Clinical UM Guideline

 

Subject: Surgical Interventions for Scoliosis and Spinal Deformity
Guideline #:  CG-SURG-47 Publish Date:    08/29/2018
Status: Reviewed Last Review Date:    07/26/2018

Description

This document addresses surgical procedures for the treatment of scoliosis and other spinal deformities to include spinal fusion, osteotomy, vertebrectomy (as an example, kyphectomy) and associated instrumentation procedures.  Spinal fusion refers to the surgical joining of two or more vertebrae at the involved levels of the spine for the treatment of severe or progressive scoliosis and other spinal deformities in children, adolescents and adults.  Osteotomy refers to the cutting of a vertebra to facilitate angular correction.  Vertebrectomy implies the removal of part or all of a vertebra at the apex of a severe curve.

Note: For information regarding other spinal topics, see:

Clinical Indications

NOTE: When fusion at more than one level is planned, the criteria below apply to each level of fusion being considered.  The criteria below also apply to fusion of a level adjacent to a prior surgical fusion.

Medically Necessary:

Spinal fusion at a single level or at multi-involved levels as a treatment of spinal deformity is considered medically necessary when one or more of the following indications are met (A through C):

  1. The individual has symptomatic degenerative scoliosis and/or sagittal deformity confirmed by imaging studies in skeletally mature adults with one or more of the following (1through 3):
    1. Persistent and severe disabling axial or radicular pain, (such as neurogenic claudication) that has been unresponsive to at least 3 months of conservative medical therapy;* or
    2. Documented functional impairment (for example, loss of pulmonary function); or
    3. Visually severe deformity with high probability of curvature and/or sagittal deformity progression;or
  2. The individual has idiopathic scoliosis with ONE of the following (1 or 2):
    1. Deformity confirmed by imaging studies with a Cobb angle greater than or equal to 40 degrees in early onset scoliosis (age 10 or younger) or functional impairment due to spinal deformity (for example, decreased pulmonary function, gait impairment or loss of sitting balance); or
    2. Deformity confirmed by imaging studies with a Cobb angle greater than 45 degrees at initial presentation in skeletally immature children and adolescents (over age of 10) or progressive curvature of the spine over 45 degrees;     or
  3. The individual has neuromuscular scoliosis due to ANY of the following conditions (1 through 7):
    1. Deformity due to neurofibromatosis with imaging that confirms a Cobb curvature greater than 40 degrees; or
    2. Deformity due to cerebral palsy with one or more of the following (a through d):
      1. Documented progression of the deformity confirmed by imaging studies as greater than 10 degrees per year; or
      2. Age 10 years or older with image-confirmed Cobb angle greater than 45 degrees; or
      3. Individuals with image-confirmed spinal maturity AND Cobb angle greater than 40 degrees; or
      4. Progressive functional impairment due to the spinal deformity (for example, inability to maintain balance while sitting upright); or
    3. Deformity due to connective tissue disorder (for example, Marfan syndrome, Ehlers Danlos syndrome) with one or more of the following (a or b):
      1. Documented progression of the deformity confirmed by imaging studies as greater than 10 degrees per year; or
      2. Individuals with image-confirmed spinal maturity AND Cobb angle greater than 40 degrees; or
    4. Deformity due to Duchenne-type muscular dystrophy with one or more of the following (a or b):
      1. Individuals with image-confirmed Cobb angle greater than or equal to 30 degrees; or
      2. When the progression of the spinal deformity has resulted in inability to ambulate; or
    5. Deformity due to spinal muscular atrophy with one or more of the following (a or b):
      1. Individuals with image-confirmed Cobb angle greater than 50 degrees; or
      2. When the spinal deformity has caused severe functional deterioration; or 
    6. The individual has myelomeningocele (spina bifida) with one of the following (a or b):
      1. Progressive functional impartment (for example, loss of sitting balance or deterioration of assisted ambulation); or
      2. Documented recurrent skin breakdown; or
    7. Severe deformity due to other conditions or diseases (for example, rotatory deformity, dwarfism).  

Repeat spinal fusion for revision of a prior fusion due to pseudarthrosis is considered medically necessary for persistent disabling pain or functional impairment due to a complication of the original fusion surgery, for example, device malfunction, infection or curve progression.  

Osteotomy or vertebrectomy are considered medically necessary for correction of a severe spinal deformity when one or more of the following criteria are met (A through C):

  1. Rigid spinal kyphosis or scoliosis greater than 75 degrees; or
  2. Progressive functional impairment due to the spinal deformity (for example, cardiopulmonary compromise, inability to maintain sitting balance or gait disturbance); or
  3. Documented recurrent skin breakdown.

*Note: Conservative medical therapy for the treatment of scoliosis includes documentation of at least 3 months of medical management including, but not limited, to:

Not Medically Necessary:

Spinal fusion for the treatment of scoliosis and other spinal deformities is considered not medically necessary when the above criteria are not met.

Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT

 

 

Fusion and kyphectomy procedures

22800

Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments

22802

Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segments

22804

Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral segments

22808

Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 vertebral segments

22810

Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7 vertebral segments

22812

Arthrodesis, anterior, for spinal deformity, with or without cast; 8 or more vertebral segments

22818

Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); single or 2 segments

22819

Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); 3 or more segments

 

Associated instrumentation (add-on codes)

22842

Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments

22843

Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 7 to 12 vertebral segments

22844

Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or more vertebral segments

22845

Anterior instrumentation; 2 to 3 vertebral segments

22846

Anterior instrumentation; 4 to 7 vertebral segments

22847

Anterior instrumentation; 8 or more vertebral segments

 

Revision, reinsertion of fixation

22849

Reinsertion of spinal fixation device

 

 

ICD-10 Procedure

 

 

Kyphectomy procedures

0PB40ZZ-0PB44ZZ

Excision of thoracic vertebra

 

 

 

Fusion procedures

0RG1070-0RG10ZJ

Fusion of cervical vertebral joint, open approach [with autologous, synthetic or nonautologous tissue substitute or interbody device, by approach; includes codes 0RG1070, 0RG1071, 0RG107J, 0RG10A0, 0RG10AJ, 0RG10J0, 0RG10J1, 0RG10JJ, 0RG10K0, 0RG10K1, 0RG10KJ, 0RG10Z0, 0RG10Z1, 0RG10ZJ]

0RG1470-0RG14ZJ

Fusion of cervical vertebral joint, percutaneous endoscopic approach [with autologous, synthetic or nonautologous tissue substitute or interbody device, by approach; includes codes 0RG1470, 0RG1471, 0RG147J, 0RG14A0, 0RG14AJ, 0RG14J0, 0RG14J1, 0RG14JJ, 0RG14K0, 0RG14K1, 0RG14KJ, 0RG14Z0, 0RG14Z1, 0RG14ZJ]

0RG2070-0RG20ZJ

Fusion of 2 or more cervical vertebral joints, open approach [with autologous, synthetic or nonautologous tissue substitute or interbody device, by approach; includes codes 0RG2070, 0RG2071, 0RG207J, 0RG20A0, 0RG20AJ, 0RG20J0, 0RG20J1, 0RG20JJ, 0RG20K0, 0RG20K1, 0RG20KJ, 0RG20Z0, 0RG20Z1, 0RG20ZJ]

0RG2470-0RG24ZJ

Fusion of 2 or more cervical vertebral joints, percutaneous endoscopic approach [with autologous, synthetic or nonautologous tissue substitute or interbody device, by approach; includes codes 0RG2470, 0RG2471, 0RG247J, 0RG24A0, 0RG24AJ, 0RG24J0, 0RG24J1, 0RG24JJ, 0RG24K0, 0RG24K1, 0RG24KJ, 0RG24Z0, 0RG24Z1, 0RG24ZJ]

0RG4070-0RG40ZJ

Fusion of cervicothoracic vertebral joint, open approach [with autologous, synthetic or nonautologous tissue substitute or interbody device, by approach; includes codes 0RG4070, 0RG4071, 0RG407J, 0RG40A0, 0RG40AJ, 0RG40J0, 0RG40J1, 0RG40JJ, 0RG40K0, 0RG40K1, 0RG40KJ, 0RG40Z0, 0RG40Z1, 0RG40ZJ]

0RG4470-0RG44ZJ

Fusion of cervicothoracic vertebral joint, percutaneous endoscopic approach [with autologous, synthetic or nonautologous tissue substitute or interbody device, by approach; includes codes 0RG4470, 0RG4471, 0RG447J, 0RG44A0, 0RG44AJ, 0RG44J0, 0RG44J1, 0RG44JJ, 0RG44K0, 0RG44K1, 0RG44KJ, 0RG44Z0, 0RG44Z1, 0RG44ZJ]

0RG6070-0RG60ZJ

Fusion of thoracic vertebral joint, open approach [with autologous, synthetic or nonautologous tissue substitute or interbody device, by approach; includes codes 0RG6070, 0RG6071, 0RG607J, 0RG60A0, 0RG60AJ, 0RG60J0, 0RG60J1, 0RG60JJ, 0RG60K0, 0RG60K1, 0RG60KJ, 0RG60Z0, 0RG60Z1, 0RG60ZJ]

0RG6470-0RG64ZJ

Fusion of thoracic vertebral joint, percutaneous endoscopic approach [with autologous, synthetic or nonautologous tissue substitute or interbody device, by approach; includes codes 0RG6470, 0RG6471, 0RG647J, 0RG64A0, 0RG64AJ, 0RG64J0, 0RG64J1, 0RG64JJ, 0RG64K0, 0RG64K1, 0RG64KJ, 0RG64Z0, 0RG64Z1, 0RG64ZJ]

0RG7070-0RG70ZJ

Fusion of 2 to 7 thoracic vertebral joints, open approach [with autologous, synthetic or nonautologous tissue substitute or interbody device, by approach; includes codes 0RG7070, 0RG7071, 0RG707J, 0RG70A0, 0RG70AJ, 0RG70J0, 0RG70J1, 0RG70JJ, 0RG70K0, 0RG70K1, 0RG70KJ, 0RG70Z0, 0RG70Z1, 0RG70ZJ]

0RG7470-0RG74ZJ

Fusion of 2 to 7 thoracic vertebral joints, percutaneous endoscopic approach [with autologous, synthetic or nonautologous tissue substitute or interbody device, by approach; includes codes 0RG7470, 0RG7471, 0RG747J, 0RG74A0, 0RG74AJ, 0RG74J0, 0RG74J1, 0RG74JJ, 0RG74K0, 0RG74K1, 0RG74KJ, 0RG74Z0, 0RG74Z1, 0RG74ZJ]

0RG8070-0RG80ZJ

Fusion of 8 or more thoracic vertebral joints, open approach [with autologous, synthetic or nonautologous tissue substitute or interbody device, by approach; includes codes 0RG8070, 0RG8071, 0RG807J, 0RG80A0, 0RG80AJ, 0RG80J0, 0RG80J1, 0RG80JJ, 0RG80K0, 0RG80K1, 0RG80KJ, 0RG80Z0, 0RG80Z1, 0RG80ZJ]

0RG8470-0RG84ZJ

Fusion of 8 or more thoracic vertebral joints, percutaneous endoscopic approach [with autologous, synthetic or nonautologous tissue substitute or interbody device, by approach; includes codes 0RG8470, 0RG8471, 0RG847J, 0RG84A0, 0RG84AJ, 0RG84J0, 0RG84J1, 0RG84JJ, 0RG84K0, 0RG84K1, 0RG84KJ, 0RG84Z0, 0RG84Z1, 0RG84ZJ]

0RGA070-0RGA0ZJ

Fusion of thoracolumbar vertebral joint, open approach [with autologous, synthetic or nonautologous tissue substitute or interbody device, by approach; includes codes 0RGA070, 0RGA071, 0RGA07J, 0RGA0A0, 0RGA0AJ, 0RGA0J0, 0RGA0J1, 0RGA0JJ, 0RGA0K0, 0RGA0K1, 0RGA0KJ, 0RGA0Z0, 0RGA0Z1, 0RGA0ZJ]

0RGA470-0RGA4ZJ

Fusion of thoracolumbar vertebral joint, percutaneous endoscopic approach [with autologous, synthetic or nonautologous tissue substitute or interbody device, by approach; includes codes 0RGA470, 0RGA471, 0RGA47J, 0RGA4A0, 0RGA4AJ, 0RGA4J0, 0RGA4J1, 0RGA4JJ, 0RGA4K0, 0RGA4K1, 0RGA4KJ, 0RGA4Z0, 0RGA4Z1, 0RGA4ZJ]

0SG0070-0SG00ZJ

Fusion of lumbar vertebral joint, open approach [with autologous, synthetic or nonautologous tissue substitute or interbody device, by approach; includes codes 0SG0070, 0SG0071, 0SG007J, 0SG00A0, 0SG00AJ, 0SG00J0, 0SG00J1, 0SG00JJ , 0SG00K0, 0SG00K1, 0SG00KJ, 0SG00Z0, 0SG00Z1, 0SG00ZJ]

0SG0470-0SG04ZJ

Fusion of lumbar vertebral joint, percutaneous endoscopic approach [with autologous, synthetic or nonautologous tissue substitute or interbody device, by approach; includes codes 0SG0470, 0SG0471, 0SG047J, 0SG04A0, 0SG04AJ, 0SG04J0, 0SG04J1, 0SG04JJ , 0SG04K0, 0SG04K1, 0SG04KJ, 0SG04Z0, 0SG04Z1, 0SG04ZJ]

0SG1070-0SG10ZJ

Fusion of 2 or more lumbar vertebral joints, open approach [with autologous, synthetic or nonautologous tissue substitute or interbody device, by approach; includes codes 0SG1070, 0SG1071, 0SG107J, 0SG10A0, 0SG10AJ, 0SG10J0, 0SG10J1, 0SG10JJ, 0SG10K0, 0SG10K1, 0SG10KJ, 0SG10Z0, 0SG10Z1, 0SG10ZJ]

0SG1470-0SG14ZJ

Fusion of 2 or more lumbar vertebral joints, percutaneous endoscopic approach [with autologous, synthetic or nonautologous tissue substitute or interbody device, by approach; includes codes 0SG1470, 0SG1471, 0SG147J, 0SG14A0, 0SG14AJ, 0SG14J0, 0SG14J1, 0SG14JJ , 0SG14K0, 0SG14K1, 0SG14KJ, 0SG14Z0, 0SG14Z1, 0SG14ZJ]

0SG3070-0SG30ZJ

Fusion of lumbosacral joint, open approach [with autologous, synthetic or nonautologous tissue substitute or interbody device, by approach; includes codes 0SG3070, 0SG3071, 0SG307J, 0SG30A0, 0SG30AJ, 0SG30J0, 0SG30J1, 0SG30JJ, 0SG30K0, 0SG30K1, 0SG30KJ, 0SG30Z0, 0SG30Z1, 0SG30ZJ]

0SG3470-0SG34ZJ

Fusion of lumbosacral joint, percutaneous endoscopic approach [with autologous, synthetic or nonautologous tissue substitute or interbody device, by approach; includes codes 0SG3470, 0SG3471, 0SG347J, 0SG34A0, 0SG34AJ, 0SG34J0, 0SG34J1, 0SG34JJ, 0SG34K0, 0SG34K1, 0SG34KJ, 0SG34Z0, 0SG34Z1, 0SG34ZJ]

 

 

 

Associated internal fixation

0RS104Z

Reposition cervical vertebral joint with internal fixation device, open approach

0RS144Z

Reposition cervical vertebral joint with internal fixation device, percutaneous endoscopic approach

0RS404Z

Reposition cervicothoracic vertebral joint with internal fixation device, open approach

0RS444Z

Reposition cervicothoracic vertebral joint with internal fixation device, percutaneous endoscopic approach

0RS604Z

Reposition thoracic vertebral joint with internal fixation device, open approach

0RS644Z

Reposition thoracic vertebral joint with internal fixation device, percutaneous endoscopic approach

0RSA04Z

Reposition thoracolumbar vertebral joint with internal fixation device, open approach

0RSA44Z

Reposition thoracolumbar vertebral joint with internal fixation device, percutaneous endoscopic approach

0SS004Z

Reposition lumbar vertebral joint with internal fixation device, open approach

0SS044Z

Reposition lumbar vertebral joint with internal fixation device, percutaneous endoscopic approach

0SS304Z

Reposition lumbosacral joint with internal fixation device, open approach

0SS344Z

Reposition lumbosacral joint with internal fixation device, percutaneous endoscopic approach

 

 

ICD-10 Diagnosis

 

G80.0-G80.9

Cerebral palsy

M40.00-M40.57

Kyphosis and lordosis

M41.00-M41.9

Scoliosis

M43.9

Deforming dorsopathy, unspecified

M96.5

Postradiation scoliosis

Q67.5

Congenital deformity of spine

Q76.0

Spina bifida occulta

Q76.3

Congenital scoliosis due to congenital bony malformation

Q76.411-Q76.419

Congenital kyphosis

Q76.425-Q76.429

Congenital lordosis

Q79.6

Ehlers-Danlos syndrome

Q87.43

Marfan’s syndrome with skeletal manifestation

Discussion/General Information

Scoliosis is a structural deformity (lateral curvature) of the spine which involves curvature of greater than 10 degrees and potentially functional impairment, as the severity of the spinal curvature progresses.  A recent review article states:

The majority of cases of scoliosis in children are idiopathic which accounts for up to 80% of cases. Congenital scoliosis arises as a result of congenital malformations of the spine that are present at birth; however, because of the effects of growth, the deformity may not be apparent until later in childhood. Congenital scoliosis is classified as a failure of formation of a vertebral body (hemivertebrae), failure of segmentation between 2 or more vertebrae (bar), or a failure of segmentation in combination with a failure of formation (El-Hawary, 2014). 

Other etiologies for pediatric and adult scoliosis include connective tissue disorders, (such as Marfan’s syndrome, homocystinuria, and Ehlers-Danlos syndrome) and neuromuscular disorders (frequently seen in conditions, such as spina bifida or cerebral palsy).  Adult onset scoliosis may develop as a result of degenerative changes, osteoporosis with atraumatic bone collapse, traumatic fracture or previous back surgery.  Treatment options for scoliosis include observation (for milder curvatures), casting (sometimes utilized for early onset scoliosis), bracing, and surgery.  “The goal of treatment in scoliosis is to prevent curvature progression.  For children with early onset scoliosis, the goal of treatment is also to maintain spine, chest, and pulmonary development throughout childhood” (El-Hawary, 2014).  When bracing (or casting) the back is ineffective or not well tolerated, surgical options are considered, including fusion techniques and other “growth friendly” techniques (growing rods and distraction-based surgeries utilized more recently in some pediatric scoliosis and not addressed in this document).  The location for spinal fusion is determined by the involved vertebral segments.  It is generally considered in the practice community that surgical treatment for scoliosis is indicated for a spinal curvature exceeding an image-confirmed Cobb angle of 45 or 50 degrees especially when there is the likelihood of curve progression (as in adolescents with idiopathic scoliosis experiencing growth spurts) because:

To date, the evidence for thoracic and thoracolumbar fusion for scoliosis has been limited to case series and cohort studies with prospective outcomes analysis.  However, the data has demonstrated favorable improvements in the morbidity associated with curve progression and functional outcomes from fusion procedures versus nonoperative medical management strategies.  In 2010, Tis reported intermediate radiographic and pulmonary function testing data from analysis of a multicenter prospective database of 101 adolescents who underwent open instrumented anterior spinal fusion (OASF) for treatment of primary thoracic (Lenke 1) adolescent idiopathic scoliosis (AIS).  At 5 year follow-up, data was available for 85 subjects.  The mean coronal correction was 26 degrees (51%; p<0.05) and the thoracolumbar/lumbar curve improved 16 degrees (51%).  A 6.7% decrease in predicted FEV1 over the 5 year period, (from 75.5% ± 13% before surgery to 68.8% ± 2% after surgery), was noted (p=0.007) but no significant change in FVC.  There were three significant adverse events.  The authors concluded that OASF is a reproducible and safe method to treat thoracic AIS (Tis, 2010).  Additional retrospective reviews of subjects with AIS who underwent fusion techniques for thoracolumbar and lumbar scoliosis reported outcomes that demonstrated maintenance of their coronal and sagittal plane correction between 2 and 5 year follow-up, as well as favorable Scoliosis Research Society (SRS)-30 and Oswestry data (Hwang, 2013; Kelly, 2010).

It is generally agreed in the practice community that fusion techniques should be reserved for those cases where conservative medical therapies have been exhausted or there is significant risk for progressive curvature and comorbidity, (for example, spinal cord compression, instability, stenosis, pseudarthrosis, spondylolisthesis).  There is no consensus in the published scientific literature regarding the optimal duration for conservative treatment prior to surgical intervention and recommendations range from at least 3 months to greater than 12 months.

Kyphosis is the normal rounded contour of the thoracic spine. Kyphosis is abnormal when present in the cervical or lumbar spine (both normally lordotic; that is, with forward bowing).  Additionally, hyperkyphosis (excessive kyphosis) of more than 40 degrees is abnormal in the thoracic spine.  Although thoracic hyperkyphosis is frequently asymptomatic, treatment with bracing and physical therapy or even with surgery may occasionally be necessary.  Severe and rigid deformity may require osteotomy, partial vertebrectomy or kyphectomy.  Multilevel kyphectomy is usually performed on individuals with myelomeningocele to facilitate correction and stabilization of the spinal deformity, decrease skin problems, potentially increase pulmonary function and improve sitting balance.  According to the American Academy of Orthopedic Surgeons, surgery may be recommended if the kyphotic curve exceeds 75 degrees.

Definitions

Arthrodesis (also known as spinal fusion): This surgical procedure involves the joining of two or more vertebrae (discs) together into one solid bony structure.

Cerebral palsy: This refers to a group of congenital movement disorders which are caused by damage to the motor control centers of the developing brain.  It is believed that cerebral palsy can occur during pregnancy, birth or in children up to the age of 3 years with resultant disabilities involving movement, coordination and communication.

Claudication: Usually refers to impairment in walking, or pain, discomfort or fatigue in the legs that occurs during walking and is relieved by rest. The perceived level of pain from claudication can be mild to extremely severe.

Cobb angle: The Cobb angle is formed by the intersection of a line parallel to the superior end plate of the most cephalad vertebra in a scoliosis curve with a line parallel to the inferior end plate of the most caudad vertebra of the curve.  This is considered the standard measurement used in the practice community to quantify a scoliosis for the purpose of measuring curve progression over time.  A curve is considered to be scoliosis at a Cobb angle of 10º or more.  Any increase greater than 5º is considered a significant change indicative of curvature progression with scoliosis considered mild at 10º-24º, moderate at 25º-50º and severe at greater than 50º.

Ehlers-Danlos syndrome (EDS): This is an inherited connective tissue disorder which is caused by a defect in the structure, production or processing of collagen or of proteins that interact with collagen.  There is no cure for EDS and treatment is supportive.

Homocystinuria: This is an autosomal recessive, genetic, connective tissue disorder which is characterized by an accumulation of the amino acid homocysteine in the serum and an increased excretion of homocysteine in the urine.  This condition affects connective tissue, muscle, the central nervous system and the cardiovascular system, and diagnosis is confirmed with laboratory analysis for abnormal levels of homocysteine in the urine and plasma.

Intervertebral disc: The soft tissues located between each vertebra; these discs act as cushions between the vertebrae during normal motion.

Kyphectomy: A surgical procedure usually performed on individuals with myelomeningocele to allow correction and stabilization of the spinal deformity, decreased skin problems, increased pulmonary function, and improved sitting balance.

Kyphosis: Refers to the normal posterior convexity of the thoracic spine as viewed from the side.  The term hyperkyphosis is used to describe excessive kyphosis or roundness and may result from degenerative diseases, such as arthritis; developmental disorders, most commonly Scheuermann's disease; osteoporosis with compression fractures of the vertebrae; or trauma.  Where the roundness of the thoracic spine exceeds 45° it is called hyperkyphosis.

Lordosis: Refers to the normal forward bowed curvature of the lumbar and cervical regions of the spine.  Excessive or hyperlordosis in the lumbar spine is commonly referred to as sway back.

Marfan’s Syndrome: This is a autosomal dominant genetic disorder of human connective tissue which can affect multiple organ systems including the cardiac valves, aorta, lungs, eyes, bone and the dural sac around the spinal cord. The condition is managed by treating symptoms, as they present, and close observation for potential life threatening cardiac complications. 

Myelomeningocele (also called meningomyelocele): A protrusion of the spinal membranes and neural elements through a defect in the vertebral column.  The defect, which occurs in approximately 2 in every 1000 live births, is readily apparent and easily diagnosed at birth.  Although the opening may be located at any point along the spinal column, the anomaly characteristically occurs in the lumbar, low thoracic, or sacral region and extends for three to six vertebral segments.  The bony defect is termed spina bifida.

Pars defect: Stress fracture in the pars interarticularis (isthmus) of the posterior elements of a vertebra, most commonly in the lumbar spine.

Pseudarthrosis: This term refers to the bony nonunion of a prior spinal fusion surgery.

Radiculopathy: The irritation of a nerve root at any level of the spine most commonly caused by protrusion of a disc.

Sagittal deformity: Refers to abnormal spinal alignment as viewed from the side or on lateral radiographs and may include hypo- or hyperlordosis, hypo- or hyperkyphosis, pelvic rotational abnormalities or shift of the spinal axis forward or backward.

Sagittal Imbalance: This term refers to a disruption in the normal balanced curvature of the human spine (cervical lordosis, thoracic kyphosis, lumbar lordosis and normal pelvic rotation).  The Scoliosis Research Society (SRS) defines sagittal imbalance as:

Sagittal imbalance is either fixed or flexible. “Flexible” means the patient can stand up straight if they work at it (with their hips and knees straight), while “fixed” suggests they cannot. Similarly, the imbalance can be either compensated or decompensated. “Compensated” means the body can adapt (usually by flexing the knees and hips), while “decompensated” implies they cannot. The problem leading to the imbalance is either local (a few vertebrae causing significant tilt), regional (many vertebrae causing a slow forward bend), or a mix of the two (SRS, 2015).

Scoliosis: Refers to lateral (side-to-side) curvature (coronal deformity) of the spine of multiple etiologies.

Spina bifida: This is a developmental congenital disorder which is caused by the incomplete closing of the embryonic neural tube.  This condition is considered one of the most common birth defects.  It affects the vertebrae, most commonly at the lumbosacral level, with malformation due to incomplete formation and fusion at the involved level.  The condition can be surgically corrected but some degree of disability is usually permanent in affected individuals.

Spinal stenosis: Refers to narrowing and compression within the anatomical regions of the vertebrae; depending on location, stenosis may result in nerve root or cauda equina compression.

Spondylolisthesis: Forward slippage of one vertebral body on another.

Spondylolysis: A defect in the posterior portion (the pars interarticularis) of a vertebra with separation of the vertebral body from the joints.  This condition can result in slippage of the involved vertebral body (spondylolisthesis).

Vertebrae: Bones that make up the spinal column which surround and protect the spinal cord and cauda equina.

References

Peer Reviewed Publications:

  1. Bridwell KH, Glassman S, Horton W, et al. Does treatment (nonoperative and operative) improve the two-year quality of life in patients with adult symptomatic lumbar scoliosis: a prospective multicenter evidence-based medicine study. Spine (Phila Pa 1976). 2009; 34(20):2171-2178.
  2. El-Hawary R, Chukwunyerenwa C. Update on evaluation and treatment of scoliosis. Pediatr Clin N Am. 2014; 61(6):1223-1241.
  3. Fischer CR, Kim Y. Selective fusion for adolescent idiopathic scoliosis: a review of current operative strategy. Eur Spine J. 2011; 20(7):1048-1057.
  4. Hacquebord JH, Leopold SS. The Risser classification: a classic tool for the clinician treating adolescent idiopathic scoliosis. Clin Orthop Relat Res. 2012; 470(8):2335-2338.
  5. Hwang SW, Samdani AF, Marks M, et al. Five-year clinical and radiographic outcomes using pedicle screw only constructs in the treatment of adolescent idiopathic scoliosis. Eur Spine J. 2013; 22(6):1292-1299.
  6. Kelly DM, McCarthy RE, McCullough FL, Kelly HR. Long-term outcomes of anterior spinal fusion with instrumentation for thoracolumbar and lumbar curves in adolescent idiopathic scoliosis. Spine. 2010; 35(2):194-198.
  7. Maruyama T, Takeshita K. Surgical treatment of scoliosis: a review of techniques currently applied. Scoliosis. 2008; 3:6.
  8. Tis JE, O’Brien MF, Newton PO, et al. Adolescent idiopathic scoliosis treated with open instrumented anterior spinal fusion: five-year follow-up. Spine (Phila Pa 1976). 2010; 35(1):64-70.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Association of Neurological Surgeons (AANS). Guideline update for the performance of fusion procedures for degenerative disease of the spine. J Neurosurg Spine. 2014; 21(1):1-139.
  2. Bettany-Saltikov J, Weiss HR, Chockalingam N, et al. Surgical versus non-surgical interventions in patients with adolescent idiopathic scoliosis. Cochrane Database Syst Rev. 2013; (7):CD010663.
  3. Scoliosis Research Society. Three-Dimensional Terminology for Spinal Deformity. 2015. Available at: https://www.srs.org/professionals/online-education-and-resources/glossary/three-dimensional-terminology-of-spinal-deformity. Accessed on July 2, 2018.
Websites for Additional Information
  1. American Academy of Orthopedic Surgeons (AAOS). Spinal Fusion. Available at: http://orthoinfo.aaos.org/topic.cfm?topic=A00348. Accessed on July 2, 2018.
  2. North American Spine Society (NASS). Know your back. Available at: http://www.knowyourback.org/Pages/Default.aspx. Accessed on July 2, 2018.
Index

Arthrodesis
Fusion, Spinal cervical, lumbar, thoracic/thoracolumbar
Kyphectomy
Spondylodesis
Spondylosyndesis

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

History

Status

Date

Action

Reviewed

07/26/2018

Medical Policy & Technology Assessment Committee (MPTAC) review. Updated References and Websites sections.

Reviewed

11/02/2017

MPTAC review. The document header wording was updated from “Current Effective Date” to “Publish Date.”  References were updated.

 

10/01/2017

Updated Coding section with 10/01/2017 ICD-10-PCS procedure code changes; removed 0RG10A1, 0RG14A1, 0RG20A1, 0RG24A1, 0RG40A1, 0RG44A1, 0RG60A1, 0RG64A1, 0RG70A1, 0RG74A1, 0RG80A1, 0RG84A1, 0RGA0A1, 0RGA4A1, 0SG00A1, 0SG04A1, 0SG10A1, 0SG14A1, 0SG30A1, 0SG34A1 deleted 09/30/2017.

Reviewed

02/02/2017

MPTAC review. Updated formatting in Clinical Indications section. Updated Definitions, References and Websites sections.

Revised

02/04/2016

MPTAC review. The medically necessary criteria for spinal fusion in degenerative scoliosis have been revised to add sagittal deformity. The Cobb angle of thoracic curvature in degenerative scoliosis has been removed. In neuromuscular scoliosis, the requirement for symptoms that have been unresponsive to at least 3 months of conservative medical therapy has been removed. The Note about conservative medical therapy has been clarified and serial casting has been removed. The Definitions and References were updated.

Revised

11/05/2015

MPTAC review. Minor editorial edits were made in the Clinical Indications section. The Definitions and References were updated. Removed ICD-9 codes from Coding section.

Revised

08/06/2015

MPTAC review. The Cobb angle in the medically necessary criteria for spinal fusion as a treatment of adult degenerative scoliosis was revised to a thoracic curvature of greater than 50 degrees (formerly was 60 degrees). References were updated.

New

05/07/2015

MPTAC review. Initial document development.