Clinical UM Guideline
|Guideline #:||CG-SURG-42||Current Effective Date:||07/07/2015|
|Status:||Reviewed||Last Review Date:||05/07/2015|
This document addresses the clinical indications for anterior and posterior cervical fusion.
Note: Please see the following related documents for additional information:
Cervical fusion is considered medically necessary for the treatment of an individual when one or more of the following indications are met:
Not Medically Necessary:
Cervical fusion is considered not medically necessary when the criteria listed above are not met and for all other indications, including but not limited to:
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.
|22548||Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 (atlas-axis), with or without excision of odontoid process|
|22551||Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2|
|22552||Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace|
|22554||Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2|
|22585||Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace [when specified as cervical]|
|22590||Arthrodesis, posterior technique, craniocervical (occiput-C2)|
|22595||Arthrodesis, posterior technique, atlas-axis (C1-C2)|
|22600||Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment|
|22614||Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment [when specified as cervical]|
|ICD-9 Procedure||[For dates of service prior to 10/01/2015]|
|81.01||Atlas-axis spinal fusion|
|81.02||Other cervical fusion of the anterior column, anterior technique|
|81.03||Other cervical fusion of the posterior column, posterior technique|
|81.31||Refusion of atlas-axis spine|
|81.32||Refusion of other cervical spine, anterior column, anterior technique|
|81.33||Refusion of other cervical spine, posterior column, posterior technique|
|ICD-9 Diagnosis||[For dates of service prior to 10/01/2015]|
|ICD-10 Procedure||[For dates of service on or after 10/01/2015]|
|0RG0070-0RG00ZJ||Fusion of occipital-cervical joint, open approach [anterior/posterior approach, with or without device; includes codes 0RG0070, 0RG0071, 0RG007J, 0RG00A0, 0RG00A1, 0RG00AJ, 0RG00J0, 0RG00J1, 0RG00JJ, 0RG00K0, 0RG00K1, 0RG00KJ, 0RG00Z0, 0RG00Z1, 0RG00ZJ]|
|0RG0470-0RG04ZJ||Fusion of occipital-cervical joint, percutaneous endoscopic approach [anterior/posterior approach, with or without device; includes codes 0RG0470, 0RG0471, 0RG047J, 0RG04A0, 0RG04A1, 0RG04AJ, 0RG04J0, 0RG04J1, 0RG04JJ, 0RG04K0, 0RG04K1, 0RG04KJ, 0RG04Z0, 0RG04Z1, 0RG04ZJ]|
|0RG1070-0RG10ZJ||Fusion of cervical vertebral joint, open approach [anterior/posterior approach, with or without device; includes codes 0RG1070, 0RG1071, 0RG107J, 0RG10A0, 0RG10A1, 0RG10AJ, 0RG10J0, 0RG10J1, 0RG10JJ, 0RG10K0, 0RG10K1, 0RG10KJ, 0RG10Z0, 0RG10Z1, 0RG10ZJ]|
|0RG1470-0RG14ZJ||Fusion of cervical vertebral joint, percutaneous endoscopic approach [anterior/posterior approach, with or without device; includes codes 0RG1470, 0RG1471, 0RG147J, 0RG14A0, 0RG14A1, 0RG14AJ, 0RG14J0, 0RG14J1, 0RG14JJ, 0RG14K0, 0RG14K1, 0RG14KJ, 0RG14Z0, 0RG14Z1, 0RG14ZJ]|
|0RG2070-0RG20ZJ||Fusion of 2 or more cervical vertebral joints, open approach [anterior/posterior approach, with or without device; includes codes 0RG2070, 0RG2071, 0RG207J, 0RG20A0, 0RG20A1, 0RG20AJ, 0RG20J0, 0RG20J1, 0RG20JJ, 0RG20K0, 0RG20K1, 0RG20KJ, 0RG20Z0, 0RG20Z1, 0RG20ZJ]|
|0RG2470-0RG24ZJ||Fusion of 2 or more cervical vertebral joints, percutaneous endoscopic approach [anterior/posterior approach, with or without device; includes codes 0RG2470, 0RG2471, 0RG247J, 0RG24A0, 0RG24A1, 0RG24AJ, 0RG24J0, 0RG24J1, 0RG24JJ, 0RG24K0, 0RG24K1, 0RG24KJ, 0RG24Z0, 0RG24Z1, 0RG24ZJ]|
|ICD-10 Diagnosis||[For dates of service on or after 10/01/2015]|
Cervical (neck) fusion, also referred to as cervical spine fusion or spinal arthrodesis, is a surgical technique which stabilizes and eliminates the motion between the adjacent vertebral segments of the spine by fusing 2 or more cervical vertebrae in the spinal column. Cervical fusion procedures may be performed alone or in conjunction with other procedures for the treatment of conditions including, but not limited to, symptomatic, progressive cervical radiculopathy, pseudarthrosis, or spondylotic myelopathy when conservative treatment options have been unsuccessful. Cervical fusion may also be performed to repair spinal fractures and dislocations or to stabilize posttraumatic spinal instability. The procedure involves permanent fusion (uniting together) of the adjacent vertebrae (segments) using bone graft material taken from another bone in the individual's body (autograft) or from a bone bank (allograft). These types of bone grafting material, with or without plating, have been suggested as the "gold standard" for cervical fusion. During cervical fusion procedures, the spine is accessed and the graft is placed from either the front (anterior approach), the back (posterior approach), or may involve a combination of both approaches. Cervical fusion may be performed with or without instrumentation, and may involve supplemental hardware such as plates, rods, screws, wires or cages that act as a splint until the bone graft fuses (heals). A systematic review of randomized controlled trials found no consistent evidence for use of cages over autograft for cervical spinal fusion (Jacobs, 2011). Other surgical procedures performed in conjunction with cervical fusion may include, but are not limited to, corpectomy, facetectomy, foraminectomy, foraminotomy, laminectomy, laminotomy, or laminoplasty. These procedures may be successful in treating most individuals with persistent pain and neurologic symptoms that have been unresponsive to nonsurgical treatment.
Disc degeneration is a complex biochemical process that occurs with the loss of normal water content within the disc resulting in the deterioration of the mechanical shock absorbing properties of the disc over time. This deterioration leads to bulging and decreased disc height. Degenerative disc disease (DDD) is most commonly a result of the effects of the natural aging process, specifically on the intervertebral discs, although various associated factors may accelerate the process. Degenerative cervical spine disorders, including DDD, will affect up to two-thirds of the population in their lifetime, 40% to 50% of people over the age of 40, and becomes increasingly common with advancing age. While often benign and episodic in nature, cervical disorders presenting as axial neck pain, radiculopathy, myelopathy, or a combination of these presentations, may become debilitating and result in symptomatic pain and neurologic outcomes. Nonsurgical, conservative therapy continues to play an important role in the treatment of individuals with self-limiting symptoms, including first-line treatment with cervical collar, oral medications (for example, corticosteroids, NSAIDs, and short-term muscle relaxants and/or narcotic analgesics), physical therapy (PT), and rest. For those individuals with persistent radicular complaints, neurologic deficits, or signs and symptoms of myelopathy, the most commonly used cervical spine decompressive procedures involve the anterior approach, with anterior cervical decompression or anterior cervical discectomy and fusion (ACDF), intended to relieve central and foraminal stenosis as well as soft disc herniation(s) (Todd, 2011). According to Todd (2011):
The location of pathology, patient anatomy and surgeon preference are all considerations in indicating these patients for specific surgical procedures... Segmental anterior fusions at multiple levels may provide a powerful corrective force in patients with kyphosis while at the same time decompressing the spinal cord.
The evidence published in the peer-reviewed medical literature consists of case series, consensus guidelines, prospective and retrospective comparative and outcome studies, systematic reviews, and a small volume of randomized controlled trials that evaluate cervical fusion and surgical techniques, with or without instrumentation and bone graft materials, for the treatment of various cervical spinal conditions (including, but not limited to: Chen, 2011; Cunningham, 2010; Dohrmann, 2014; Dvorak, 2007; Faldini, 2010; Ghogawala, 2011; Harai, 2011; Herkowitz, 1990; Iwasaki, 2007; Koakulsu, 2010; Kwon, 2007; Lehmann, 2014; Papadopoulos, 2006; Raizman, 2009; Riew, 2007; Sakai, 2012; Seng, 2013; Siemionow, 2012).
Symptomatic Cervical Radiculopathy
Studies and consensus guidelines published by the American Association of Neurological Surgeons (AANS) and Congress of Neurological Surgeons and the North American Spine Society (NASS) suggest that both anterior cervical discectomy (ACD) and ACDF are comparable treatment strategies, producing similar clinical outcomes, in the treatment of single level cervical radiculopathy from degenerative disorders (Bono, 2011; Gebremariam, 2012; Matz, 2009b). The NASS evidence-based clinical guideline for the diagnosis and treatment of cervical radiculopathy from degenerative disorders (Bono, 2011) gives a grade B recommendation to both ACD and ACDF (Grade B: Fair evidence [Level II or III studies with consistent findings] for or against recommending intervention). The AANS and Congress of Neurological Surgeons systematic review (Matz, 2009b) used evidence-based medicine to identify the best techniques for anterior cervical nerve root decompression with cervical radiculopathy, stating:
Both ACD and ACDF are equivalent treatment strategies for 1-level disease with regard to functional outcome (Class II). Anterior cervical discectomy with fusion may achieve a more rapid reduction of neck and arm pain compared to ACD with a reduced risk of kyphosis, although functional outcomes may be similar. Anterior cervical discectomy with fusion is not a lasting means of increasing foraminal or disc height compared to ACD. Anterior cervical plating (ACDF with instrumentation) improves arm pain (but not other clinical parameters) better than ACDF in the treatment of 2-level disease (Class II). With respect to 1-level disease, plating may reduce the risk of pseudarthrosis and graft problems (Class III) but does not necessarily improve clinical outcome alone (Class II). Cervical arthroplasty is recommended as an alternative to ACDF in selected patients for control of neck and arm pain (Class II).
Matz and colleagues (2009a) published another consensus guideline on the indications for anterior cervical decompression for the treatment of cervical degenerative radiculopathy stating:
Anterior nerve root decompression via ACD, with or without fusion for radiculopathy, is associated with rapid relief (three to four months) of arm/neck pain, weakness, and/or sensory loss compared with physical therapy or cervical collar immobilization. ACD and ACDF are associated with long term (12 months) improvement in certain motor functions compared to physical therapy. Other rapid gains observed after anterior decompression, including diminished pain, improved sensation, and improved strength in certain muscle groups, are also maintained over the course of 12 months. However, comparable clinical improvements with PT or cervical immobilization therapy are also present in these clinical modalities (Class I).
Albert and Murrell (1999) reviewed the surgical management of cervical radiculopathy, stating:
Despite conservative nonoperative therapy, a large subset of patients will require surgical intervention. Indications for surgery include recalcitrant radiculopathy despite nonoperative treatment for more than 6 weeks and progressive motor deficit or disabling motor deficit (deltoid palsy, wrist drop) prior to 6 weeks. Anterior and posterior approaches have both yielded successful results in appropriately selected patients. Anterior cervical discectomy and fusion is the generally preferred treatment for radiculopathy when there is a significant component of axial neck pain, when the disease is centrally located, or when there is any degree of segmental kyphosis.
A Cochrane review and meta-analysis of randomized trials, however, found limited evidence that although surgery may provide pain relief sooner than nonoperative therapy (for example, physiotherapy or cervical collar) for individuals with cervical radiculopathy, there was no significant difference in outcomes at 1 year (Nikolaidis, 2010). Additional Cochrane reviews have been published evaluating surgery for cervical radiculomyelopathy (Fouyas, 2011), single or double-level anterior interbody fusion techniques for cervical DDD (Jacobs, 2011), and arthroplasty versus fusion in single-level cervical DDD (Boselie, 2013).
Symptomatic Cervical Myelopathy
Both anterior and posterior cervical surgical approaches exist for the treatment of cervical myelopathy and include, but are not limited to, ACDF, anterior corpectomy and fusion, and posterior cervical laminectomy with or without fusion. In individuals with single level compression, anterior cervical fusion has been shown to be effective for individuals with myelopathy (Geck, 2002). Mummaneni and colleagues (2009) compared the efficacy of different surgical techniques for the treatment of cervical spondylotic myelopathy (CSM), including ACDF, anterior cervical corpectomy with fusion (ACCF), laminectomy with fusion, and other techniques stating:
ACDF and ACCF appear to yield similar results in multilevel spine decompression for lesions at the disc level. The use of anterior plating allows for equivalent fusion rates between these techniques (Class III). ACDF, ACCF, laminectomy, laminoplasty, and laminectomy with arthrodesis all provide near-term functional improvement for CSM.
Anderson and colleagues (2009) published a systematic review to examine the efficacy of cervical laminectomy and fusion for the treatment of CSM. The authors state that "cervical laminectomy with fusion improves functional outcomes in individuals with CSM and OPLL, Class III." In contrast to laminectomy, cervical laminectomy with fusion is not associated with late deformity. Lawrence and colleagues (2012) reviewed indications, techniques, and outcomes for posterior surgery for cervical myelopathy, stating that laminectomy and fusion "seems to combine the early improvement in neurologic function seen with decompressive laminectomy with less late loss of function or kyphotic collapse and with a lower overall complication rate." Thus, "it has become the standard surgical treatment of patients with CSM due to multilevel stenosis and cord compression, to which other treatments are most commonly compared." In a systematic review and meta-analysis, Zhu and colleagues (2013) compared the clinical outcomes, complications, and surgical trauma between anterior and posterior approaches for the treatment of multilevel CSM. A total of eight nonrandomized controlled high quality studies were included in the meta-analysis. The authors reported the anterior approach was associated with better postoperative neural function than the posterior approach in the treatment of multilevel CSM. There were no apparent differences in the neural function recovery rate. The complications and reoperation rates were significantly higher in the anterior group compared with the posterior group.
Han and colleagues (2014) conducted a meta-analysis comparing clinical outcomes, complications, and surgical trauma between ACDF and ACCF for the treatment of CSM. Of the 1372 participants reviewed in 15 peer-reviewed publications, the authors reported that although complications (odds ratio [OR] = 0.50, 95% Confidence interval [CI], 0.35-0.73) and increased lordosis of C2-C7 (mean difference [MD] = 3.70, 95% CI, 0.96 to 6.45) were significantly better in the ACDF group, there was no strong evidence to support the routine use of ACDF over ACCF in CSM.
Acute Cervical Spine and Spinal Cord Injuries
Walters and colleagues (2013) published a guideline update for the management of acute cervical spine and spinal cord injuries. The guidelines include detailed recommendations for the diagnosis, including radiologic evaluation, and management of acute cervical spine injuries with cervical fusion, with and without combined procedures, such as decompression, occipital-cervical internal fixation, or laminectomy. The review includes 19 Level I recommendations in the guidelines, each supported by Class I medical evidence for radiologic assessment, cervical subaxial injury, and pediatric spinal injuries (not an all-inclusive list); and, additional Level II and III recommendations for surgical stabilization and fusion, based on specific fracture type, instability, and severity, for conditions including, but not limited to, traumatic atlanto-occipital dislocation injuries, C1 to C2 rotary subluxations, isolated fractures of the axis in adults (including fractures of the odontoid, traumatic spondylolisthesis of the axis [hangman's fracture]), os odontoideum, subaxial cervical spinal injuries, and acute central cervical spinal cord injuries. Aarabi and colleagues (2013) published an update on the medical evidence on the management of acute traumatic central cord syndrome (ATCCS) and the potential surgical treatment of this incomplete spinal cord injury in which the upper extremities are weaker than the lower extremities with variable involvement of the sensory system and variable effect on bladder function. The authors state that approximately 20% of individuals present with an acute disc herniation as the cause of ATCCS. Surgical intervention is recommended for this group. Another 30% of individuals with ATCCS have cervical spine skeletal injuries in the form of fracture subluxation injuries which require early re-alignment of the spinal column, closed or open, with spinal cord decompression. Class III medical evidence "suggests that surgery for ATCCS is safe and appears to be efficacious (in conjunction with medical management) for patients with focal cord compression, or to provide operative reduction and internal fixation and fusion of cervical spinal fracture dislocation injuries."
Other Cervical Spine Conditions
Cervical fusion procedures may be performed for other less common indications. The peer-reviewed medical literature includes, but is not limited to, case reports, comparative studies, retrospective studies, and review articles evaluating the use of cervical fusion in individuals with cervical spine conditions such as:
Cervical fusion is performed for many different clinical indications. Despite a lack of large randomized controlled clinical trials comparing fusion to nonsurgical interventions, evidenced-based consensus guidelines and peer-reviewed publications exist in the medical literature comparing surgical techniques and outcomes of cervical fusion procedures to each other.
Cervical fusion does involve some risk associated with the procedure(s) and varies depending on the individual's age and overall health, diagnosis, and type of fusion procedure. Risks and complications of cervical fusion procedures include, but are not limited to, breakage of metal implants (if used), deep vein thrombosis (blood clots inside the veins of the legs), excessive bleeding, fusion failure (for example, pseudarthrosis), graft rejection, infection, nerve or spinal cord injury, pain in a bone graft site (donor site), and the risks of general anesthesia. Fountas and colleagues (2007) conducted a retrospective case review of 1015 individuals undergoing first-time ACDF for cervical radiculopathy and/or myelopathy due to DDD and/or cervical spondylosis. The mortality rate was reported as 0.1% (n=1; death occurred secondary to an esophageal perforation). The overall morbidity rate was 19.3% (196 of 1015 individuals). The most common complications were postoperative dysphagia (9.5%), hematoma (5.6%), and recurrent laryngeal nerve palsy (3.1%). Management of complications was successful in the vast majority of cases. Bydon and colleagues (2014) retrospectively evaluated a large case series of individuals (n=888) treated at a single institution over a 20-year period who underwent ACDF for cervical spondylosis. Of these individuals, 108 had re-do surgery as a result of symptomatic adjacent segment disease (ASD). Individuals were followed for an average of 92.4 ± 52.6 months after the index ACDF. Individuals were more likely to develop ASD, known to occur after ACDF, above the index level of fusion. The study findings are consistent with previous ACDF case series, as the authors identified the highest rate of cervical spinal degenerative disease requiring surgery was at C5/C6, followed by C6/C7.
Anterior: Referring to the front of the body.
Arthrodesis (also known as spinal fusion): A surgical procedure involving the joining of 2 or more cervical vertebrae (discs) together into 1 solid bony structure.
Arthroplasty: A surgical procedure in which an artificial joint replaces a damaged joint.
Axis fracture: Fracture of the second cervical (C2/axis) vertebra.
Burst fracture: Injury to the spine in which the vertebral body is severely compressed. Burst fractures typically result from severe trauma, such as a motor vehicle accident or a fall from a height. The degree of neurologic injury is usually due to the amount of force that is present at the time of the injury and the amount of compromise of the spinal canal.
Cervical spine: The neck region of the spine consisting of the first 7 vertebrae.
Degenerative disc disease (DDD): A disease of a vertebral disc where the intervertebral disc breaks down and may result in pain and disability.
Herniated disc: A condition in which part, or all of the soft, jelly-like core material of an intervertebral disc bulges or ruptures out of its normal position; a herniated disc may exert pressure on the surrounding nerve root and/or the spinal cord resulting in back pain and nerve root irritation.
Instrumented fusion: A fusion procedure involving the use of plates, screws, cages or rods to increase the stability of the joint during the healing process.
Intervertebral discs: Soft tissues located between each vertebra, acting as cushions between the vertebrae during normal motion.
Laminectomy: A surgical procedure for treating spinal stenosis by relieving pressure on the spinal cord. The lamina of the vertebra is removed or trimmed to widen the spinal canal and create more space for the spinal nerves.
Myelopathy: Compression on the spinal cord that occurs when the spinal canal becomes restricted in the neck or upper back. This may be due to degeneration in the discs and facet joints (spondylotic myelopathy) or bone spur formation in the spinal canal (stenosis with myelopathy).
Neurologic: Having to do with the nervous system.
Ossification of the posterior longitudinal ligament (OPLL): A condition of abnormal calcification of the posterior longitudinal ligament, most commonly located at the cervical spine region. Compression of spinal cord caused by OPLL may lead to neurologic symptoms and in the cases with severe neurologic deficit, may require surgical treatments.
Posterior: The back or rear side of the body.
Pseudarthrosis: A condition in which failure of callus formation (nonunion) of bone fragments occurs at a fracture site or prior spinal fusion surgery site resulting in formation of a "false joint."
Radiculopathy: The irritation of a nerve root at any level of the spine which can be caused by compression, inflammation or protrusion of a disc. Cervical radiculopathy involves pain and neurological symptoms that can radiate along that nerve's pathway into the arm and hand. The most common causes include cervical DDD, herniated disc, and spinal stenosis; less frequent causes include conditions such as cervical fracture or tumor.
Recombinant human bone morphogenic protein (rhBMP): A substance that may be used to stimulate the growth of bone.
Spinal fusion: A surgical procedure to stabilize the spine by fusing together 2 or more spinal vertebrae (spine bones).
Spinal stenosis: Abnormal narrowing of the spinal canal diameter in the cervical area that may result in pressure (compression) on the spinal cord, spinal sac, or nerve toots stemming from the spinal cord.
Spondylolisthesis: A condition that occurs when one vertebra slips forward (out of position) onto the vertebra below it.
Spondylosis: A cervical spine condition involving degenerative changes to the bones, discs, and joints of the neck, caused by the normal wear-and-tear of aging. The discs of the cervical spine gradually break down, lose fluid, and become stiffer. Cervical spondylosis usually occurs in middle-aged and older adults. Cervical spondylosis with cervical myelopathy, commonly referred to as cervical spondylotic myelopathy (CSM), refers to impaired function of the spinal cord caused by degenerative changes of the discs and facet joints in the cervical spine.
Vertebrae: Bones that make up the spinal column, which surround and protect the spinal cord.
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
|Websites for Additional Information|
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|Reviewed||05/07/2015||Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Description, Discussion, References, and Websites for Additional Information sections.|
|New||05/15/2014||MPTAC review. Initial document development.|