Number: 0576

  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.

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.

In a meta-analysis, Sun and associates (2015) compared the clinical outcomes of anterior approaches (anterior cervical corpectomy with fusion, cervical discectomy with fusion) and posterior approaches (laminectomy, laminoplasty) in multilevel cervical spondylotic myelopathy (MCSM) patients.  PubMed, Embase, Scopus, and the Cochrane library were searched for literatures up to March 27, 2015 without language restriction.  The reference lists of selected articles were also screened.  Heterogeneity was identified using Q test and I2 statistic.  A fixed effect model was used for homogeneous data and a random effects model for heterogeneous data.  Weighted mean difference (WMD) or odds ratio (OR) with 95 % confidence intervals (CIs) were calculated.  Subgroup analysis was conducted according to the cause of MCSM.  A total of 17 articles were selected.  Higher post-Japanese Orthopedic Association (JOA, p = 0.002) and shorter length of stay (p = 0.004) were found in anterior approaches group compared with posterior approaches.  Moreover, operation time was shorter (p < 0.00001) and neurological recovery rate was higher (p = 0.005) in ossification of posterior longitudinal ligament patients who underwent posterior approaches.  Complication rate of posterior approaches was lower in spinal stenosis subgroup (p < 0.0001).  The authors concluded that MCSM patients who underwent anterior approaches showed superior post-JOA and shorten length of stay.  However, the outcomes such as operation time and complication rate are associated with the cause of MCSM.  Therefore, the favorable surgical strategy for MCSM still needs more studies.

Lee and colleagues (2015) stated that posterior cervical surgery (expansive laminoplasty (EL) or laminectomy followed by fusion (LF)) is usually performed in patients with MCSM (greater than or equal to 3).  However, the superiority of either of these techniques is still open to debate.  These investigators compared clinical outcomes and post-operative kyphosis in patients undergoing EL versus LF by performing a meta-analysis.  Included in the meta-analysis were all studies of EL versus LF in adults with multi-level CSM in MEDLINE (PubMed), EMBASE, and the Cochrane library.  A random-effects model was applied to pool data using the MD for continuous outcomes, such as the JOA grade, the cervical curvature index (CCI), and the visual analog scale (VAS) score for neck pain.  A total of 7 studies comprising 302 and 290 patients treated with EL and LF, respectively, were included in the final analyses.  Both treatment groups showed slight cervical lordosis and moderate neck pain in the baseline state.  Both groups were similarly improved in JOA grade (MD 0.09, 95 % CI: -0.37 to 0.54, p = 0.07) and neck pain VAS score (MD -0.33, 95 % CI: -1.50 to 0.84, p = 0.58).  Both groups evenly lost cervical lordosis.  In the LF group, lordosis seemed to be preserved in long-term follow-up studies, although the difference between the 2 treatment groups was not statistically significant.  The authors concluded that both EL and LF lead to clinical improvement and loss of lordosis evenly.  There is no evidence to support EL over LF in the treatment of multi-level CSM.  Any superiority between EL and LF remains in question, although the LF group showed favorable long-term results.

CPT Codes / HCPCS Codes / ICD-10 Codes
Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":
ICD-10 codes will become effective as of October 1, 2015:
CPT codes covered if selection criteria are met:
63050 Laminoplasty, cervical with decompression of the spinal cord, two or more vertebral segments
63051     with reconstruction of the posterior bony elements (including the application of bridging bone graft and non-segmental fixation devices (e.g., wire, suture, mini-plates), when performed)
ICD-10 codes covered if selection criteria are met:
M47.011 - M47.019 Anterior spinal artery compression syndromes
M48.00 - M48.03
M99.20 - M99.21
M99.30 - M99.31
M99.40 - M99.41
M99.50 - M99.51
M99.60 - M99.61
M99.70 - M99.71
Spinal stenosis of cervical region
M50.00 - M50.03 Cervical disc disorder with myelopathy
ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):
M46.41 - M46.43
M50.80 - M50.83
M50.90 - M50.93
Other and unspecified cervical disc disorders
M47.21 - M47.23
M47.811 - M47.813
M47.891 - M47.893
Cervical spondylosis without myelopathy
M50.10 - M50.13
M54.11 - M54.13
Cervical disc disorder with radiculopathy
M50.20 - M50.23 Other cervical disc displacement
M50.30 - M50.33 Other cervical disc degeneration
M53.0 Cervicocranial syndrome
M53.1 Cervicobrachial syndrome
M53.81 - M53.83 Other specified dorsopathies
M54.2 Cervicalgia
M54.81 Occipital neuralgia
M54.89 - M54.9 Other and unspecified dorsalgia
M62.40 - M62.49
M62.830 - M62.838
Contracture of muscle
M96.1 Postlaminectomy syndrome, not elsewhere classified
M99.10 - M99.11 Subluxation complex, cervical
S13.100+ - S13.29x+ Subluxation and dislocation of cervical vertebra
S13.8xx+ - S13.9xx+
Sprain and strain of ligaments of cervical spine

The above policy is based on the following references:
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    8. Edwards CC 2nd, Riew KD, Anderson PA, et al. Cervical myelopathy. Current diagnostic and treatment strategies. Spine J. 2003;3(1):68-81.
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    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.
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    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.
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    40. Lee CH, Lee J, Kang JD, et al. Laminoplasty versus laminectomy and fusion for multilevel cervical myelopathy: A meta-analysis of clinical and radiological outcomes. J Neurosurg Spine. 2015;22(6):589-595.

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