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Clinical Policy Bulletin:
Laminoplasty
Number: 0576


Policy

  1. Aetna considers cervical laminoplasty (laminaplasty) medically necessary for members with severe cervical spinal stenosis at multiple (greater than or equal to 3) levels and compressive myelopathy.

  2. Aetna considers cervical laminoplasty experimental and investigational for members with mechanical axial neck pain (cervical strain) without myelopathy, and for all other indications because its effectiveness for these indications has not been established.


Background

Laminoplasty (laminaplasty) may be indicated in patients with myelopathy and multiple-level cervical spondylosis, such as in congenital cervical stenosis.  When cervical spinal stenosis is severe, various symptoms may develop which include pain, weakness in arms and/or legs and unsteadiness in the gait (myelopathy).

For mild conditions conservative treatment may be sufficient.  When symptoms are severe or progressive then a surgical treatment may be necessary.  Surgical goals include a decompression of all compressed levels of the spine and stabilization with solid fusion.  Surgical techniques are very dependent upon the specific problems of each patient.  Anterior and posterior surgical approaches can be applied.  In certain cases a decompression laminoplasty without fusion may be employed.  Laminoplasty consists of a careful splitting of the laminae, which are then held apart in order to enlarge the spinal canal diameter.  The procedure involves opening and fusion of the cervical spinal canal.

In a retrospective study, Sakaura and colleagues (2005) compared the long-term outcomes after laminoplasty and anterior spinal fusion (ASF) for patients with cervical myelopathy secondary to disc herniation.  The authors concluded that because the 2 procedures provided the same neurological improvement, the risks of bone graft complication with ASF must be weighed against the risks of chronic neck pain associated with laminoplasty for determining the best technique.  For these investigators, laminoplasty is the procedure of choice for cervical myelopathy due to disc herniation except for patients with single-level disc herniation without developmental canal stenosis, who are considered to be good surgical candidates for ASF.

Ohnari et al (2006) noted that cervical laminoplasty is a good strategy for cervical myelopathy, but some post-operative patients complain of obstinate axial symptoms after surgery (i.e., nuchal pain, neck stiffness, and shoulder pain).  It was reported that these symptoms proved to be more serious than has been believed and should be considered in the evaluation of the outcome of cervical spinal surgery.  However, axial symptoms are sometimes recognized before surgery, or also after corpectomy.  These investigators examined the difference in axial symptoms before and after laminoplasty and discussed the characteristics of these symptoms as a surgical complication.  They conducted a questionnaire survey and reviewed the medical records of respondents.  A total of 180 patients who underwent a spinous process-splitting laminoplasty for cervical myelopathy caused by degenerative disease in the authors’ institution from 1993 until 2002 were included in the study, and were followed-up for 2 years or longer after surgery.  Major outcome measures were self-report measures and functional measures.  The questionnaire elicited information as follows: the location and characteristics of pre- and post-operative symptoms, frequency and duration of post-operative symptoms, and impairment in activities of everyday living, analgesic use, and the duration of use of cervical orthosis after surgery.  The researchers divided axial symptoms into 4 characteristics based on previous reports: (i) pain, (ii) heaviness, (iii) stiffness, and (iv) other.  An illustration of the upper back on which respondents could mark each characteristic was used to acquire information about the location of axial symptoms.  The following information was gathered from medical records and statistically analyzed: whether post-operative axial symptoms were related or not, age, sex, neurological findings, the period of cervical orthosis, surgery time, blood loss, with or without reconstruction surgery of the semi-spinalis cervicis muscle, and pre-operative axial symptoms.  For all of the 51 respondents, the average time since surgery was 4.1 years at the time of investigation; 42 patients complained of post-operative axial symptoms; 26 patients stated the duration of symptoms after surgery to be more than 2 years.  The surgical outcome of this group, however, did not differ from that of the 2-year-or-less group.  Axial symptoms, which accounted for 13.3 % of all answers about post-operative impairment of everyday living, were similar to hand numbness.  Of respondents with post-operative axial symptoms, 52.2 % stated the frequency of affliction to be "all day long", but 34.8 % replied "rarely" to frequency of use of analgesics.  Axial symptoms in the nuchal region increased from 45.2 % to 48.6 % after surgery.  Stiffness was the most common characteristic before and following surgery, but pain significantly increased from 24.6 % before surgery to 38.4 % after surgery.  It was speculated that the principal manifestation of axial symptoms might be pain and that the nuchal region might be the predominant region for axial symptoms.  There was no significant difference in age, blood loss, operative time, sex, duration of use of cervical orthosis, reconstructive surgery, and pre-operative symptoms between 2 groups -- those who complained of axial symptoms after surgery, and those who did not.  The authors concluded that axial symptoms were not usually so severe as to require analgesic use and did not worsen the Japanese Orthopedic Association score after surgery; symptoms were, however, considered to continuously affect everyday life as much as hand numbness.  Regarding their features, the authors speculated that the main characteristics of axial symptoms might be pain and that the nuchal region might be the predominant region for axial symptoms.  These findings are consistent with the hypothesis that laminoplasty is not, as such, an effective treatment for axial neck pain and that axial symptoms may in fact be worsened by the procedure.

The Work Loss Data Institute's clinical practice guideline on "Neck and upper back (acute & chronic)" (2011) stated that a relative contraindication to laminoplasty is pre-operative neck pain as disruption of the musculature can aggravate axial pain.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
63050
63051
ICD-9 codes covered if selection criteria are met:
721.1 Cervical spondylosis with myelopathy
722.71 Intervertebral disc disorder with myelopathy, cervical region
723.0 Spinal stenosis of cervical region
ICD-9 codes not covered for indications listed in the CPB (not all-inclusive):
721.0 Cervical spondylosis without myelopathy
722.0 Displacement of cervical intervertebral disc without myelopathy
722.4 Degeneration of cervical intervertebral disc
722.81 Postlaminectomy syndrome, cervical region
722.91 Other and unspecified disc disorder, cervical region
723.1 Cervicalgia
723.2 Cervicocranial syndrome
723.3 Cervicobrachial syndrome (diffuse)
723.4 Brachial neuritis or radiculitis NOS
723.8 Other syndromes affecting cervical region
724.5 Backache, unspecified
724.8 Other symptoms referable to back
728.85 Spasm of muscle
839.00 - 839.18 Dislocation cervical vertebra
847.0 Sprain and strain of neck


The above policy is based on the following references:
  1. Narayan P, Haid RW. Treatment of degenerative cervical disc disease. Neurol Clin. 2001;19(1):217-229.
  2. Liew SM, Simmons ED. Cervical deformity. Rationale for selecting the appropriate fusion technique. Orthoped Clin North Am. 1998;29(4):779-786.
  3. Tsuji H. Laminoplasty for patients with compressive myelopathy due to so-called spinal canal stenosis in cervical and thoracic regions. Spine. 1982;7(1):28-34.
  4. Laminaplasty. In: Wheeless' Textbook of Orthopaedics. CR Wheeless III, ed. European ed. CR Wheeless; 1996. Available at: http://wheeless.belgianorthoweb.be/o11/1180.htm. Accessed July 31, 2001.
  5. Laminaplasty. In: Spine-Health.com. PF Ullrich, ed. Evanston, IL: Spine-Health.com; 1999-2001. Available at: http://www.spine-health.com/dir/laminaplasty.html. Accessed July 31, 2001.
  6. Emery SE. Cervical spondylotic myelopathy: Diagnosis and treatment. J Am Acad Orthop Surg. 2001;9(6):376-388.
  7. Geck MJ, Eismont FJ. Surgical options for the treatment of cervical spondylotic myelopathy. Orthop Clin North Am. 2002;33(2):329-348.
  8. Edwards CC 2nd, Riew KD, Anderson PA, et al. Cervical myelopathy. Current diagnostic and treatment strategies. Spine J. 2003;3(1):68-81.
  9. Wang MY, Green BA. Open-door cervical expansile laminoplasty. Neurosurgery. 2004;54(1):119-123; discussion 123-124.
  10. Sakaura H, Hosono N, Mukai Y, et al. Long-term outcome of laminoplasty for cervical myelopathy due to disc herniation: A comparative study of laminoplasty and anterior spinal fusion. Spine. 2005;30(7):756-759.
  11. Takeshita K, Seichi A, Akune T, et al. Can laminoplasty maintain the cervical alignment even when the C2 lamina is contained? Spine. 2005;30(11):1294-1298.
  12. Sakaura H, Hosono N, Mukai Y, et al. Long-term outcome of laminoplasty for cervical myelopathy due to disc herniation: A comparative study of laminoplasty and anterior spinal fusion. Spine. 2005;30(7):756-759.
  13. Ohnari H, Sasai K, Akagi S, et al. Investigation of axial symptoms after cervical laminoplasty, using questionnaire survey. Spine J. 2006;6(3):221-227.
  14. Steinmetz MP, Resnick DK. Cervical laminoplasty. Spine J. 2006;6(6 Suppl):274S-281S.
  15. Hale JJ, Gruson KI, Spivak JM. Laminoplasty: A review of its role in compressive cervical myelopathy. Spine J. 2006;6(6 Suppl):289S-298S.
  16. Iwasaki M, Okuda S, Miyauchi A, et al. Surgical strategy for cervical myelopathy due to ossification of the posterior longitudinal ligament: Part 1: Clinical results and limitations of laminoplasty. Spine. 2007;32(6):647-653.
  17. Masaki Y, Yamazaki M, Okawa A, et al. An analysis of factors causing poor surgical outcome in patients with cervical myelopathy due to ossification of the posterior longitudinal ligament: Anterior decompression with spinal fusion versus laminoplasty. J Spinal Disord Tech. 2007;20(1):7-13.
  18. Iwasaki M, Okuda S, Miyauchi A, et al. Surgical strategy for cervical myelopathy due to ossification of the posterior longitudinal ligament: Part 2: Advantages of anterior decompression and fusion over laminoplasty. Spine. 2007;32(6):654-660.
  19. Yukawa Y, Kato F, Ito K, et al. Laminoplasty and skip laminectomy for cervical compressive myelopathy: Range of motion, postoperative neck pain, and surgical outcomes in a randomized prospective study. Spine. 2007;32(18):1980-1985.
  20. Yang SC, Niu CC, Chen WJ, et al. Open-door laminoplasty for multilevel cervical spondylotic myelopathy: Good outcome in 12 patients using suture anchor fixation. Acta Orthop. 2008;79(1):62-66.
  21. Ishii M, Wada E, Ishii T, et al. Laminoplasty for patients aged 75 years or older with cervical myelopathy. J Orthop Surg (Hong Kong). 2008;16(2):211-214.
  22. Shigematsu H, Ueda Y, Koizumi M, et al. Does developmental canal stenosis influence surgical results of bilateral open-door laminoplasty for cervical spondylotic myelopathy? J Neurosurg Spine. 2008;9(4):358-362.
  23. Xia Y, Wan J, Yu B, et al. Treatment of fluorosis cervical canal stenosis by open-door cervical expansive laminoplasty using anchor fixation. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2009;23(10):1204-1208.
  24. Mummaneni PV, Kaiser MG, Matz PG, et al; Joint Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons and Congress of Neurological Surgeons. Cervical surgical techniques for the treatment of cervical spondylotic myelopathy. J Neurosurg Spine. 2009;11(2):130-141.
  25. Matz PG, Anderson PA, Groff MW, et al; Joint Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons and Congress of Neurological Surgeons. Cervical laminoplasty for the treatment of cervical degenerative myelopathy. J Neurosurg Spine. 2009;11(2):157-169.
  26. Koakutsu T, Morozumi N, Ishii Y, et al. Anterior decompression and fusion versus laminoplasty for cervical myelopathy caused by soft disc herniation: A prospective multicenter study. J Orthop Sci. 2010;15(1):71-78.
  27. Cunningham MR, Hershman S, Bendo J. Systematic review of cohort studies comparing surgical treatments for cervical spondylotic myelopathy. Spine (Phila Pa 1976). 2010;35(5):537-543.
  28. Work Loss Data Institute. Neck and upper back (acute & chronic). Encinitas, CA: Work Loss Data Institute; 2011.
  29. Mikhael MM, Wolf CF, Wang JC. Cervical spine surgery: Cervical laminaplasty. Instr Course Lect. 2012;61:461-468.
  30. Fourney DR, Skelly AC, DeVine JG. Treatment of cervical adjacent segment pathology: A systematic review. Spine (Phila Pa 1976). 2012;37(22 Suppl):S113-S122.
  31. Zhu B, Xu Y, Liu X, et al. Anterior approach versus posterior approach for the treatment of multilevel cervical spondylotic myelopathy: A systemic review and meta-analysis. Eur Spine J. 2013;22(7):1583-1593.
  32. Bartels RH, van Tulder MW, Moojen WA, et al. Laminoplasty and laminectomy for cervical sponydylotic myelopathy: A systematic review. Eur Spine J. 2013 Apr 11. [Epub ahead of print]


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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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