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Clinical Policy Bulletin:
Spinal Ultrasound
Number: 0628


Policy

Aetna considers ultrasound of the spine and para-spinal tissues medically necessary in newborns and infants for the following indications:

  • Detection of sequelae of injury (e.g., hematoma after spinal tap or birth injury; post-traumatic leakage of cerebrospinal fluid; and sequelae of prior instrumentation, infection, or hemorrhage).
  • Evaluation of suspected defects such as cord tethering, diastematomyelia, hydromyelia, and syringomyelia.
  • Guidance for lumbar puncture.
  • Lumbosacral stigmata known to be associated with spinal dysraphism.
  • Post-operative assessment for cord retethering.
  • Spectrum of caudal regression syndrome (e.g., anal atresia or stenosis; sacral agenesis).
  • Visualization of fluid with characteristics of blood products within the spinal canal in neonates and infants with intra-cranial hemorrhage.

Aetna considers ultrasound of the spine and para-spinal tissues medically necessary when performed intra-operatively.

Aetna considers diagnostic ultrasound of the spine and para-spinal tissues experimental and investigational for evaluation of neuromusculoskeletal conditions and all other indications (e.g., in the practice of neuraxial (epidural and subarachnoid) blocks, and to assist in lumbar puncture (except in newborns and infants)) because its effectiveness for these indications has not been established.



Background

This policy is based on position statements of the American College of Radiology (ACR), and the American Academy of Neurology (AAN).

The ACR (1996) adopted the following statement on spinal ultrasound: “Over the past several years interest has developed in the use of ultrasound technology for the evaluation of the spine and paraspinal regions in adults.  While diagnostic ultrasound is appropriately used 1) intraoperatively; 2) in the newborn and infants for the evaluation of the spinal cord and canal; and 3) for multiple musculoskeletal applications in adults, there is currently no documented scientific evidence of the efficacy of this modality in the evaluation of the paraspinal tissues and the spine in adults.  Any claims or inferences that the use of spinal or paraspinal ultrasound is more advantageous or has a greater diagnostic accuracy than established procedures such as computed tomography (CT) or magnetic resonance imaging (MRI) cannot be made today based on recognized medical research.”

An AAN Report (1998) on spinal ultrasound for the evaluation of back pain and radicular disorders concluded: “Currently, no published peer reviewed literature supports the use of diagnostic ultrasound in the evaluation of patients with back pain or radicular symptoms.  The procedure cannot be recommended for use in the clinical evaluation of such patients.”

The American Institute of Ultrasound Medicine (AIUM, 2002) made the following official statement: “There is insufficient evidence in the peer-reviewed medical literature establishing the value of non-operative spinal/paraspinal ultrasound in adults.  Therefore, the AIUM states that, at this time, the use of non-operative spinal/paraspinal ultrasound in adults (for study of facet joints and capsules, nerve and fascial edema, and other subtle paraspinous abnormalities) for diagnostic evaluation, for evaluation of pain or radiculopathy syndromes, and for monitoring of therapy has no proven clinical utility.  Non-operative spinal/paraspinal ultrasound in adults should be considered investigational.  The AIUM urges investigators to perform proper double-blind research projects to evaluate the efficacy of these diagnostic spinal ultrasound examinations.”

Glotzbecker and colleagues (2009) noted that the risk of thrombo-embolic disease is well-studied for some orthopedic procedures.  However, the incidence of post-operative thrombo-embolic disease is less well-defined in patients who have had spinal surgery.  These investigators performed a systematic review on thrombo-embolic disease in spinal surgery.  The Medline database was queried using the search terms deep venous thrombosis or DVT, pulmonary embolus, thromboembolic disease, and spinal or spine surgery.  Abstracts of all identified articles were reviewed.  Detailed information from eligible articles was extracted.  Data were compiled and analyzed by simple summation methods when possible to stratify rates of DVT and/or pulmonary embolus for a given prophylaxis protocol, screening method, and type of spinal surgery.  A total of 25 articles were eligible for full review.  The risk of DVT ranged from 0.3 % to 31 %, varying between patient populations and methods of surveillance.  Pooling data from the 25 studies, the overall rate of DVT was 2.1 %.  The rate of DVT was influenced by prophylaxis method: no prophylaxis, 2.7 %; compression stockings (CS), 2.7 %; pneumatic sequential compression device (PSCD), 4.6 %; PSCD and CS, 1.3 %; chemical anti-coagulants, 0.6 %; and inferior vena cava filters with/without another method of prophylaxis, 22 %.  The rate of DVT was also influenced by the method of diagnosis, ranging from 1 % to 12.3 %.  The authors concluded that as risk of DVT after routine elective spinal surgery is fairly low, it seems reasonable to use CS with PSCD as a primary method of prophylaxis.  There is insufficient evidence to support or refute the use of chemical anti-coagulants in routine elective spinal surgery.  Furthermore, there is insufficient evidence to suggest that screening patients undergoing elective spinal surgery with ultrasound or venogram is routinely warranted.

Tsui and Suresh (2010) presented a comprehensive review of the evidence pertaining to techniques described and outcomes evaluated for ultrasound imaging in pediatric neuraxial anesthesia.  Neuraxial anesthesia pertains to local anesthetics placed around the nerves of the central nervous system, such as spinal anesthesia also called subarachnoid anesthesia and epidural anesthesia.  These researchers described and illustrated the anatomy related to each block to serve as a foundation for better understanding the block techniques described.  For neuraxial blockade, ultrasound may fairly reliably predict the depth to loss of resistance and can enable a dynamic view of the needle and catheter after entry into the spinal canal.  Particularly, in young infants, direct visualization of the needle and catheter tip may be possible, whereas in older children surrogate markers including the displacement of dura mater by the injection of fluid may be necessary for confirming needle and catheter placement.  The authors stated that more outcome-based, prospective, randomized, controlled trials are needed to prove the benefits of ultrasound when compared with conventional methods.

Perlas (2010) summarized the existing evidence behind the role of ultrasonography in neuraxial anesthesia techniques.  A literature search of the MEDLINE, PubMed, ACP Journal Club databases, and the Cochrane Database of Systematic Reviews was performed using the term ultrasonography combined with each of the following: spinal, intrathecal, epidural, and lumbar puncture.  Only studies related to regional anesthesia or acute pain practice were included.  Case reports and letters to the editor were excluded.  A total of 17 relevant studies were identified and included in this review.  Neuraxial ultrasonography is a recent development in regional anesthesia practice.  Most clinical studies to date come from a limited number of centers and have been performed by very few and highly experienced operators.  The existing evidence may be classified in 2 main content areas: (i) ultrasound-assisted neuraxial techniques and (ii) real-time ultrasound-guided neuraxial techniques.  The author concluded that neuraxial ultrasonography has been recently introduced to regional anesthesia practice.  The limited data available to date suggested that it is a useful adjunct to physical examination, allowing for a highly precise identification of regional landmarks and a precise estimation of epidural space depth, thus facilitating epidural catheter insertion.  Moreover, they stated that further research is needed to conclusively establish its impact on procedure success and safety profile, especially in the adult non-obstetric population.  This is in agreement with Tsui and Pillay (2010) who noted that although there is some evidence to support ultrasound for various outcomes in pediatric regional anesthesia, more randomized controlled studies with sufficient power are needed to further support these findings and to evaluate the potential for ultrasound to reduce complications for regional anesthesia in children.

Javanshir and colleagues (2010) reviewed the literature concerning size measurement of cervical muscles using real-time ultrasound imaging (RUSI) in patients with neck pain and in healthy populations.  A literature search from 1996 to December 2009 making use of Science Direct and PubMed databases was conducted.  Medical Subject Headings and other terms were as follows: ultrasonography, cervical, muscle, neck, size, pain, validity, reliability, neck pain, and healthy subjects.  These researchers included studies using RUSI for assessing cervical paraspinal muscles both in healthy subjects as well as in patients with neck pain.  They assessed muscles investigated and the reliability and validity of the method used.  The literature search yielded 16 studies -- 12 (75 %) studies assessed the posterior muscles, whereas in the remaining 4 (25 %), the anterior muscles were studied.  Three studies quantified the size of the muscles during contraction; 3 assessed the relationship between cross-sectional area, linear dimensions, and anthropometric variables; 1 evaluated the training-induced changes in muscle size; 1 assessed the differences in muscle shape and cross-sectional area of cervical multifidus between patients with chronic neck pain and controls; 8 studies looked at the reliability of using RUSI in patients with neck pain or healthy subjects; and 3 studies evaluated the validity of RUSI compared with magnetic resonance imaging.  The authors concluded that this literature review has shown that there are insufficient studies for assessing neck muscles with RUSI.  It seems that using constant landmarks, knowledge of anatomy and function of target muscle, and a proper definition of muscle borders can help to take a clear image.  Standardized position of the subject, correct placement of the transducer, and using multiple RUSI for statistical analyses may improve results.

The Work Loss Data Institute's clinical practice guideline on "Neck and upper back (acute & chronic)" (2011) listed diagnostic ultrasound as one of the interventions that was considered, but was not recommended.

The American Institute of Ultrasound in Medicine's practice guideline for the performance of an ultrasound examination of the neonatal spine (2012) states that this guideline has been developed to assist practitioners performing a sonographic examination of the neonatal and infant spine.  In some cases, an additional or specialized examination may be necessary.  While it is not possible to detect every abnormality, following this guideline will maximize the detection of abnormalities of the infant spine.  Sonographic examination of the pediatric spinal canal is accomplished by scanning through the normally incompletely ossified posterior elements.  Therefore, it is most successful in the newborn period and in early infancy.  In infants older than 6 months, the examination can be very limited, although the level of termination of the cord may be identified.  In experienced hands, ultrasound imaging of the infant spine has been shown to be an accurate and cost-effective examination that is comparable to magnetic resonance imaging for evaluating congenital or acquired abnormalities in the neonate and young infant.

The guideline lists the following indications for ultrasound examination of the neonatal spine:

  • Detection of sequelae of injury (e.g., hematoma after spinal tap or birth injury; post-traumatic leakage of cerebrospinal fluid; and sequelae of prior instrumentation, infection, or hemorrhage).
  • Evaluation of suspected defects such as cord tethering, diastematomyelia, hydromyelia, and syringomyelia.
  • Guidance for lumbar puncture.
  • Lumbosacral stigmata known to be associated with spinal dysraphism.
  • Post-operative assessment for cord retethering.
  • Spectrum of caudal regression syndrome (e.g., anal atresia or stenosis; sacral agenesis).
  • Visualization of fluid with characteristics of blood products within the spinal canal in neonates and infants with intra-cranial hemorrhage.
 
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
76800
Other CPT codes related to the CPB:
62310 - 62319 Injection(s), of diagnostic or therapeutic substance(s)(including anesthetic, antispasmodic,opioid, steroid, other solution), not including neurolytic substances,including needle or catheter placement, includes contrast for localization when performed, epidural, lumbar, sacral, subarachnoid, cervical, or thoracic
64400 - 64530 Introduction/injection of anesthetic agent (nerve block), diagnostic or therapeutic
ICD-9 codes covered if selection criteria are met:
741.00 - 741.93 Spinal bifida
742.51 - 742.59 Other specified anomalies of spinal cord [spinal dysraphism]
751.2 Atresia and stenosis of large intestine, rectum, and anal canal
756.13 Absence of vertebra, congenital [sacral agenesis]
767.0 Subdural and cerebral hemorrhage [due to birth trauma]
767.4 Injury to spine and spinal cord [hematoma after birth injury]
772.10 Intraventricular hemorrhage unspecified grade
772.11 - 772.14 Intraventricular hemorrhage grade I-1V
772.2 Subarachnoid hemorrhage
997.09 Other nervous system complication [post-traumatic leakage of CSF]
998.12 Hematoma complicating a procedure [after spinal tap]
ICD-9 codes not covered for indications listed in the CPB:
353.0 - 359.9 Nerve root and plexus disorders, mononeuritis, hereditary and idiopathic peripheral neuropathy, inflammatory and toxic neuropathy, myoneural disorders, and muscular dystrophies and other myopathies
722.0 - 722.93 Intervertebral disc disorders
723.0 - 724.9 Other disorders of cervical region and other and unspecified disorders of back


The above policy is based on the following references:
  1. American Academy of Neurology. Review of the literature on spinal ultrasound for the evaluation of back pain and radicular disorders. Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 1998;51:343-344.
  2. American College of Radiology (ACR). Statement on spinal ultrasound. Reston, VA: ACR; 1996.
  3. Dick EA, Patel K, Owens CM, et al. Spinal ultrasound in infants. Br J Radiol. 2002;75(892):384-392.
  4. Moon SH, Park MS, Suk KS, et al. Feasibility of ultrasound examination in posterior ligament complex injury of thoracolumbar spine fracture. Spine. 2002;27(19):2154-2158.
  5. Lee W, Chaiworapongsa T, Romero R, et al. A diagnostic approach for the evaluation of spina bifida by three-dimensional ultrasonography. J Ultrasound Med. 2002;21(6):619-626.
  6. American Institute of Ultrasound in Medicine (AIUM). Nonoperative spinal/paraspinal ultrasound in adults. Official Statements. Laurel, MD: AIUM; approved June 2002. Available at: http://www.aium.org/provider/statements/. Accessed February 12, 2004.
  7. Dick EA, de Bruyn R. Ultrasound of the spinal cord in children: Its role. Eur Radiol. 2003;13(3):552-562.
  8. Blaicher W, Prayer D, Bernaschek G. Magnetic resonance imaging and ultrasound in the assessment of the fetal central nervous system. J Perinat Med. 2003;31(6):459-468.
  9. Rhodes DW, Bishop PA. A review of diagnostic ultrasound of the spine and soft tissue. J Manipulative Physiol Ther. 1997;20(4):267-273.
  10. Kamei K, Hanai K, Matsui N. Ultrasonic level diagnosis of lumbar disc herniation. Spine. 1990;15(11);1170-1174.
  11. Hides JA, Stokes MJ Saide M, et al. Evidence of lumbar multifidus muscle wasting ipsilateral to symptoms in patients with acute/subacute low back pain. Spine. 1994;19(2):165-172.
  12. Bodley R, Jamous A, Short D. Ultraound in the early diagnosis of heteotopic ossification in patients with spinal injuries. Paraplegia. 1993;31(8):500-506.
  13. Hides JA, Richardson CA, Jull GA. Magnetic resonance imaging and ultrasonography of the lumbar multifidus muscle. Comparison of two different modalities. Spine. 1995;20(1):54-58.
  14. Dupont A, Sauerbrei EE, Fenton PV, et al. Real-time sonography to estimate muscle thickness: Comparison with MRI and CT. J Clin Ultrasound. 2001;29(4):230-235.
  15. Ledsome JR, Lessoway V, Susak LE, et al. Diurnal changes in lumbar intervertebral distance, measured using ultrasound. Spine. 1996;21(14):1671-1675.
  16. Suzuki S, Yamamuro T, Shikata H, et al. Ultrasound measurement of vertebral rotation in idiopathic scoliosis. J Bone Joint Surg. 1989;71-B:252-255.
  17. Lin K, Wang H, Chou M, Lui T. Sonography for detection of spinal dermal sinus tracts. J Ultrasound Med. 2002;21:903-907.
  18. Gerscovich EO, Maslen L, Cronan MS, et al. Spinal sonography and magnetic resonance imaging in patients with repaired myelomeningocele: Comparison of modalities. J Ultrasound Med. 1999;18:655-664.
  19. Schultz GD. Diagnostic ultrasound of the adult spine: State of the technology. Top Clin Chiro. 1997:4(1):45-49.
  20. Engel JM, Engel GM, Gunn DR. Ultrasound of the spine in focal stenosis and disc disease. Spine. 1985;10(10):928-931.
  21. Chovil AC, Anderson DJ, Adcock DF. Ultrasonic measurement of lumbar canal diameter: A screening tool for low back disorders? South Med J. 1989;82(8):977-980, 984.
  22. Porter RW, Wicks M, Ottewell D. Measurement of the spinal canal by diagnostic ultrasound. J Bone Joint Surg. 1978:60-B(4):481-484.
  23. Weiss GM. Spinal ultrasound: Clinical correlation of spinal ultrasound and MRI. Am J Pain Manag. 1996;6(4):123-126.
  24. Koivukangas J, Tervonen O. Intraoperative ultrasound imaging in lumbar disc herniation surgery. Acta Neurochir. 1989;98:47-54.
  25. de Graaf I, Prak A, Bierma-Zeinstra S, et al. Diagnosis of lumbar spinal stenosis: A systematic review of the accuracy of diagnostic tests. Spine. 2006;21(10):1168-1176.
  26. Lowe LH, Johanek AJ, Moore CW. Sonography of the neonatal spine: Part 2, Spinal disorders. AJR Am J Roentgenol. 2007;188(3):739-744.  
  27. Cummings T, Jones JS. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Use of ultrasonography for lumbar puncture. Emerg Med J. 2007;24(7):492-493.
  28. Glotzbecker MP, Bono CM, Wood KB, Harris MB. Thromboembolic disease in spinal surgery: A systematic review. Spine. 2009;34(3):291-303.
  29. Cameron M, Moran P. Prenatal screening and diagnosis of neural tube defects. Prenat Diagn. 2009;29(4):402-411.
  30. Tsui BC, Suresh S. Ultrasound imaging for regional anesthesia in infants, children, and adolescents: A review of current literature and its application in the practice of neuraxial blocks. Anesthesiology. 2010;112(3):719-728.
  31. Perlas A. Evidence for the use of ultrasound in neuraxial blocks. Reg Anesth Pain Med. 2010;35(2 Suppl):S43-S46.
  32. Tsui BC, Pillay JJ. Evidence-based medicine: Assessment of ultrasound imaging for regional anesthesia in infants, children, and adolescents. Reg Anesth Pain Med. 2010;35(2 Suppl):S47-S54.
  33. Javanshir K, Amiri M, Mohseni-Bandpei MA, et al. Ultrasonography of the cervical muscles: A critical review of the literature. J Manipulative Physiol Ther. 2010;33(8):630-637.
  34. Work Loss Data Institute. Neck and upper back (acute & chronic). Encinitas, CA: Work Loss Data Institute; 2011.
  35. American Institute of Ultrasound in Medicine; American College of Radiology; Society for Pediatric Radiology; Society of Radiologists in Ultrasound. AIUM practice guideline for the performance of an ultrasound examination of the neonatal spine. J Ultrasound Med. 2012;31(1):155-164.
  36. Shaikh F, Brzezinski J, Alexander S, et al. Ultrasound imaging for lumbar punctures and epidural catheterisations: Systematic review and meta-analysis. BMJ. 2013;346:f1720.


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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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