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Clinical Policy Bulletins:
Vertebral Axial Decompression
Number: 0180


Policy

Aetna considers vertebral axial decompression (e.g., by means of the VAX-D Table, the Accu-SPINA™ System, DRX2000, DRX3000, DRX5000, the Axiom Worldwide DRX9000, the DRS (Decompression Reduction Stabilization) System, DRX, the Alpha-SPINA System, the Dynatron DX2,  the Lordex Lumbar Spine System, the Saunders 3D ActiveTrac, Spinerx LDM, Tru Tac 401, NuChoice Medical Healthstar Elite Decompression Therapy, the Antalgic-Trak, the Cert Health Sciences SpineMED, or Internal Disc Decompression (IDD) Therapy, also known as Intervertebral Differential Dynamics Therapy) experimental and investigational.  Currently, there is no adequate scientific evidence that proves that vertebral axial decompression is an effective adjunct to conservative therapy for back pain.  In addition, vertebral axial decompression devices have not been adequately studied as alternatives to back surgery.

See also CPB 0569 - Lumbar Traction Devices.



Background

VAX-D therapy for the management of low back pain (LBP) uses a computer-driven table to control the level of disc decompression.

Although results from an early uncontrolled, retrospective study (Gose et al, 1998) regarding the benefits of the VAX-D table appeared to be encouraging, the findings need to be validated in prospective, randomized, controlled clinical trials because the study was poorly designed.  In addition, there has been no follow-up publication indicating whether any reported improvements were temporary or permanent.  Thus, there is still insufficient scientific evidence to support the effectiveness of the VAX-D table in treating patients with LBP associated with herniated discs and degenerative disc problems.  The Center for Medicare and Medicaid Services (CMS) Technology Advisory Committee did not recommend coverage of the VAX-D system because of the absence of scientific data on its effectiveness.

A subsequent randomized study (Sherry et al, 2001) compared VAX-D to transcutaneous electrical nerve stimulation (TENS) in the treatment of patients with chronic (greater than 3 months in duration) LBP.  Successful outcome was defined as a 50 % decrease in pain using the visual analog pain scale and an improvement in the level of functioning as measured by patient-nominated disability ratings.  The TENS-treated group (n = 21) reported a success rate of 0 %, while the group treated with VAX-D (n = 19) showed a success rate of 68.4 %.  It is difficult to conclude from this study that VAX-D is effective in treating chronic back pain since detailed statistics regarding the outcomes for each group were not included in the analysis.  Furthermore, patients were not blinded to the treatment received, thus, there may have been a negative placebo effect in the TENS-treated group.

The Australian Medical Services Advisory Committee (MSAC) (2001) performed an assessment of the literature on VAX-D therapy.  The Committee concluded that “there is currently insufficient evidence pertaining to the effectiveness of vertebral axial decompression (VAX-D) therapy...”.

An evidence review by the Workers Compensation Board of British Columbia (Martin et al, 2005) concluded: "To date there is no evidence that the VAX-D system is effective in treating chronic LBP associated with herniated disc, degenerative disc, posterior facet syndrome, sciatica or radiculopathy".

In a prospective, longitudinal, case series, Beattie et al (2008) examined outcomes after administration of a prone lumbar traction protocol.  A total of 296 subjects with low LBP and evidence of a degenerative and/or herniated intervertebral disk at 1 or more levels of the lumbar spine were included in this study.  Patients who were involved in litigation and those receiving workers' compensation were excluded.  Patients underwent an 8-week course of prone lumbar traction, using the VAX-D system, consisting of five 30-min sessions a week for 4 weeks, followed by one 30-min session a week for 4 additional weeks.  The numeric pain rating scale (NRS) and the Roland-Morris Disability Questionnaire (RMDQ) were completed at pre-intervention, discharge (within 2 weeks of the last visit), and at 30 days and 180 days after discharge.  Intention-to-treat strategies were used to account for those subjects lost to follow-up.  A total of 250 (84.4 %) subjects completed the treatment protocol.  On the 30-day follow-up, 247 (83.4 %) subjects were available; on the 180-day follow-up, data were available for 241 (81.4 %) subjects.  These researchers noted significant improvements for all post-intervention outcome scores when compared with pre-intervention scores (p < 0.01).  The authors concluded that traction applied in the prone position using the VAX-D for 8 weeks was associated with improvements in pain intensity and RMDQ scores at discharge, and at 30 and 180 days after discharge in a sample of patients with activity-limiting LBP.  Moreover, the authors noted that causal relationships between these outcomes and the intervention should not be made until further study is performed using randomized comparison groups.

The DRS System is marketed for the treatment of LBP associated with herniated and degenerated discs.  According to the manufacturer, the DRS System applies pressures on the disc in a graduated manner, which bypasses the inherent neurological mechanisms that lead to firing of stretch receptors in the paravertebral structures.  This decreased resistance to the distractive forces allows a marked reduction in intradiscal pressures, which promotes retraction of herniated disc material and facilitates influx of oxygen, proline and other substrates.

Similar to the VAX-D table, there is little scientific evidence to support the effectiveness of the DRS System or the Internal Disc Decompression (IDD) Therapy in treating LBP.  Further investigation is needed to determine their value in the management of patients with LBP.

An assessment by the Washington State Department of Labor and Industries Office of the Medical Director (Wang, 2004) concluded that "[p]ublished literature has not substantially shown whether powered traction devices are more effective than other forms of traction, other conservative treatments, or surgery".

The Agency for Healthcare Research and Quality's technology assessment on decompression therapy for the treatment of lumbosacral pain (Jurecki-Tiller et al, 2007) concluded that "[c]urrently available evidence is too limited in quality and quantity to allow for the formulation of evidence-based conclusions regarding the efficacy of decompression therapy as a therapy for chronic back pain when compared with other non-surgical treatment options.  Of the studies examined for assessment of efficacy, neither included patients over 65 years of age.  Adverse event reporting for decompression therapy is infrequent.  There was 1 case report of an enlargement of an existing disc protrusion, and other studies reported worsening of pain in some patients".

Macario and associates (2008) discussed the retrospective chart audit of 100 patients with discogenic LBP lasting more than 12 weeks treated with a 2-month course of motorized spinal decompression via the DRX9000.  Patients at a convenience sample of 4 clinics received 30-min DRX9000 sessions daily for the first 2 weeks tapering to 1 session/week.  Treatment protocol included lumbar stretching, myofascial release, or heat prior to treatment, with ice and/or muscle stimulation afterwards.  Primary outcome was verbal NRS 0 to 10 before and after the 8-week treatment.  Of the 100 subjects, 3 withdrew their protected health information, and 3 were excluded because their LBP duration was less than 12 weeks.  The remaining 94 subjects (63 % female, 95 % white, age = 55 (SD 16) year, 52 % employed, 41 % retired, LBP median duration of 260 weeks) had diagnoses of herniated disc (73 % of patients), degenerative disc disease (68 %), or both (27 %).  Mean NRS equaled 6.05 (SD 2.3) at presentation and decreased significantly to 0.89 (SD 1.15) at end of 8-week treatment (p < 0.0001).  Analgesic use also appeared to decrease (charts with data = 20) and activities of daily living improved (charts with data = 38).  Follow-up (mean of 31 weeks) on 29/94 patients reported mean 83 % LBP improvement, NRS of 1.7 (SD 1.15), and satisfaction of 8.55/10 (median of 9).  The authors concluded that this retrospective chart audit provides preliminary data that chronic LBP may improve with DRX9000 spinal decompression.  They stated that randomized double-blind trials are needed to measure the effectiveness of such systems.

The Work Loss Data Institute's clinical practice guideline Low back - lumbar & thoracic (acute & chronic) (2011) does not recommend the use of powered traction devices/Lordex/VAX-D.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
Other CPT codes related to the CPB:
64722
97012
HCPCS codes not covered for indications listed in the CPB:
S9090 Vertebral axial decompression, per session
ICD-9 codes not covered for indications listed in the CPB (not all-inclusive):
720.0 - 724.9 Dorsopathies


The above policy is based on the following references:
  1. U.S. Department of Health and Human Services, Health Care Financing Administration (HCFA). HCFA Technology Advisory Committee Minutes, August 6 - 7, 1996. Baltimore, MD: HCFA; 1996. Available at: http://www.hcfa.gov/events/tacminit.htm. Accessed July 13, 2001.
  2. F-D-C Reports. FDA Recalls & Court Actions: Manuals for VAX-D Therapeutic Table. The Gray Sheet. 1996 Aug;22(34).
  3. Gose EE, Naguszewski WK, Naguszewski RK. Vertebral axial decompression therapy for pain associated with herniated or degenerated discs or facet syndrome: An outcome study. Neurol Res. 1998;20(3):186-190.
  4. Ramos G, Martin W. Effects of vertebral axial decompression on intradiscal pressure. J Neurosurg. 1994;81(3):350-353.
  5. Shealy CN, Borgmeyer V. Decompression, reduction, and stabilization of the lumbar spine: A cost-effective treatment for lumbosacral pain. Am J Pain Mgmt. 1997;7(2):63-65.
  6. Sherry E, Kitchener P, Smart R. A prospective randomized controlled study of VAX-D and TENS for the treatment of chronic low back pain. Neurol Res. 2001;23(7):780-784.
  7. Medical Services Advisory Committee (MSAC). Vertebral axial decompression (VAX-D) therapy for low back pain. Assessment Report. MSAC application 1012. Canberra, ACT: MSAC; June 2001. Available at: http://www.health.gov.au/msac/pdfs/msac1012.pdf. Accessed April 2, 2004.
  8. Tilaro F. An overview of vertebral axial decompression. Canadian J Clin Med. 1998;5(1):1-7.
  9. Tilaro F, Miskovich D. The effects of vertebral axial decompression on sensory nerve dysfunction in patients with low back pain and radiculopathy. Canadian J Clin Med. 1999;6(1):2-7.
  10. Naguszewski WK, Naguszewski RK, Gose EE. Dermatosomal somatosensory evoked potential demonstration of nerve root decompression after VAX-D therapy. Neurol Res. 2001;23(7):706-714.
  11. Washington State Department of Labor and Industries, Office of the Medical Director. Vertebral axial decompression (Vax-D). Technology Assessment. Olympia, WA: Washington State Department of Labor and Industries; 1999. Available at: http://www.lni.wa.gov/omd/TechAssessDocs.htm. Accessed August 7, 2003.
  12. Deen HG Jr, Rizzo TD, Fenton DS. Sudden progression of lumbar disk protrusion during vertebral axial decompression traction therapy. Mayo Clin Proc. 2003;78(12):1554-1556.
  13. Wang G. Powered traction devices for intervertebral decompression. Health Technology Assessment Update. Olympia, WA: Washington State Department of Labor and Industries, Office of the Medical Director; June 14, 2004. Available at: www.lni.wa.gov/ClaimsIns/Files/OMD/TractionTechAssessJun142004.pdf. Accessed February 28, 2005. 
  14. Martin CW; Workers Compensation Board of British Columbia (WCB) Evidence Based Practice Group. Vertebral axial decompression for low back pain. Report. Richmond, BC: Workers Compensation Board of British Columbia (WorkSafe BC); 2005. 
  15. Jurecki-Tiller M, Bruening W, Tregear S, et al. Decompression therapy for the treatment of lumbosacral pain. Prepared by the ECRI Institute Evidence-Based Practice Center for the Agency for Healthcare Research and Quality (AHRQ) (Contract No. 290-02-0019). Rockville, MD: AHRQ; April 26, 2007. Available at: http://www.cms.hhs.gov/determinationprocess/downloads/id47TA.pdf. Accessed February 6, 2008.
  16. Beattie PF, Nelson RM, Michener LA, et al. Outcomes after a prone lumbar traction protocol for patients with activity-limiting low back pain: A prospective case series study. Arch Phys Med Rehabil. 2008;89(2):269-274.
  17. Macario A, Richmond C, Auster M, Pergolizzi JV. Treatment of 94 outpatients with chronic discogenic low back pain with the DRX9000: A retrospective chart review. Pain Pract. 2008;8(1):11-17.
  18. Work Loss Data Institute. Low back - lumbar & thoracic (acute & chronic). Encinitas, CA: Work Loss Data Institute; 2011.


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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