrument#was#used#to#evaluate#pa=ents'#sa=sfac=on,#pain
and#func=onal#ability#following#discectomy,#as#well#as#quality
of#life.##Pa=ents#were#also#asked#whether#they#were
improved#or#worsened#with#surgery.##Those#undergoing
revision#surgery#were#asked#whether#the#improvement
following#the#second#surgery#was#more#or#less#than#the
improvement#following#the#rst#surgery.##Improvement
following#the#repeat#discectomy#was#not#sta=s=cally
dierent#from#the#improvement#that#occurred#in#pa=ents
who#underwent#just#the#primary#opera=on.##Dierences#in
residual#numbness/=ngling#in#the#leg#and/or#the#foot#as#well
as#in#frequency#of#back#and/or#bucock#pain#were#iden=ed.#
The#authors#concluded#that#revision#discectomy#is#as
ecacious#as#primary#discectomy#in#selected#pa=ents.
An#assessment#of#spinal#fusion#by#the#Andalusian#Agency#for
Health#Technology#Assessment#(AETSA)#(Mar=nez#Ferez#et
al,#2009)#concluded#that#the#available#scien=c#evidence
about#spinal#fusion#is#scarce#and#is#based#on#low#or
moderate#quality#studies.##The#assessment#found#no#clear
evidence#that#fusion#combined#with#spinal#decompression
provides#some#benets#in#degenera=ve#lumbar#stenosis.#
The#assessment#found#weak#evidence#in#favor#of#spinal
fusion#in#contrast#with#decompression#for#degenera=ve
spondylolisthesis,#but#it#is#based#on#studies#of#low
methodological#quality.##The#report#found#that,#for
degenera=ve#discopathies,#spinal#fusion#does#not#provide
clinical#benets#compared#to#structured#and#intense
conserva=ve#treatments#with#cogni=veDbehavioural#therapy;
on#the#contrary,#it#seems#to#provide#benets#compared
to#less#intensive#treatments#which#are#commonly#used#in
prac=ce.##For#degenera=ve#discopathies#with#radicular
compression,#spinal#fusion#does#not#seem#to#provide#a#clear
clinical#benet#compared#to#decompression#alone.##The
report#found#that#total#replacement#of#the#degenerated
discs#by#ar=cial#discs#such#as#Charit#and#ProDDisc#L#shows
results#at#least#as#good#or#becer#than#those#obtained#by
spinal#fusion,#which#is#considered#the#standard#treatment#in
these#cases.##The#report#concluded#that#clinical#trials#of
higher#quality#are#necessary#in#order#to#get#clear#results
about#the#real#benet#which#fusion#provides#for#the
treatment#of#the#spinal#degenera=ve#pathologies#which#have
been#included#in#this#report.
Anterior#spinal#fusion#with#instrumenta=on#has#been#used
for#many#years#in#the#treatment#of#thoracolumbar#and
lumbar#curves#in#adolescent#idiopathic#scoliosis#(AIS).##Tis#et
al#(2010)#reported#the#intermediate#radiographical#and
pulmonary#func=on#tes=ng#(PFT)#data#from#pa=ents#who
underwent#open#instrumented#anterior#spinal#fusion#(OASF)
using#modern,#rigid#instrumenta=on#for#the#treatment#of
primary#thoracic#(Lenke#1)#adolescent#idiopathic#scoliosis
(AIS).##Of#101#poten=al#pa=ents#who#underwent#OASF#with#a
minimum#5Dyear#followDup,#85#(85#%)#were#studied.#
Standing#radiographs#were#analyzed#before#surgery#and#at
rst#standing#erect,#2Dyear,#and#5Dyear#followDup.##Data#on
PFT#were#collected#before#surgery#and#at#5#years#aqer
surgery.##Complete#5Dyear#followDup#was#obtained#in#85
pa=ents.##Five#years#aqer#surgery,#the#mean#coronal
correc=on#was#26#degrees#(51#%;#p#<#0.05)#and#the
thoracolumbar/lumbar#curve#improved#16#degrees#(51#%).#
There#was#a#9Ddegree#(p#<#0.001)#increase#in#kyphosis,#and
there#were#9#pa=ents#(11#%)#in#whom#the#C7#plumb#line
translated#greater#than#2#cm.##There#was#a#6.7#%#decrease#in
predicted#forced#expiratory#volume#in#one#second#over#the
5Dyear#period,#from#75.5#%#+/D#13#%#before#surgery#to#68.8#%
+/D#2#%#at#5Dyear#followDup#(p#=#0.007);#however,#there#was
no#signicant#change#in#forced#vital#capacity.##There#were#3
signicant#adverse#events:#1#implant#breakage#requiring#reD
opera=on#and#2#cases#of#progression#of#the#main#thoracic
curve#requiring#reDopera=on.##The#authors#concluded#that
OASF#is#a#reproducible#and#safe#method#to#treat#thoracic
AIS.##It#provides#good#coronal#and#sagical#correc=on#of#the
main#thoracic#and#compensatory#thoracolumbar/lumbar
curves#that#is#maintained#with#intermediate#term#followDup.#
In#skeletally#immature#children,#this#technique#can#cause#an
increase#in#kyphosis#beyond#normal#values,#and#less
correc=on#of#kyphosis#should#be#considered#during
instrumenta=on.##As#with#any#procedure#that#employs#a
thoracotomy,#pulmonary#func=on#is#mildly#decreased#at#nal
followDup.
In#a#retrospec=ve#review,#Kelly#and#colleagues#(2010)
evaluated#a#group#of#pa=ents#based#on#Scoliosis#Research
Society#(SRS)D30#and#Oswestry#data#as#well#as#radiographical
and#MRI#ndings;#and#reported#the#results#of#longDterm
followDup#of#anterior#spinal#fusion#with#instrumenta=on#for
thoracolumbar#and#lumbar#curves#in#AIS.##Eighteen#pa=ents
were#available#for#review.##Average#followDup#for#this#study
was#16.97#years.##Based#on#SRSD30#and#the#Oswestry
Disability#Index#data,#most#pa=ents#had#good#func=on#scores
and#acceptable#pain#levels.##Radiographs#demonstrated#no
progression#of#the#thoracolumbar#or#thoracic#curves.
#Implant#failure#was#iden=ed#in#2#pa=ents.##Radiographical
changes#of#early#degenera=ve#disc#disease#were#iden=ed#in
most#pa=ents#but#had#no#correla=on#with#SRS#or#Oswestry
data.##These#degenera=ve#changes#were#evident#on#both
radiographs#and#MRI.##The#authors#concluded#that#the
anterior#approach#in#the#treatment#of#thoracolumbar#and
lumbar#curves#in#AIS#oers#good#longDterm#func=onal
outcomes#for#pa=ents.##Despite#expected#degenera=ve
changes,#pa=ents#scored#well#on#the#SRS#and#Oswestry#tests,
and#were#able#to#pursue#careers#and#family#ac=vi=es.
Lehman#and#Lenke#(2007)#reviewed#the#case#of#a#44DyearDold
woman#who#underwent#longDsegment#fusion#and#an
ar=cial#disc#replacement#(ADR).##There#have#been#many
reported#advantages#and#disadvantages#of#stopping#the
fusion#at#L5,#with#the#theore=cal#benets#being#preserved
mo=on,#shorter#opera=ve#=me,#allowing#the#remaining#disc
to#compensate#for#curve#correc=on#cephalad#in#the#lumbar
spine,#and#a#decreased#likelihood#for#the#development#of#a
pseudarthrosis#at#that#distal#level.##As#the#issue#of#the#fate#of
the#L5#to#S1#mo=on#segment#con=nues#to#be#debated,#these
inves=gators#presented#the#case#of#a#mediumDsegment
thoracoDlumbar#fusion#carried#down#to#the#L4#stable
vertebra,#an#intervening#healthy#L4#to#L5#disc#space,#with#the
placement#of#an#ar=cial#disc#arthroplasty#at#the#L5#to#S1
level#for#a#degenera=ve#and#discographically#posi=ve#pain
generator.##At#2Dyear#followDup,#her#L5#to#S1#ar=cial#disc
replacement#level#shows#11#degrees#range#of#mo=on
(ROM)#and#consolidated#fusion#from#T12#to#L4#with
complete#resolu=on#of#her#axial#back#pain.##Her#T12#to#L4
construct#is#stable,#and#the#L4#to#L5#level#is#unaected#at#the
latest#followDup.##Her#clinical#outcome#has#been#excellent
with#her#return#to#a#very#ac=ve#lifestyle.##The#authors
concluded#that#ADR#below#a#longDsegment#fusion#is#a#viable
alterna=ve#to#performing#fusion#to#addi=onal#mo=on
segments.
In#an#inDvitro#human#cadaveric#biomechanical#study,#Erkan#et
al#(2009)#compared#the#biomechanical#proper=es#of#a#2D
level#Maverick#disc#replacement#at#L4#to#L5,#L5#to#S1,#and#a
hybrid#model#consis=ng#of#an#L4#to#L5#Maverick#disc
replacement#with#an#L5#to#S1#anterior#lumbar#interbody
fusion#using#mul=Ddirec=onal#exibility#test.##A#total#of#6
fresh#human#cadaveric#lumbar#specimens#(L4#to#S1)#were
subjected#to#unconstrained#load#in#axial#torsion#(AT),#lateral
bending#(LB),#exion#(F),#extension#(E),#and#exionDextension
(FE)#using#mul=Ddirec=onal#exibility#test.##Four#surgical
treatments#DD#intact,#1Dlevel#Maverick#at#L5#to#S1,#2Dlevel
Maverick#between#L4#and#S1,#and#the#hybrid#model#(anterior
fusion#at#L5#to#S1#and#Maverick#at#L4#to#L5)#were#tested#in
sequen=al#order.##The#ROM#of#each#treatment#was
calculated.##The#Maverick#disc#replacement#slightly#reduced
intact#mo=on#in#AT#and#LB#at#both#levels.##The#total#FE
mo=on#was#similar#to#the#intact#mo=on.##However,#the#E
mo=on#is#signicantly#increased#(approximately#50#%#higher)
and#F#mo=on#is#signicantly#decreased#(30#%#to#50#%
lower).##The#anterior#fusion#using#a#cage#and#anterior#plate
signicantly#reduced#spinal#mo=on#compared#with#the
condi=on#(p#<#0.05).##No#signicant#dierences#were#found
between#2Dlevel#Maverick#disc#prosthesis#and#the#hybrid
model#in#terms#of#all#mo=on#types#at#L4#to#L5#level#(p#>
0.05).##The#authors#concluded#that#the#Maverick#disc
preserved#total#mo=on#but#altered#the#mo=on#pacern#of
the#intact#condi=on.##This#result#is#similar#to#unconstrained
devices#such#as#Charit.##The#mo=on#at#L4#to#L5#of#the#hybrid
model#is#similar#to#that#of#2Dlevel#Maverick#disc
replacement.##The#fusion#procedure#using#an#anterior#plate
signicantly#reduced#intact#mo=on.##The#authors#concluded
that#clinical#studies#are#recommended#to#validate#the
eec=veness#of#the#hybrid#model.
On#behalf#of#the#American#Pain#Society,#Chou#et#al#(2009)
systema=cally#evaluated#benets#and#harms#of#surgery#for
nonDradicular#back#pain#with#common#degenera=ve
changes,#radiculopathy#with#herniated#lumbar#disc,#and
symptoma=c#spinal#stenosis.##For#nonDradicular#LBP#with
common#degenera=ve#changes,#these#researchers#found#fair
evidence#that#fusion#is#no#becer#than#intensive
rehabilita=on#with#a#cogni=veDbehavioral#emphasis#for
improvement#in#pain#or#func=on,#but#slightly#to#moderately
superior#to#standard#(nonDintensive)#nonDsurgical#therapy.#
Less#than#half#of#pa=ents#experience#op=mal#outcomes
(dened#as#no#more#than#sporadic#pain,#slight#restric=on#of
func=on,#and#occasional#analgesics)#following#fusion.#
Clinical#benets#of#instrumented#versus#nonDinstrumented
fusion#are#unclear.##For#radiculopathy#with#herniated#lumbar
disc,#these#inves=gators#found#good#evidence#that#standard
open#discectomy#and#microdiscectomy#are#moderately
superior#to#nonDsurgical#therapy#for#improvement#in#pain
and#func=on#through#2#to#3#months.##For#symptoma=c#spinal
stenosis#with#or#without#degenera=ve#spondylolisthesis,
they#found#good#evidence#that#decompressive#surgery#is
moderately#superior#to#nonDsurgical#therapy#through#1#to#2
years.##For#both#condi=ons,#pa=ents#on#average#experience
improvement#either#with#or#without#surgery,#and#benets
associated#with#surgery#decrease#with#longDterm#followDup
in#some#trials.##Although#there#is#fair#evidence#that#ADR#is
similarly#eec=ve#compared#to#fusion#for#single#level
degenera=ve#disc#disease#and#that#an#interDspinous#spacer
device#is#superior#to#nonDsurgical#therapy#for#1D#or#2Dlevel
spinal#stenosis#with#symptoms#relieved#with#forward#exion,
insucient#evidence#exists#to#judge#longDterm#benets#or
harms.##The#authors#concluded#that#surgery#for
radiculopathy#with#herniated#lumbar#disc#and#symptoma=c
spinal#stenosis#is#associated#with#shortDterm#benets
compared#to#nonDsurgical#therapy,#although#benets
diminish#with#longDterm#followDup#in#some#trials.##For#nonD
radicular#back#pain#with#common#degenera=ve#changes,
fusion#is#no#more#eec=ve#than#intensive#rehabilita=on,#but
associated#with#smallDtoDmoderate#benets#compared#to
standard#nonDsurgical#therapy.##This#review#did#not#metnion
the#hybrid#use#of#lumbar#fusion#and#ADR#for#the
management#of#LBP/spinal#disorders.
Brox#et#al#(2010)#compared#the#longDterm#eec=veness#of
surgical#and#nonDsurgical#treatment#in#pa=ents#with#chronic
LBP.##The#study#was#conducted#at#4#university#hospitals#in
Norway.##The#limita=ons#on#study#enrollment#ensured#that
pa=ents#with#more#signicant#symptoms#and#ndings#were
not#included#in#the#protocol.##All#par=cipants#had#LBP#for#at
least#1#year,#moderate#disability,#and#evidence#of#disk
degenera=on#at#L4DL5#or#L5DS1;#those#with#symptoma=c
spinal#stenosis#were#excluded#from#study#par=cipa=on.#
Similarly,#pa=ents#with#disk#hernia=on#or#lateral#recess
stenosis#plus#signs#of#radiculopathy#were#excluded,#as#were
those#with#generalized#disk#degenera=on,#ongoing#serious
soma=c#or#psychiatric#disease,#or#"reluctance"#(term#not
dened)#to#undergo#one#of#the#study#treatments.#
Par=cipants#were#randomized#to#receive#instrumented
transpedicular#fusion#or#nonDsurgical#therapy.##The#nonD
surgical#therapy#was#very#intensive#and#included#ini=al
educa=on,#support,#and#physical#training#sessions#that#lasted
an#average#of#25#hours#per#week#over#3#weeks.##There#were
4#to#7#par=cipants#assigned#to#this#training#at#a#=me,#and
they#stayed#in#a#hotel#for#pa=ents#during#the#3#weeks.#
Specialists#in#physical#medicine#and#rehabilita=on#guided#the
program,#and#par=cipants#also#met#with#a#peer#who#had
previously#completed#the#nonDsurgical#program.##At#the#end
of#the#3#weeks,#par=cipants#were#prescribed#a#home
exercise#program.##The#primary#study#outcome#was#the
Oswestry#disability#index,#which#measures#both#pain#and
disability.##Researchers#also#followed#par=cipants'#ra=ngs#of
treatment#eec=veness,#quality#of#life,#and#eects#of#the
interven=ons#on#medica=on#use#and#=me#missed#from
work.##The#study#focused#on#these#results#measured#at#4
years#aqer#randomiza=on,#and#results#were#adjusted#to
account#for#sex,#age,#previous#surgery#for#disk#hernia=on,
and#baseline#pain#and#disability#scores.##Of#234#eligible
pa=ents,#124#were#enrolled#in#the#trials.##Baseline#data#were
similar#for#the#2#groups.##The#mean#age#of#par=cipants#was
42#years,#and#72#%#were#women.##The#average#dura=on
of#LBP#was#9#years,#and#the#mean#severity#of#back#pain#was
64#on#a#scale#of#0#to#100,#with#100#being#the#most#severe
pain.##Both#treatment#groups#professed#stronger#beliefs#in
surgical#versus#nonDsurgical#treatment#of#chronic#LBP#at
baseline.##In#the#surgical#group,#the#rates#of#undergoing
surgery#were#88#%#at#1#year#and#91#%#at#4#years.##The
respec=ve#rates#of#surgery#in#the#nonDsurgical#group#were#5
%#and#24#%.##Study#followDup#was#excellent,#with#rates#of#92
%#and#86#%#in#the#surgical#and#nonDsurgical#groups#at#4
years.##Beyond#comparing#surgical#and#nonDsurgical
treatment#for#chronic#LBP,#the#study#also#gave#some#insight
into#the#use#of#healthcare#and#other#resources#by#these
pa=ents.##Only#a#slight#majority#of#pa=ents#saw#a#physician
for#back#pain#in#the#year#before#study#followDup#at#year#4.#
Less#than#25#%#received#physical#therapy.##However,#the#rate
of#repeat#surgery#aqer#the#ini=al#study#surgery#was#25#%
over#4#years.##This#high#repeat#surgery#rate#was#recorded
despite#the#fact#that#no#major#adverse#events#related#to
surgery#occurred#through#year#1#of#the#study.
Par=cipants#who#received#surgery#were#more#than#twice#as
likely#to#receive#a#disability#pension,#regardless#of#their
randomized#group.##However,#it#would#be#wrong#to#infer#that
surgery#itself#promoted#a#higher#rate#of#disability.##These
pa=ents#had#surgery#in#response#to#more#severe#symptoms,
and#were#therefore#more#likely#to#receive#a#disability
pension#in#the#rst#place.##Moreover,#applica=ons#for
disability#pension#from#pa=ents#who#had#received#surgery
could#have#received#more#favorable#reviews.##There#were#no
dierences#between#randomized#groups#in#the#outcomes#of
pain#and#disability#in#either#intentDtoDtreat#or#asDtreated
analyses#at#4#years.##The#mean#Oswestry#disability#index
score#declined#in#both#groups#from#an#approximate#mean#of
44#at#baseline#to#28#at#4#years.##Among#secondary#outcomes,
the#only#dierence#between#treatment#groups#was#a
reduc=on#in#fear#and#avoidance#of#physical#ac=vity,#favoring
the#nonDsurgical#group.##Measurements#of#general#func=on
improved#by#approximately#40#%#in#both#groups,#and#life
sa=sfac=on#also#improved.##The#number#of#par=cipants
returning#to#work#improved#with#both#treatments#to#a
similar#degree,#and#the#propor=ons#of#par=cipants#ra=ng
their#treatment#as#successful#at#1#year#were#61#%#and#65#%
in#the#surgical#and#nonDsurgical#cohorts,#respec=vely.##Use#of
pain#medica=on#was#higher#among#par=cipants#who
received#surgery,#but#any#dierence#between#treatment
groups#was#not#signicant#on#intentDtoDtreat#analysis.
Appendix
Types%of%Spondylolisthesis%Descrip/on
The#following#types#of#spondylolisthesis#are#based#on
e=ology:
Type#1:#The#dysplas=c#(congenital)#type#represents#a#defect
in#the#upper#sacrum#or#arch#of#L5.##A#high#rate#of#associated
spina#bida#occulta#and#a#high#rate#of#nerve#root
involvement#exist.
Type#2:#This#results#from#a#defect#in#pars#interar=cularis,
which#permits#forward#slippage#of#the#superior#vertebra,
usually#L5.
The#following#3#subcategories#are#recognized:
Acutely#fractured#pars
Elongated#yet#intact#pars
Ly=c#(i.e.,#spondylolysis)#or#stress#fracture#of#the#pars
Type#3:#The#degenera=ve#(late#in#life)#type#is#an#acquired
condi=on#resul=ng#from#chronic#disc#degenera=on#and#facet
incompetence,#leading#to#longDstanding#segmental#instability
and#gradual#slippage,#usually#at#L4DL5.##Spondylosis#is#a
general#term#reserved#for#acquired#ageDrelated#degenera=ve
changes#of#the#spine#(i.e.,#discopathy#or#facet#arthropathy)
that#can#lead#to#this#type#of#spondylolisthesis.
Type#4:#The#trauma=c#(any#age)#type#results#from#fracture#of
any#part#of#the#neural#arch#or#pars#that#leads#to#listhesis.
Type#5:#The#pathologic#type#results#from#a#generalized#bone
disease,#such#as#Paget#disease#or#osteogenesis#imperfecta.
The%Myerding%Grading%System
The#Myerding#grading#system#measures#the#percentage#of
vertebral#slip#forward#over#the#body#beneath:
grade#1 25#%#of#vertebral#body#has#slipped#forward
grade#2 25#%#to#49#%#of#vertebral#body#has#slipped#forward
grade#5 Vertebral#body#has#completely#fallen#o#(i.e.,
spondyloptosis)
Adapted#from:#Vokshoor%A.%Spondylolisthesis,%spondylolysis,
and%spondylosis.%eMedicine.%Orthopedic%Topic%560.%Omaha,
NE:%eMedicine.com:%Updated%June%30,%2004.
Note%on%Stenosis%Grading:
As#a#rule#of#thumb,#severe#stenosis#is#dened#as#75%D99
reduc=on#in#canal#diameter,#moderate#is#50D75%
reduc=on,#and#mild#is#less#than#50%.#Example:
For#a#nonelderly#person#with#no#congenital#abnormality,#the
normal#lumbar#canal#width#is#12#mm,#so#that#a#6#mm
stenosis#would#be#graded#severe.#However,#for#a#person#with
a#congenitally#small#canal#(6D7mm),#a#6#mm#canal
width#would#not#indicate#stenosis.
CPT(Codes(/(HCPCS(Codes(/(ICDJ10(Codes
Informa)on!in!the![brackets]!below!has!been!added!for
clarica)on!purposes.!!!Codes!requiring!a!7th!character!are
represented!by!"+":
Cervical!laminectomy!(and/or!an!anterior!cervical!diskectomy,
corpectomy,!and!cervical!fusion)!for!herniated!disc:
CPT(codes(covered(if(selec>on(criteria(are(met:
22548 Arthrodesis,#anterior#transoral#or#extraoral
technique,#clivusDC1DC2#(atlasDaxis),#with#or
without#excision#of#odontoid#process
22551 Arthrodesis,#anterior#interbody,#including#disc
space#prepara=on,
space#prepara=on,#discectomy,#osteophytectomy
and#decompression#of#spinal#cord#and/or#nerve
roots;#cervical#below#C2;#each#addi=onal
interspace
22554 Arthrodesis,#anterior#interbody#technique;
including#minimal#diskectomy#to#prepare
interspace#(other#than#for#decompression);
cervical#below#c2
63020 Laminotomy#(hemilaminectomy),#with
decompression#of#nerve#root(s),#including#par=al
facetectomy,#foraminotomy#and/or#excision#of
herniated#intervertebral#disc,#including#open#and
endoscopicallyDassisted#approaches;#1#interspace,
cervical
herniated#intervertebral#disc,#reexplora=on,#single
interspace;#cervical
+#63043 ####each#addi=onal#cervical#interspace#(List
separately#in#addi=on#to#code#for#primary
procedure)
63075 Discectomy,#anterior,#with#decompression#of
spinal#cord#and/or#nerve#root(s),#including
osteophytectomy;#cervical,#single#interspace
+63076 Cervical,#each#addi=onal#interspace#(List
procedure)
63081 Vertebral#corpectomy#(vertebral#body#resec=on),
par=al#or#complete,#anterior#approach#with
decompression#of#spinal#cord#and/or#nerve
root(s);#cervical,#single#segment
+63082 ####cervical,#each#addi=onal#segment#(List
procedure)
Other(CPT(codes(related(to(the(CPB:
+#63035 Laminotomy#(hemilaminectomy),#with
herniated#intervertebral#disc;#each#addi=onal
interspace,#cervical#or#lumbar#(List#separately#in
addi=on#to#code#for#primary#procedure)
ICDJ10(codes(covered(if(selec>on(criteria(are(met:
M25.78 Osteophyte,#vertebrae#[of#spine#causing#spinal
cord#or#nerve#root#compression,#conrmed#by
imaging#studies]
M50.00#D Cervical#disc#disorder#with#myelopathy
M50.03
M50.20#D Other#cervical#disc#displacement
M50.23
M54.12#D Radiculopathy,#cervical#and#cervicothoracic#region
M54.13 [cervical#nerve#root#compression]
Thoracic!laminectomy!(and/or!thoracic!diskectomy!and
fusion):
22222 Osteotomy#of#spine,#including#discectomy,
anterior#approach,#single#vertebral#segment;
thoracic
22532 Arthrodesis,#lateral#extracavitary#technique,
including#minimal#discectomy#to#prepare
thoracic
+22534 ####each#addi=onal#vertebral#segment#(List
procedure)
22556 Arthrodesis,#anterior#interbody#technique,
thoracic
+22585 ####each#addi=onal#interspace#(List#separately#in
63003 Laminectomy#with#explora=on#and/or
decompression#of#spinal#cord#and/or#cauda
equina,#without#facetectomy,#foraminotomy#or
discectomy#(eg,#spinal#stenosis),#1#or#2#vertebral
segments;#thoracic
63016 ####more#than#2#vertebral#segments;#thoracic
63046 Laminectomy,#facetectomy#and#foraminotomy
(unilateral#or#bilateral#with#decompression#of
spinal#cord,#cauda#equina#and/or#nerve#root[s],
[eg,#spinal#or#lateral#recess#stenosis]),#single
vertebral#segment;#thoracic
+63048 ####each#addi=onal#segment,#cervical,#thoracic,#or
lumbar#(List#separately#in#addi=on#to#code#for
primary#procedure)
63077 Discectomy,#anterior,#with#decompression#of
spinal#cord#and/or#nerve#root(s),#including
osteophytectomy;#thoracic,#single#interspace
G54.3 Thoracic#root#disorders,#not#elsewhere#classied
[nerve#root#compression]
M24.28 Disorder#of#ligament#vertebrae#[spinal#ligament
hypertrophy]
M47.14#D Others#pondylosis#with#myelopathy#thoracic#or
M47.15 thoracolumar#region
M48.9 Spondylopathy,#unspecied
M51.04#D Intervertebral#disc#disorders#with#myelopathy,
M51.05 thoracic#or#thoracolumbar#region
M51.24#D Other#intervertebral#disc#displacement,#thoracic#or
M51.25 thoracolumbar#region
M96.1 Postlaminectomy#syndrome,#not#elsewhere
classied#[thoracic#region]
S14.2xx+, Injury#to#mul=ple#sites#of#nerve#roots#and#spinal
S24.2xx+, plexus
S34.21x+,
S34.22x+,
S34.4xx+
S23.101+, Disloca=on#of#thoracic#vertebra
S23.111+,
S23.121+,
S23.123+,
S23.131+,
S23.133+,
S23.141+,
S23.143+,
S23.151+,
S23.153+,
S23.161+,
S23.163+,
S23.171+
Lumbar!laminectomy!for!herniated!disc:
lumbar
interspace;#lumbar
+#63044 ####each#addi=onal#lumbar#interspace#(List
procedure)
vertebral#segment;#lumbar
63056 Transpedicular#approach#with#decompression#of
spinal#cord,#equina#and#/or#nerve#root(s)#(eg,
herniated#intervertebral#disc),#single#segment;
lumbar#(including#transfacet,#or#lateral
extraforaminal#approach)#(eg,#far#lateral#herniated
intervertebral#disc)
endoscopicallyDassisted#approaches;#each
addi=onal#interspace,#cervical#or#lumbar#(List
procedure)
+#63048 Laminectomy,#facetectomy#and#foraminotomy
vertebral#segment;#each#addi=onal#segment,
cervical,#thoracic,#or#lumbar#(List#separately#in
+#63057 Transpedicular#approach#with#decompression#of
spinal#cord,#equina#and/or#nerve(s)#(eg,#herniated
intervertebral#disc),#single#segment;#each
addi=onal#segment,#thoracic#or#lumbar#(List
procedure)
M51.06#D Intervertebral#disc#disorders#with#myelopathy,
M51.07 lumbar#and#lumbosacral#region
M51.26#D Other#intervertebral#disc#displacement,#lumbar
M51.27 and#lumbosacral#region
Cervical,!thoracic,!or!lumbar!laminectomy!other!than!for
herniated!disc:
segments;#cervical
63003 ####thoracic
63005 ####lumbar,#except#for#spondylolisthesis
63011 ####sacral
63012 Laminectomy#with#removal#of#abnormal#facets
and/or#pars#interDar=cularis#with#decompression
of#cauda#equina#and#nerve#roots#for
spondylolisthesis,#lumbar#(Gill#type#procedure)
discectomy#(eg,#spinal#stenosis),#more#than#2
vertebral#segments;#cervical
63016 ####thoracic
63017 ####lumbar
cervical
63030 ####1#interspace,#lumbar
+#63035 ####each#addi=onal#interspace,#cervical#or#lumbar
(List#separately#in#addi=on#to#code#for#primary
procedure)
interspace;#cervical
63042 ####lumbar
+#63043 ####each#addi=onal#cervical#interspace#(List
procedure)
+#63044 ####each#addi=onal#lumbar#interspace#(List
procedure)
vertebral#segment;#cervical
63046 ####thoracic
63047 ####lumbar
+#63048 ####each#addi=onal#segment,#cervical,#thoracic,#or
lumbar#(List#separately#in#addi=on#to#code#for
primary#procedure)
63055 Transpedicular#approach#with#decompression#of
spinal#cord,#equina#and#/or#nerve#root(s)#(eg,
herniated#intervertebral#disc),#single#segment;
thoracic
63056 ####lumbar#(including#transfacet,#or#lateral
extraforaminal#approach)#(eg,#far#lateral#herniated
intervertebral#disc)
+#63057 ####each#addi=onal#segment,#thoracic#or#lumbar
(List#separately#in#addi=on#to#code#for#primary
procedure)
C41.2 Malignant#neoplasm#of#vertebral#column,
excluding#sacrum#and#coccyx
C70.1 Malignant#neoplasm#of#spinal#meninges
C72.0#D Malignant#neoplasm#of#spinal#cord#and#cauda
C72.1 equina
C79.31#D Secondary#malignant#neoplasm#of#brain#and#spinal
C79.32 cord
C79.49 Secondary#malignant#neoplasm#of#other#parts#of
nervous#system
C79.51#D Secondary#malignant#neoplasm#of#bone#and#bone
C79.52 marrow
D16.6 Benign#neoplasm#of#vertebral#column,#excluding
sacrum#and#coccyx
D32.1 Benign#neoplasm#of#spinal#meninges
D33.4 Benign#neoplasm#of#spinal#cord
D42.0#D Neoplasm#of#uncertain#behavior#of#meninges
D42.9
D43.0#D Neoplasm#of#uncertain#behavior#of#brain#and
D43.2, spinal#cord
D43.4
D48.0 Neoplasm#of#uncertain#behavior#of#bone#and
ar=cular#car=lage
G06.1 Intraspinal#abscess#and#granuloma
I62.00#D Nontrauma=c#subdural#hemorrhage
I62.03
I62.1 Nontauma=ce#extradural#hemorrhage
M46.20#D Osteomyeli=s#of#vertebra#and#infec=on#of
M46.39 intervertebral#disc#(pyogenic)#[spinal]
M48.00#D Spinal#stenosis
M48.08
M71.38 Other#bursal#cyst,#other#site#[of#spine#causing
spinal#cord#or#nerve#root#compression,#conrmed
by#imaging#studies#(e.g.,#CT#or#MRI)#and#with
corresponding#neurological#decit]
M86.18, Other#acute,#subacute#and#other#chonic
M86.28, osteomyeli=s,#other#site#[spinal]
M86.68
S14.0xx+#D Injury#of#spinal#cord#at#neck#level#[causing#spinal
S14.159+ cord#or#nerve#root#compression,#conrmed#by
imaging#studies#(e.g.,#CT#or#MRI)#and#with
S24.0xx+#D Injury#of#spinal#cord#at#thorax#level#[causing#spinal
S24.159+ cord#or#nerve#root#compression,#conrmed#by
imaging#studies#(e.g.,#CT#or#MRI)#and#with
S31.000+ Unspecied#open#wound#of#lower#back#and#pelvis
without#penetra=on#into#retroperitoneum
S32.000+#D Fracture#of#lumbar#vertebra
S32.059+
S33.100+#D Subluxa=on#and#disloca=on#of#lumbar#vertebra
S33.141+
S34.101+#D Other#and#unspecied#injury#of#lumbar#and#sacral
S34.139+ spinal#cord
Lumbar!decompression:
62287 Decompression#procedure,#percutaneous,#of
nucleus#pulposus#of#intervertebral#disc,#any
method,#single#or#mul=ple#levels,#lumbar#(eg,
manual#or#automated#percutaneous#discectomy,
percutaneous#laser#discectomy)
segments;#lumbar,#except#for#spondylolisthesis
63012 Laminectomy#with#removal#of#abnormal#facets
and/or#pars#interDar=cularis#with#decompression
of#cauda#equina#and#nerve#roots#for
spondylolisthesis,#lumbar#(Gill#type#procedure)
discectomy#(eg,#spinal#stenosis),#more#than#2
vertebral#segments;#lumbar
herniated#intervertebral#disc;#1#interspace,#lumbar
herniated#intervertebral#disc;#each#addi=onal
interspace,#cervical#or#lumbar#(List#separately#in
G83.4 Cauda#equina#syndrome
M21.371#D Foot#drop
M21.379
Cervical!spinal!fusion:
22548 Arthrodesis,#anterior#transoral#or#extraoral
technique,#clivusDC1DC2#(atlasDaxis),#with#or
without#excision#of#odontoid#process
space#prepara=on,#discectomy,#osteophytectomy
and#decompression#of#spinal#cord#and/or#nerve
roots;#cervical#below#C2
+22552 ####cervical#below#C2,#each#addi=onal#interspace
(List#separately#in#addi=on#to#code#for#separate
procedure)
cervical#below#C2
22590 Arthrodesis,#posterior#technique,#craniocervical
(occiputDC2)
22595 Arthrodesis,#posterior#technique,#atlasDaxis#(C1D
C2)
22600 Arthrodesis,#posterior#or#posterolateral#technique,
single#level;#cervical#below#C2#segment
procedure)
C41.2 Malignant#neoplasm#of#vertebral#column#[cervical]
C72.0#D Malignant#neoplasm#of#spinal#cord#and#cauda
C72.1 equina#[cervical]
nervous#system#[cervical#spinal#cord]
C79.52 marrow#[cervical#spine]
D16.6 Benign#neoplasm#of#vertebral#column#[cervical]
D33.4 Benign#neoplasm#of#spinal#cord#[cervical]
D43.4 Neoplasm#of#uncertain#behavior#of#spinal#cord
[cervical]
ar=cular#car=lage#[cervical#spine]
D49.2 Neoplasm#of#unspecied#behavior#of#bone,#soq
=ssue,#and#skin
D49.7 Neoplasm#of#unspecied#behavior#of#endocrine
glands#and#other#parts#of#nervous#system#[cervical
spinal#cord]
G06.1 Intraspinal#abscess#and#granuloma#[cervical]
G54.2 Cervical#root#disorders,#not#elsewhere#classied
[nerve#root#compression]
G95.20#D Other#and#unspecied#cord#compression#[cervical
G95.29 cord#compression]
M40.03, Kyphosis#[cervical]
M40.12#D
M40.13,
M40.202#D
M40.203,
M40.292#D
M40.293
M40.40, Lordosis#[cervical]
M40.50
M41.02#D Scoliosis#[cervical]
M41.03,
M41.112#D
M41.113,
M41.122#D
M41.123,
M41.22#D
M41.23,
M41.41#D
M41.43,
M41.52#D
M51.53,
M41.82#D
M41.83
M43.11#D Spondylolisthesis,#occipitoDatlantoDaxial,#cervical
M43.13 and#cervicothoracic#region#[subaxial
spondylolisthesis]
M43.3 Recurrent#atlantoaxial#disloca=on#with
myelopathy
M43.4 Other#recurrent#atlantoaxial#disloca=on
M47.011#D Spondylosis#[cervical#cord#compression]
M47.013,
M47.021#D
M47.022,
M47.11#D
M47.13,
M47.21#D
M47.23,
M47.811#D
M47.813,
M47.891#D
M47.893
M48.01#D Spinal#stenosis,#[cervical#region]
M48.03,
M50.00#D Cervical#disc#disorders#[cervical#cord#compression]
M50.93
M54.11#D Radiculopathy#[cervical#nerve#root#compression]
M54.13
M66.18 Rupture#of#synovium,#other#site#[synovial#cyst]
M71.38 Other#bursal#cyst,#other#site#[synovial#cyst]
M96.0 Pseudarthrosis#aqer#fusion#or#arthrodesis
[cervical]
M96.1 Postlaminectomy#syndrome,#not#elsewhere
classied#[cervical]
Q67.5 Congenital#deformity#of#spine#[cervical]
Q75.9 Congenital#malforma=on#of#skull#and#face#bones,
unspecied#[basilar#invagina=on]
Q76.2 Congenital#spondylolisthesis#[cervical]
Q76.3 Congenital#scoliosis#due#to#congenital#bony
malforma=on#[cervical]
Q76.49 Other#congenital#malforma=ons#of#spine,#not
associated#with#scoliosis#[cervical]
S12.000+#D Fracture#of#cervical#vertebra#and#other#parts#of
S12.9xx+ neck
S13.0xx+#D Disloca=on#and#sprain#of#joints#and#ligaments#at
S13.9xx+ neck#level
S14.0xx+#D Injury#of#nerves#and#spinal#cord#at#neck#level
S14.9xx+
Z98.1 Arthrodesis#status#[nonDunion#of#prior#fusion]
[cervical]
Thoracic!spinal!fusion:
thoracic
+22534 ####thoracic#or#lumbar,#each#addi=onal#vertebral
segment#(List#separately#in#addi=on#to#code#for
primary#procedure)
thoracic
single#level;#thoracic#(with#lateral#transverse
technique,#when#performed)
procedure)
C72.0 Malignant#neoplasm#of#spinal#cord
C79.32 cord#[thoracic#spinal#cord]
C79.52 marrow#[spine,#spinal#(column)]
D16.6 Benign#neoplasm#of#vertebral#column
D43.2, spinal#cord
D43.4
ar=cular#car=lage#[spine,#spinal#(column)]
D49.2 Neoplasms#of#unspecied#nature#of#bone,#soq
=ssue,#and#skin#[spine,#spinal#(column)]
D49.7 Neoplasm#of#unspecied#behavior#of#endocrine
glands#and#other#parts#of#nervous#system#[thoracic
spinal#cord]
G06.1 Intraspinal#abscess
M40.00#D Kyphosis#(acquired)
M40.299,
M96.2#D
M96.3
M41.112#D Kyphosis#and#scoliosis
M41.9
M43.10#D Spondylolisthesis
M43.19
M47.14 Other#spondylosis#with#myelopathy,#thoracic
region
M48.04#D Spinal#stenosis#thoracic#region
M48.05
M51.04#D Interverteral#disc#disorders#with#myelopathy,
M51.05 thoracic#region
M51.24#D Other#intervertebral#disc#displacement,#thoracic
M51.25 region
M54.14#D Radiculopathy,#thoracic#region
M54.15
S12.000K+#D Fracture#of#spinal#column,#[open,#closed,#nonD
S12.691+, union,#with#or#without#spinal#cord#injury]
S22.000+#D
S22.089+,
S32.000+#D
S32.2xx+
S21.201+#D Open#wound#of#back#wall#of#thorax#without#or
S21.259+, with#penetra=on#into#thoracic#cavity#[allowed
S21.401+#D when#billed#with#S23.1xx#codes#only]
S21.95x+
S23.101+, Disloca=on#of#thoracic#vertebra#[open#disloca=on
S23.111+, must#be#billed#with#S21.2xx#or#S21.4xx#codes]
S23.121+,
S23.123+,
S23.131+,
S23.133+.
S23.141+,
S23.143+,
S23.151+,
S23.153+,
S23.161+,
S23.163+,
S23.171+,
S23.20x+#D
S23.29x+
S24.101+#D Other#and#unspecied#injury#of#thoracic#spinal
S24.159+ cord
Z98.1 Arthrodesis#status
Lumbar!spinal!fusion:
lumbar
lumbar
single#level;#lumbar#(with#or#without#lateral
transverse#technique)
+#22614 ####each#addi=onal#vertebral#segment#(List
procedure)
22630 Arthrodesis,#posterior#interbody#technique,
including#laminectomy#and/or#discectomy#to
prepare#interspace#(other#than#for
decompression),#single#interspace;#lumbar
22633 Arthrodesis,#combined#posterior#or#posterolateral
technique#with#posterior#interbody#technique,
including#laminectomy#and/or#discectomy
sucient#to#prepare#interspace#(other#than#for
decompression),#single#interspace;#lumbar
22634 ####each#addi=onal#interspace#and#segment#(List
procedure)
C70.1 Malignant#neoplasm#of#spinal#meninges
C79.32 cord
nervous#system
C79.52 marrow
D32.1 Benign#neoplasm#of#spinal#meninges
D42.0#D Neoplasm#of#uncertain#behavior#of#meninges
D42.9
D43.2, spinal#cord
D43.4
ar=cular#car=lage
G06.1 Intraspinal#abscess#and#granuloma
M40.35#D Flatback#syndrome,#thoracolumbar,#lumbar,#and
M40.37 lumbosacral#region#[with#signicant#sagical
imbalance,#when#fusion#is#performed#with#spinal
osteotomy]
M40.50#D Lordosis,#unspecied
M40.57
M41.00#D Scoliosis
M41.35
M41.80#D
M41.9
M43.00#D Spondylolysis#and#spondylolisthesis
M43.19
M46.20 Osteomyeli=s#of#vertebra,#site#unspecied
M46.30 Infec=on#of#intervertebral#disc#(pyogenic),#site
unspecied
M48.06#D Spinal#stenosis,#lumbar#and#lumbosacral#region
M48.07
M48.50x+#D Pathologic#fracture#of#vertebrae
M48.58x+
M80.08x+
M84.48x+
M84.58x+
M84.68x+
M86.18 Other#acute#osteomyeli=s,#other#site#[spinal]
M86.28 Subacute#osteomyeli=s,#other#site#[spinal]
M86.68 Other#chronic#osteomyeli=s,#other#site#[spinal]
M96.0 Pseudoarthrosis#aqer#fusion#or#arthrodesis
M96.5 Postradia=on#scoliosis
Q76.2 Congenital#spondylolisthesis
S31.000+ Unspecied#open#wound#of#lower#back#and#pelvis
without#penetra=on#into#retroperitoneum
S32.000+#D Fracture#of#lumbar#vertebra
S32.059+
S33.100+#D Subluxa=on#and#disloca=on#of#lumbar#vertebra
S33.141+
S34.101+#D Other#and#unspecied#injury#of#lumbar#spinal#cord
S34.129+
Z98.1 Arthrodesis#status
Numerous Nonunion#of#fracture#[Codes#not#listed#due#to
op=ons expanded#specicity]
ICDJ10(codes(not(covered(for(indica>ons(listed(in(the(CPB((not
all(inclusive):
M51.34#D Other#thoracic,#thoracolumbar#and#lumbosacral
M51.37 intervertebral#disc#degenera=on
The(above(policy(is(based(on(the(following(references:
1.# Bigos#S,#Bowyer#O,#Braen#G,#et#al.#Acute#low#back
problems#in#adults.#Clinical#Prac=ce#Guideline#No.#14.
AHCPR#Publica=on#No.#95D0642.#Rockville,#MD:
Agency#for#Health#Care#Policy#and#Research#(AHCPR);
December#1994.
2.# Jarvik JG, Deyo RA. Diagnostic evaluation of low back pain
with emphasis on imaging. Ann Intern Med. 2002;137(7):586-
597.
3.# Carroll#S,#Wiesel#S.#Neurologic#complica=ons#and
lumbar#laminectomy.#Clin#Orthop#Relat#Res.
1992;284:14D23.
4.# Nachemson#A,#Carlsson#CDA,#Englund#L,#et#al.#Back#and
neck#pain#[summary].#SBU#Report#No.145.#Stockholm,
Sweden:#Swedish#Council#on#Technology#Assessment
in#Health#Care#(SBU);#2000.
5.# Norwegian#Knowledge#Centre#for#the#Health#Services
(NOKC).#Treatment#of#lumbar#disc#hernia=on.#SMMD
Report#1/2001.#Oslo,#Norway:#NOKC;#2001.
6.# ECRI#Health#Technology#Assessment#Group.#Treatment
of#degenera=ve#lumbar#spinal#stenosis.#Volume#1:
Evidence#report.#Volume#2:#Evidence#tables#and
bibliography.#Evidence#Report/Technology
Assessment#No.#32.#Rockville,#MD:#Agency#for
Healthcare#Research#and#Quality#(AHRQ);#2001.
7.# Gibson#JNA,#Waddell#G.#Surgery#for#degenera=ve
lumbar#spondylosis.#Cochrane#Database#Syst#Rev.
2005;(4):CD001352.
8.# The#North#American#Spine#Society#(NASS).#Adult
isthmic#spondylolisthesis.##North#American#Spine
Society#Public#Educa=on#Series.#LaGrange,#IL:#NASS;
2006.#Available#at:
hCp://www.spine.org/Documents/spondy_2006.pdf
(hCp://www.spine.org/Documents/spondy_2006.pd
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Prepared#for#the#Agency#for#Healthcare#Research#and
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54.# Dawodu#ST.#Cauda#equina#and#conus#medullaris
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Accessed#April#14,#2006.
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56.# Small#SA,#Perron#AD,#Brady#WJ.#Orthopedic#pi~alls:
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86.# Turner#JA,#Ersek#M,#Herron#L,#et#al.#Surgery#for#lumbar
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97.# Jang#JS,#Lee#SH,#Min#JH,#et#al.#Surgical#treatment#of
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102.# Ones=#ST.#Failed#back#syndrome.#Neurologist.
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103.# Duggal#N,#Mendiondo#I,#Pares#HR,#et#al.#Anterior
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105.# Fritsch#EW,#Heisel#J,#Rupp#S.#The#failed#back#surgery
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112.# Mar=nez#Ferez#IM,#Molina#Linde#JM,#Villegas#Portero
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123.# Dr.#Robert#Bree#Collabora=ve,#Accountable#Payments
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Copyright#Aetna#Inc.#All#rights#reserved.#Clinical#Policy#Bulle=ns#are#developed#by#Aetna#to#assist#in
administering#plan#benets#and#cons=tute#neither#oers#of#coverage#nor#medical#advice.#This#Clinical
Policy#Bulle=n#contains#only#a#par=al,#general#descrip=on#of#plan#or#program#benets#and#does#not
cons=tute#a#contract.#Aetna#does#not#provide#health#care#services#and,#therefore,#cannot#guarantee#any
results#or#outcomes.#Par=cipa=ng#providers#are#independent#contractors#in#private#prac=ce#and#are
neither#employees#nor#agents#of#Aetna#or#its#aliates.#Trea=ng#providers#are#solely#responsible#for
medical#advice#and#treatment#of#members.#This#Clinical#Policy#Bulle=n#may#be#updated#and#therefore#is
subject#to#change.
Copyright##2001D2017#Aetna#Inc.

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