GL173-interlaminar-interspinous-tabilization-distraction ...



In January 2018, these codes were moved to Guideline Note 173.CPT 22867-22870 Insertion of interlaminar/interspinous process stabilization/distraction deviceLast reviewed at VbBS in November 2016. Minutes indicate that the staff recommendation was accepted without significant discussion.The following was presented in the meeting materials for the November, 2016 VbBS meeting:22867-22870 Insertion of interlaminar/interspinous process stabilization/distraction deviceCodes22867 Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level22868 second level22869 Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level22870 second levelPrevious coding: there are no previous codes for this type of procedureDefinition: Interspinous spacers are devices implanted between vertebral spinous processes. Interlaminar spacers are implanted between adjacent lamina and have 2 sets of wings that are placed around the inferior and superior spinous processes. These implants aim to restrict painful motion while otherwise enabling normal motion. The devices (spacers) distract the laminar space and/or spinous processes and restrict extension. This procedure theoretically enlarges the neural foramen and decompresses the cauda equina in patients with spinal stenosis and neurogenic claudication. These devices can be used as part of decompressive surgery or can be used alone as a minimally invasive surgery. There are several FDA approved devices, including the X-STOP? Interspinous Process Decompression (IPD?) System (the manufacturer has removed this from the market), Coflex? Interlaminar Technology implant (formerly known as Interspinous U), and the Superion? Interspinous Spacer (ISS, VertiFlex).Evidence—interspinous spacers vs decompressive surgery for lumbar spinal stenosisWu 2014, systematic review and meta-analysis of interspinous spacers vs traditional decompressive surgery for lumbar spinal stenosis N=5 (2 RCTs and 2 non-randomized prospective studies)N=204 in the interspinous spacer (IS) group and 217 patients in the traditional decompressive surgery (TDS) group. Pooled analysis showed no significant difference between the IS and TDS groups for low back pain (WMD: 1.2; 95% CI: 210.12, 12.53; P = 0.03; I2 = 66%), leg pain (WMD: 7.12; 95% CI: 23.88, 18.12; P = 0.02; I2 = 70%), ODI (WMD: 6.88; 95% CI: 214.92, 28.68; P = 0.03; I2 = 79%), RDQ (WMD: 21.30, 95% CI: 23.07, 0.47; P = 0.00; I2 = 0%), or complications (RR: 1.39; 95% CI: 0.61, 3.14; P = 0.23; I2 = 28%). The TDS group had a significantly lower incidence of reoperation (RR: 3.34; 95% CI: 1.77, 6.31; P = 0.60; I2 = 0%).Conclusion: Although patients may obtain some benefits from interspinous spacers implanted through a minimally invasive technique, interspinous spacer use is associated with a higher incidence of reoperation and higher cost. The indications, risks, and benefits of using an interspinous process device should be carefully considered before surgery.Evidence— interspinous spacers vs conservative care for lumbar spinal stenosisZucherman 2006RCT of interspinous spacers (X-stop) vs conservative therapyN=191 patients (100 in the X STOP group and 91 in the control group). At every follow-up visit, X STOP patients had significantly better outcomes in each domain of the Zurich Claudication Questionnaire. At 2 years, the X STOP patients improved by 45.4% over the mean baseline Symptom Severity score compared with 7.4% in the control group; the mean improvement in the Physical Function domain was 44.3% in the X STOP group and _0.4% in the control group. In the X STOP group, 73.1% patients were satisfied with their treatment compared with 35.9% of control patients. Conclusions. The X STOP provides a conservative yet effective treatment for patients suffering from lumbar spinal stenosis. In the continuum of treatment options, the X STOP offers an attractive alternative to both conservative care and decompressive surgery Pullizzi 2014, RCT of interspinous spacers (X-stop) vs conservative therapyN=542 patients (422 X-Stop, 120 conservative care controls)One-year follow-up evaluation revealed positive good results in the 83.5% of patients treated with IPD with respect to 50% of the nonoperative group cases. During the first three years, in 38 out of the 120 control cases, a posterior decompression and/or spinal fixation was performed because of unsatisfactory results of the conservative therapy. In 24 of 422 patients, the IPD device had to be removed, and a decompression and/or pedicle screw fixation was performed because of the worsening of neurological symptoms. Conclusions: Our results support the effectiveness of surgery in patients with stenosis. IPD may offer an effective and less invasive alternative to classical microsurgical posterior decompression in selected patients with spinal stenosis and lumbar degenerative disk diseasesEvidence—complicationsKim 2013, case series of 50 implants (various type) in 38 patientsPostoperative CT revealed 11 nondisplaced spinous process fractures in 11 patients. (28.9% of patients, 22% of levels). Five fractures were associated with mild to moderate lumbar back pain and six fractures were asymptomatic. Three patients underwent IPS removal and laminectomy.Barbagallo 2009, case series of 69 patients treated with X-Stop for lumbar spinal stenosisEight complications were recorded: 4 device dislocations and 4 spinous process (SP) fractures, including 2 spontaneous fractures of the L4 SP in patients treated at L3–L4 and L4–L5. Other policiesNICE 2010, interspinous distraction for lumbar spinal stenosis causing neurogenic claudicationCurrent evidence on interspinous distraction procedures for lumbar spinal stenosis causing neurogenic claudication shows that these procedures are efficacious for carefully selected patients in the short and medium term, although failure may occur and further surgery may be needed.Aetna, Cigna and BCBS consider interspinous distraction and spacers experimental for all indicationsLack of better outcomes vs traditional decompression with higher rates of complications; lack of evidence for use as stand-alone procedureExpert guidelinesNorth American Spine Society 2011, guidelines for treatment of lumbar spinal stenosis; study not included due to length, can be found here: ()There is insufficient evidence at this time to make a recommendation for or against the placement of an interspinous process spacing device in patients with lumbar spinal stenosis [compared to medical/non-surgical management]HERC staff summary: There is no evidence of benefit of these devices compared to traditional decompression surgery, but there is a higher complication and re-operation rate. Two trials have shown benefit of these devices compared to medical management; however, NASS and private insurers have not found sufficient evidence for use as a stand-alone procedure.HERC staff recommendation:Place 22867-22870 Insertion of interlaminar/interspinous process stabilization/distraction device on the Services Recommended for Non-Coverage tableAs effective as current therapy with higher rates of complications ................
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