Selective Peripheral Denervation (Bertrand Procedure)

Number: 0401

Policy

Aetna considers selective peripheral denervation (Bertrand procedure) medically necessary for the treatment of members with severe spasmodic torticollis (cervical dystonia) when both of the following criteria are met:

  • Current symptoms are disabling; and
  • Member has failed an appropriate course of pharmacotherapies or has had adverse side effects from the medications or the member has developed resistance to botulinum toxin type A or type B.

Aetna considers selective peripheral denervation experimental and investigational for the treatment of members with severe spasmodic torticollis when criteria are not met because the value of this procedure in persons without disability or in persons who have not failed medical management is unproven.

Aetna considers combined selective peripheral denervation and deep brain stimulation experimental and investigational for the treatment of spasmodic torticollis because the effectiveness of this approach has not been established.

Aetna considers selective peripheral neurectomy experimental and investigational for the treatment of upper limb spasticity because the effectiveness of this approach has not been established.

See also CPB 0113 - Botulinum Toxin.

Background

Spasmodic torticollis (cervical dystonia), or torticollis, is the most common of the focal dystonias.  It is a disorder in which neck muscles contract involuntarily, resulting in abnormal movements and posture of the head and neck.  In general, the term -- spasmodic torticollis (ST) -- is used to describe spasms in any direction: forward (anterocollis), backward (retrocollis), and sideway (torticollis).  The movement may be sustained or jerky.  Spasm in the muscles or pinching nerves in the neck can result in severe pain.  In this regard, cervical pain is seen in approximately 80 % of patients with ST.  Torticollis generally occurs in middle age; beginning slowly and usually reaching a plateau.  Approximately 10 to 20 % of individuals with this condition experience a spontaneous remission; however, the remission may not be permanent.

Since the cause of ST is unknown, there is currently no cure for this disorder.  Treatment is geared towards symptomatic relief.  Various medications are used in treating this condition.  Botox (botulinum toxin type A) injections have been demonstrated to improve both pain and head position in 70 to 80 % of patients with ST.  The toxin is injected into the 2 or 3 most functionally active muscles, most commonly the sternomastoid, spenius capitus or trapezius.

In very severe cases of disabling ST when pharmacotherapies including Botox injections have failed or the side effects are too severe, selective peripheral denervation may offer relief of symptoms.  Selective peripheral denervation is a procedure in which nerves are removed at the point where they enter the selected hyperactive muscles; while innervation to uninvolved muscles is maintained.  Studies have indicated that this procedure is useful in selected patients.  Positive response to prior botulinum toxin therapy appears to be a very good indicator of outcome following selective peripheral denervation.

A systematic evidence review of dystonias by the EFNS/MDS-ES Task Force (Albanese, et al., 2006) concluded: "Selective peripheral denervation is a safe procedure with infrequent and minimal side effects that is indicated exclusively in cervical dystonia. This procedure requires a specialized expertise."

Guidance from the National Institute for Clinical Excellence (2004) concluded:"Current evidence on the safety and efficacy of selective peripheral denervation for cervical dystonia appears adequate to support the use of this procedure provided that the normal arrangements are in place for consent, audit and clinical governance." The guidance stated that "patient selection for this procedure is important" and that "patients should be offered the procedure only when their disease has become refractory to best medical treatment." Standard medical treatments for cervical dystonia identified by NICE includes physiotherapy, drugs to reduce spasm, and injections of botulinum toxin. The NICE guidance said that selective peripheral denervation may be an alternative, especially for people who have not responded to other treatments.

Wang and colleagues (2015) noted that selective peripheral denervation (SPD) is currently the primary surgical treatment for ST.  These investigators reported on the outcome of patients treated with this procedure for ST in their department.  Between June 1995 and June 2013, a total of 648 patients underwent SPD for ST.  Participants included 293 women (45.2 %) and 355 men (54.8 %) with a mean age of 41.1 years (range of 8 to 74 years) at the onset of dystonia.  Surgery was performed at a mean of 3.6 years (range of 1 to 32 years) after onset of symptoms.  Data on clinical presentation, radiological studies, operation tragedy, clinical outcomes and complications were analyzed retrospectively.  For evaluation of clinical outcomes, patients' responses were assessed using the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS).  Results were obtained from all 648 patients with a follow-up period ranging from 11 months to 154 months (mean of 33.4 months).  The mean pre-operative TWSTRS score was 54.7 ± 18.3 points (range of 39 to 67 points), which decreased to 31.1 ± 11.6 points post-operatively (range of 1 to 67 points); a significant improvement was observed between pre-operative and post-operative TWSTRS evaluation; the clinical improvement of TWSTRS was 73.5 ± 11.9 %.  In addition, no deaths and serious complications occurred in this cohort of patients.  The authors concluded that SPD is an effective surgical method for patients with ST.  This procedure should be recommended if conservative therapy does not offer satisfactory relief of symptoms.

Combined Selective Peripheral Denervation and Deep Brain Stimulation

Chung et al (2015) stated that SPD and deep brain stimulation of the globus pallidus (GPi-DBS) are available surgical options for patients with medically refractory cervical dystonia (CD).  There are few data available concerning whether patients who have unsatisfactory treatment effects after primary surgery benefit from a different type of subsequent surgery.  These researchers examined if combining these surgical procedures (SPD plus GPi-DBS) was effective in patients with unsatisfactory treatment effects after their initial surgery.  A total of 41 patients with medically refractory idiopathic CD underwent SPD and/or GPi-DBS.  Patients who were dissatisfied with their primary surgery (SPD or GPi DBS) elected to subsequently undergo a different type of surgery.  These patients were assessed with the TWSTRS.  Selective peripheral denervation alone and GPi-DBS alone were performed in 16 and 21 patients, respectively.  Four patients had unsatisfactory treatment effects after the initial surgery and subsequently underwent another type of surgery.  Among them, 2 patients with persistent dystonia after SPD subsequently underwent GPi-DBS, and 2 other patients who had insufficient treatment effects following GPi-DBS were subsequently treated with SPD.  All of these patients experienced sustained improvement from the combined surgical procedures according to the TWSTRS score during a long-term follow-up of 12 to 90 months.  The authors concluded that patients with unsatisfactory treatment effects after an SPD or GPi-DBS experienced improvement from subsequently undergoing other types of surgery.  They stated that combined surgical procedures are additional surgical options with good outcomes in the treatment of patients with residual symptoms after their initial surgery.  The main drawback of this study was its small sample size – only 4 patients combined surgical procedures (SPD and GPi-DBS).

Selective Peripheral Neurectomy for the Treatment of Upper Limb Spasticity

Yong and colleagues (2018) stated that management of upper limb spasticity remains challenging.  Selective peripheral neurectomy (SPN) is a relatively recent intervention for cases refractory to medical therapy.  These researchers carried out a systematic review examining the efficacy and outcomes of SPN to clarify the patient selection criteria and surgical technique.  They performed a search of Medline, Embase, Cochrane Central Register of Controlled Trials, Web of Science Core Collection, Open Grey and CINAHL.  Inclusion criteria included studies comparing pre- and post-operative outcomes for SPN, neurectomy, fasciculotomy and upper limb spasticity.  Only case series were reported with no randomized controlled trials (RCTs) found; 7 studies met the inclusion criteria with a total of 174 patients.  A meta-analysis was not possible due to the degree of baseline heterogeneity.  All studies had no control arm for comparison of outcomes, with a high risk of bias due to poor internal and external validity, as well as design and performance bias.  Surgical techniques differed vastly between studies, with percentage of fascicles ablated between 30 to 80 % and length of neurectomy between 5 to 10 mm.  Some advocated removing end branches while others performed fascicular SPN proximally.  A total of 13 patients underwent orthopedic or neurosurgical procedures, which were both confounding factors.  All studies reported an improvement in spasticity although functional outcomes were reported with non-standardized measures.  Recurrence rates were reported to be 0 to 16.1 % (mean of 3.72 %).  The authors concluded that from this systematic review, SPN appeared to be a useful technique in selected cases, but overall no firm conclusions could be drawn regarding the best surgical technique, or the extent of functional improvement. 

Furthermore, UpToDate reviews on “Cerebral palsy: Treatment of spasticity, dystonia, and associated orthopedic issues” (Barkoudah and Glader, 2019) and “Chronic complications of spinal cord injury and disease” (Abrams and Wakasa, 2019) do not mention selective peripheral neurectomy as a therapeutic option.


Table: CPT Codes / HCPCS Codes / ICD-10 Codes
Code Code Description

Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":

Selective Peripheral Denervation (Bertrand Procedure) for Spasmodic Torticollis:

No specific code

Other CPT codes related to the CPB:

64616 Chemodenervation of muscle(s); neck muscle(s), excluding muscles of the larynx, unilateral (eg, for cervical dystonia, spasmodic torticollis)
64640 Destruction by neurolytic agent; other peripheral nerve or branch

Other HCPCS codes related to the CPB:

J0585 Botulinum toxin type A, per unit
J0587 Botulinum toxin type B, per 100 units

ICD-10 codes covered if selection criteria are met:

G24.3 Spasmodic torticollis [severe, disabling]

ICD-10 codes not covered for indications listed in the CPB:

G80.1 Spastic diplegic cerebral palsy [upper limb spasticity]

The above policy is based on the following references:

  1. Hughes AJ. Botulinum toxin in clinical practice. Drugs. 1994;48(6):888-893.
  2. Davis DH, Ahlskog JE, Litchy WJ, Root LM. Selective peripheral denervation for torticollis: Preliminary results. Mayo Clin Proc. 1991;66(4):365-371.
  3. Bertrand CM. Selective peripheral denervation for spasmodic torticollis: Surgical techniques, results, and observations in 260 cases. Surg Neurol. 1994;40(2):96-103.
  4. Braun V, Richter HP. Selective peripheral denervation for the treatment of spasmodic torticollis. Neurosurgery. 1994;35(1):58-62.
  5. Braun V, Richter HP, Schroder JM. Selective peripheral denervation for spasmodic torticollis: Is the outcome predictable? J Neurol. 1995;242(8):504-507.
  6. Ford B, Louis ED, Greene P, Fahn S. Outcome of selective ramisectomy for botulinum toxin resistant torticollis. J Neurol Neurosurg Psychiatry. 1998;65(4):472-478.
  7. Munchau A, Palmer JD, Dressler D, et al. Prospective study of selective peripheral denervation for botulinum-toxin resistant patients with cervical dystonia. Brain. 2001;124(Pt 4):769-783.
  8. Braun V, Richter HP. Selective peripheral denervation for spasmodic torticollis: 13-year experience with 155 patients. J Neurosurg. 2002;97(2 Suppl):207-212.
  9. Dent THS. Selective denervation for spasmodic torticollis. Succinct and Timely Evaluated Evidence Review (STEER). Bazian, Ltd., eds. London, UK: Wessex Institute for Health Research and Development, University of Southampton; March 2002; 2(10).
  10. Cohen-Gadol AA, Ahlskog JE, Matsumoto JY, et al. Selective peripheral denervation for the treatment of intractable spasmodic torticollis: Experience with 168 patients at the Mayo Clinic. J Neurosurg. 2003;98(6):1247-1254.
  11. National Institute for Clinical Excellence (NICE). Selective peripheral denervation for cervical dystonia. Interventional Procedure Guidance 80. London, UK: NICE; August 2004.
  12. Othee GS, Menckhoff GR. Torticollis. eMedicine Orthopedic Surgery Topic 452. Omaha, NE: eMedicine.com; updated June 30, 2004. Available at: http://www.emedicine.com/orthoped/topic452.htm. Accessed: June 17, 2005.
  13. Loher TJ, Pohle T, Krauss JK. Functional stereotactic surgery for treatment of cervical dystonia: Review of the experience from the lesional era. Stereotact Funct Neurosurg. 2004;82(1):1-13.
  14. Taira T, Ochiai T, Goto S, Hori T. Multimodal neurosurgical strategies for the management of dystonias. Acta Neurochir Suppl. 2006;99:29-31.
  15. Albanese A, Barnes MP, Bhatia KP, et al. A systematic review on the diagnosis and treatment of primary (idiopathic) dystonia and dystonia plus syndromes: Report of an EFNS/MDS-ES Task Force. Eur J Neurol. 2006;13(5):433-444.
  16. Ferreira JJ, Costa J, Coelho M, Sampaio C. The management of cervical dystonia. Expert Opin Pharmacother. 2007;8(2):129-140.
  17. Anderson WS, Lawson HC, Belzberg AJ, Lenz FA. Selective denervation of the levator scapulae muscle: An amendment to the Bertrand procedure for the treatment of spasmodic torticollis. J Neurosurg. 2008;108(4):757-763.
  18. Huh R, Han IB, Chung M, Chung S. Comparison of treatment results between selective peripheral denervation and deep brain stimulation in patients with cervical dystonia. Stereotact Funct Neurosurg. 2010;88(4):234-238.
  19. Contarino MF, Van Den Munckhof P, Tijssen MA, et al. Selective peripheral denervation: Comparison with pallidal stimulation and literature review. J Neurol. 2014;261(2):300-308.
  20. Wang J, Li J, Han L, et al. Selective peripheral denervation for the treatment of spasmodic torticollis: Long-term follow-up results from 648 patients. Acta Neurochir (Wien). 2015;157(3):427-433.
  21. Chung M, Han I, Chung SS, et al. Effectiveness of selective peripheral denervation in combination with pallidal deep brain stimulation for the treatment of cervical dystonia. Acta Neurochir (Wien). 2015;157(3):435-442.
  22. Yong LY, Wong CHL, Gaston M, Lam WL. The role of selective peripheral neurectomy in the treatment of upper limb spasticity. J Hand Surg Asian Pac Vol. 2018;23(2):181-191.
  23. Barkoudah E, Glader L. Cerebral palsy: Treatment of spasticity, dystonia, and associated orthopedic issues. UpToDate [online serial]. Waltham, MA: UpToDate; reviewed February 2019.
  24. Abrams GM, Wakasa M. Chronic complications of spinal cord injury and disease. UpToDate [online serial]. Waltham, MA: UpToDate; reviewed February 2019.
  25. Ravindran K, Ganesh Kumar N, Englot DJ, et al. Deep brain stimulation versus peripheral denervation for cervical dystonia: A systematic review and meta-analysis. World Neurosurg. 2019;122:e940-e946.