Laminectomy, Lumbar, +/- Discectomy/Foraminotomy/Fusion

[Pages:3]2011 Procedures Adult Criteria

Laminectomy, Lumbar, +/- Discectomy/Foraminotomy/Fusion

2011 Procedures Adult Criteria

Laminectomy, Lumbar, +/- Discectomy/Foraminotomy/Fusion(1*RIN)

CLIENT: CPT/ICD9: PROVIDER:

Name Code Name Signature

D.O.B. Facility

ICD-9-CM: 03.09, 80.51

INDICATIONS (choose one and see below)

ID# Service Date ID# Date

GROUP# Phone#

100 Cauda equina syndrome

200 Lumbar spinal stenosis

Indication Not Listed (Provide clinical justification below)

100 Cauda equina syndrome [Both] (2*RIN, 3)

110 Sx/findings [One](4) 111 Bilateral lower extremity weakness/numbness/pain(5, 6) 112 Bowel incontinence and other etiologies excluded 113 Bladder dysfunction and other urologic etiologies excluded(7) 114 Diminished rectal sphincter tone by PE 115 Perianal/perineal "saddle" anesthesia by PE

120 Cauda equina compression by imaging [Both] 121 Study performed [One] -1 MRI(8) -2 CT -3 MYL-CT(9) 122 Pathology causing compression [One] -1 Central/median/paramedian disc herniation(10) -2 Spondylosis with degenerative disease (spinal stenosis)(11) -3 Spondylolisthesis, degenerative(11, 12, 13)

200 Lumbar spinal stenosis [All](11, 14) 210 Low back/bilateral lower extremity Sx/findings [All](15, 16) 211 Pain/paresthesias/numbness worse with walking 212 Pain/paresthesias/numbness worse with spinal extension 213 Pain/paresthesias/numbness improved with forward flexion 220 Continued Sx/findings after Rx [Both](17)

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2011 Procedures Adult Criteria

Laminectomy, Lumbar, +/- Discectomy/Foraminotomy/Fusion

221 NSAID [One](18) -1 Rx 3 wks -2 Contraindicated/not tolerated(19)

222 Activity modification 12 wks(20) 230 Imaging study performed [One]

231 MRI(21) 232 CT 233 MYL-CT(9)

Notes

(1)-RIN: For spinal cord compression secondary to metastatic disease, see the "Metastatic Tumor Excision, Spine, +/- Fusion" criteria subset. (2)-RIN: Primarily as the result of aging, degenerative changes occur in the lumbar spine (e.g., spondylolisthesis) that can lead to spinal instability and cauda equina compression. Fusion may accompany decompressive laminectomy in this situation, and does not require separate authorization. (3)-DEF: The cauda equina (horse's tail) is a collection of dorsal and ventral nerve roots caudal to the termination of the spinal cord. Cauda equina syndrome is compression of these multiple nerve roots in the lumbar spinal canal, usually due to a large central herniated disc. The primary symptoms of cauda equina syndrome include lower extremity weakness, bowel and bladder dysfunction, diminished rectal sphincter tone, or perianal or perineal "saddle" anesthesia. (4) The usual presentation is urinary retention or stool incontinence. Loss of bowel or bladder control implies significant cauda equina compression and requires urgent evaluation and treatment. (5) Muscle strength can be graded on a 0 to 5 scale (0 is no visible or palpable muscle contraction and 5 is normal strength) (Braddom and Buschbacher, Physical medicine and rehabilitation, 2nd ed. 2000). For the purposes of these criteria, severe muscle weakness is defined as "less than 2 out of 5" muscle strength by PE (less than full ROM with gravity eliminated) or the inability to ambulate. (6) An isolated sensory deficit as the sole manifestation of cauda equina compression is rare. If an isolated sensory deficit is present, peripheral neuropathy (e.g., diabetic neuropathy) is more likely. The pattern of sensory loss in cauda equina compression is often diffuse (with overlapping nerve root distributions) and asymmetric or unilateral. (7) Urinary retention is a common symptom of cauda equina syndrome. Other urinary symptoms may include frequency, hesitancy, urgency, or incontinence. (8) MRI is the preferred imaging procedure since it will better demonstrate the cause and extent of the cord compression and may also demonstrate cord edema. Imaging findings should correlate with symptoms and PE findings before surgery is considered. (9) Myelography readings of contrast truncation, effacement or thinning, filling defects, or thecal sac compression should be accompanied by specific mention of neurocompression. (10) Disc bulging and degeneration are common imaging findings in patients without symptoms or PE findings. These criteria address disc pathology seen by imaging which causes neurocompression.

InterQual? copyright ? 2011 and CareEnhance? Review Manager copyright ? 2011 McKesson Corporation and/or one of its subsidiaries. All Rights

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May contain CPT? codes. CPT only ? 2010 American Medical Association. All Rights Reserved.

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2011 Procedures Adult Criteria

Laminectomy, Lumbar, +/- Discectomy/Foraminotomy/Fusion

(11) Multiple levels (vertebral interspaces) may be involved with spondylolisthesis or stenosis.

(12)-DEF: Spondylolisthesis is anterior slippage of one of the lumbar vertebrae in relation to the vertebral body below it.

(13) Patients undergoing surgery for degenerative spondylolisthesis with spinal stenosis benefit by achieving a solid fusion (Kornblum et al., Spine 2004; 29(7): 726-733; discussion 733-734).

(14)-DEF: Lumbar spinal stenosis is a syndrome of single or multiple level narrowing of the spinal canal. It is usually caused by degenerative changes involving the spine. Severe cases of lumbar spinal stenosis can result in cauda equina compression.

(15) Symptoms of pain in the buttocks, thighs, or calves with walking or after prolonged standing are known as neurogenic claudication.

(16) Neurogenic intermittent claudication secondary to lumbar spinal stenosis is a degenerative condition generally affecting patients 50 years of age or older. Characteristic symptoms include back and leg pain, tingling, numbness, and weakness that are present depending on the patient's posture; symptoms become worse with spinal extension, such as with walking or after prolonged standing and are relieved with forward flexion.

(17) Lumbar spinal stenosis is usually treated nonoperatively for 8 to 12 weeks before surgery is considered (Harwood and Smith, Clin Fam Pract 2005; 7(2): 279-303). In a controlled trial comparing conservative treatment with surgery, patients treated conservatively for up to 3 months reported satisfactory relief of pain (Amundsen et al., Spine 2000; 25(11): 1424-1435; discussion 1435-1436).

(18)-POL: NSAIDs are preferred for the treatment of this condition because of their anti-inflammatory effect. It is a matter of local medical policy whether to accept acetaminophen or other analgesics as alternatives for NSAIDs.

(19) Contraindications to NSAIDs may be absolute (e.g., pregnancy, history of allergic reaction) or relative (e.g., anticoagulant use, history of PUD).

(20) Activity modification for lumbar spinal stenosis involves limiting activities that provoke or aggravate symptoms, and may include a brief period of rest. PT with exercises to improve posture and strengthen lumbar muscles, and flexion exercises (e.g., riding a stationary bike in a forward flexed position) may be beneficial in some patients (Sengupta and Herkowitz, Orthop Clin North Am 2003; 34(2): 281-295; Patel, J Neurol Neurosurg Psychiatry 2002; 73 Suppl 1: i42-48).

(21) MRI is the imaging procedure of choice for suspected lumbar spinal stenosis. MRI is more sensitive than CT in demonstrating disc degeneration, disc protrusion, and nerve root compression. CT or MYL-CT is reasonable when MRI is unavailable or contraindicated (Sengupta and Herkowitz, Orthop Clin North Am 2003; 34(2): 281-295; Patel, J Neurol Neurosurg Psychiatry 2002; 73 Suppl 1: i4248).

InterQual? copyright ? 2011 and CareEnhance? Review Manager copyright ? 2011 McKesson Corporation and/or one of its subsidiaries. All Rights

Reserved.

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