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Brachial Plexus Surgery

Number: 0850



Policy

Aetna considers neuroplasty (neurolysis or nerve decompression) medically necessary in the treatment of a brachial plexus neuromas and other brachial plexus lesions.

Aetna considers dorsal root entry zone (DREZ) coagulation medically necessary in the treatment of brachial plexus avulsion.

Aetna considers computer-assisted dorsal root entry zone microcoagulation (CA-DREZ) experimental and investigational in the treatment of brachial plexus avulsion because there is inadequate evidence in the peer-reviewed published clinical literature regarding its effectiveness.

Aetna considers soft tissue reconstruction surgeries (e.g., triangle tilt surgery and the Mod-Quad procedure) medically necessary in the treatment of obstetric brachial plexus injury if functional recovery does not ensue in 3 or more months.  Note: There is a lack of reliable evidence that one type of reconstructive soft tissue technique is more effective than others for obstetric brachial plexus injuries.

Background

The brachial plexus is a network of nerves located in the neck and axilla, composed of the anterior branches of the lower 4 cervical and first 2 thoracic spinal nerves that supply the chest, shoulder, and arm.  Injuries to the brachial plexus affect the nerves supplying the shoulder, upper arm, forearm and hand, causing numbness, tingling, pain, weakness, limited movement, or even paralysis of the upper limb.  Brachial plexus lesions are classified as either traumatic or obstetric.  Brachial plexopathy is the pathologic dysfunction of the brachial plexus.  When the brachial plexus is injured during delivery, the nerves become damaged and result in loss of muscle control and paralysis.  This condition is also known as Erb’s palsy.

Brachial plexus avulsion is the tearing away or forcible separation of nerves of the brachial plexus (a network of nerves that conducts signals from the spine to the shoulder, arm and hand) from the spine, the point of origin.  Symptoms of brachial plexus injuries may include a limp or paralyzed arm, lack of muscle control in the arm, hand, or wrist, and lack of feeling or sensation in the arm or hand.  Brachial plexus injuries may occur during birth: the baby's shoulders may become impacted during the birth process causing the brachial plexus nerves to stretch or tear. 

Brachial neuroplasty (neurolysis or nerve decompression) is the surgical repair or restoration of nerve tissue.  The release of adhesions around a nerve (freeing of intact nerve from scar tissue) is performed to relieve pain and disability.  It is written in the 2008 textbook "Frontera: Essentials of Physical Medicine and Rehabilitation", that surgery is an option in cases of traumatic plexopathy but has variable results.  Surgical techniques such as nerve grafting, free muscle transfer, neurolysis, and neurotization are used.  Surgeons who use these techniques frequently differ considerably in their approach to them, making conclusions about their efficacy difficult.  According to the textbook "Bradley: Neurology", the surgical treatment of traumatic plexopathy depends on the extent of the lesion.  Depending on the findings, neurolysis, nerve grafting or re-neurotization is performed.  In the textbook "Browner; Skeletal Trauma", it is written in reference to nerve injuries of the brachial plexus, when a neuroma in continuity is found it may be resected and repaired or neurolysis may be performed.

Dorsal root entry zone (DREZ) coagulation (also known as dorsal root entry zone lesion) is a surgical procedure in which ablative lesions are made at the dorsal root entry zones of the spinal cord.  These lesions are made with a radiofrequency lesion generator or laser through an open exposure of the cord via laminectomy.  Pain-producing nerve cells are destroyed with radiofrequency heat lesions.

Computer-assisted dorsal root entry zone microcoagulation (CA-DREZ) is a surgical procedure in which ablative lesions are made at the dorsal root entry zones of the spinal cord.  These lesions are made with a radiofrequency lesion generator or laser through an open exposure of the cord via laminectomy.  It involves electrical recording inside the spinal cord at the time of surgery to identify regions of abnormally active pain-producing nerve cells.  These abnormal cells are then destroyed with radiofrequency heat lesions.

The Triangle Tilt is a surgical procedure that addresses scapular elevation in children with obstetric brachial plexus injury (OBPI) through the bony realignment of the clavicle and scapula.  This realignment, or tilting, is of the triangle formed by clavicle and scapula.  As the scapula elevates, the plane of the triangle is steepened.  The purpose of the triangle tilt, therefore, is to normalize the plane of this triangle or, to reduce the elevation of the scapula and normalize the spatial relationship between the sides of the triangle.

Nath et al wrote in 2010 the triangle tilt surgery restores the distal acromioclavicular triangle from an abnormal superiorly angled position to a neutral position, thereby restoring normal glenohumeral anatomic relationships.  The findings of a study investigating the effects of triangle tilt surgery on glenohumeral joint anatomy in 100 OBPI patients were reported.  Axial computed tomography and magnetic resonance images taken before and 12- to 38-months after surgery showed significant improvements in both posterior subluxation and glenoid version.  Patients with complete posterior glenohumeral dislocation improved from 19 % pre-operatively to 11 % post-operatively.  Glenoid shape was also improved, with 81 % of patients classified as concave or flat after surgery compared with 53 % before surgery.  The authors concluded these anatomic improvements after triangle tilt surgery hold promise for improving shoulder function and quality of life for OBPI patients.

The Mod Quad procedure is considered a secondary surgery in children with brachial plexus injury used to correct muscle imbalances.  Among the muscles injured in Erb's are the abductors of the shoulder (that lift the arm over the head), as well as the external rotators (that help to turn the upper arm outward and to open the palm of the hand).  At the same time, the internal rotators (muscles that turn the arm and palm inward) and adductors (muscles that pull the arm to the side) of the arm are not involved in the injury because they are supplied by the lower roots of the plexus.  These strong muscles overpower the weak muscles and over time the child cannot lift the arm over the head or turn the palm out, because of the muscle imbalance.  In order to use the hand effectively, the elbow becomes bent, which eventually becomes fixed because of weakness of the triceps (the elbow straightening muscle).  The elbow-bent posture (also known as the Erb's Engram) contributes to the appearance of the arm being shorter. 

For this muscle imbalance, a group of muscle releases and transfers can put the arm in a more natural position and help to lift the arm over the head.  Known as the "quad" procedure, it has 4 components:

  • Latissimus dorsi muscle transfer for external rotation and abduction
  • Teres major muscle transfer for scapular stabilization
  • Subscapularis muscle release
  • Axillary nerve decompression and neurolysis).  Depending on the individual child, other nerve decompressions or muscle/ tendon transfers (such as pectoralis muscle releases) might be performed at the same time (the modified quad or "Mod Quad" procedure).

Louden et al (2013) conduct a meta-analysis and systematic review analyzing the clinical outcomes of neonatal brachial plexus palsy (NBPP) treated with a secondary soft-tissue shoulder operation. These researchers performed a literature search to identify studies of NBPP treated with a soft-tissue shoulder operation. A meta-analysis evaluated success rates for the aggregate Mallet score (greater than or equal to 4-point increase), global abduction score (greater than or equal to 1-point increase), and external rotation score (greater than or equal to 1-point increase) using the Mallet scale. Subgroup analysis was performed to assess these success rates when the author chose arthroscopic release technique versus open release technique with or without tendon transfer. Data from 17 studies and 405 patients were pooled for meta-analysis. The success rate for the global abduction score was significantly higher for the open technique (67.4 %) relative to the arthroscopic technique (27.7 %, p < 0.0001). The success rates for the global abduction score were significantly different among sexes (p = 0.01). The success rate for external rotation was not significantly different between the open (71.4 %) and arthroscopic techniques (74.1 %, p = 0.86). No other variable was found to have significant impact on the external rotation outcomes. The success rate for the aggregate Mallet score was 57.9 % for the open technique, a non-significant increase relative to the arthroscopic technique (53.5 %, p = 0.63). Data suggested a correlation between increasing age at the time of surgery and a decreasing likelihood of success with regards to aggregate Mallet with an odds ratio of 0.98 (p = 0.04). The authors concluded that overall, the secondary soft-tissue shoulder operation is an effective treatment for improving shoulder function in NBPP in appropriately selected patients. The open technique had significantly higher success rates in improving global abduction. There were no significant differences in the success rates for improvement in the external rotation or aggregate Mallet score among these surgical techniques.

Ali and colleagues (2014) stated that NBPP represents a significant health problem with potentially devastating consequences. The most common form of NBPP involves the upper trunk roots. Currently, primary surgical repair is performed if clinical improvement is lacking. There has been increasing interest in "early" surgical repair of NBPPs, occurring within 3 to 6 months of life. However, early treatment recommendations ignore spontaneous recovery in cases of Erb's palsy. This study was undertaken to evaluate the optimal timing of surgical repair in this group with respect to quality of life. These investigators formulated a decision analytical model to compare 4 treatment strategies (no repair or repair at 3, 6, or 12 months of life) for infants with persistent NBPPs. The model derived data from a critical review of published studies and projects health-related quality of life (QOL) and quality-adjusted life years (QALY) over a lifetime. When evaluating the QOL of infants with NBPP, improved outcomes were seen with delayed surgical repair at 12 months, compared with no repair or repair at early and intermediate time points, at 3 and 6 months, respectively. ANOVA showed that the differences among the 4 groups were highly significant (F = 8369; p < 0.0001). Pair-wise post-hoc comparisons revealed that there were highly significant differences between each pair of strategies (p < 0.0001). Meta-regression showed no evidence of improved outcomes with more recent treatment dates, compared with older ones, for either non-surgical or for surgical treatment (p = 0.767 and p = 0.865, respectively). The authors concluded that these data supported a delayed approach of primary surgical reconstruction to optimize QOL. They stated that early surgery for NBPPs may be an overly aggressive strategy for infants who would otherwise demonstrated spontaneous recovery of function by 12 months. They stated that a randomized, controlled trial would be needed to fully elucidate the natural history of NBPP and determine the optimal time point for surgical intervention.

Tse and colleagues (2015) stated that nerve transfers have gained popularity in the treatment of adult brachial plexus palsy; however, their role in the treatment of NBPP remains unclear. Brachial plexus palsies in infants differ greatly from those in adults in the patterns of injury, potential for recovery, and influences of growth and development. This International Federation of Societies for Surgery of the Hand committee report on NBPP was based upon review of the current literature. These investigators found no direct comparisons of nerve grafting to nerve transfer for primary reconstruction of NBPP. Although the results contained in individual reports that used each strategy for treatment of Erb palsy were similar, comparison of nerve transfer to nerve grafting was limited by inconsistencies in outcomes reported, by multiple confounding factors, and by small numbers of patients. Although the role of nerve transfers for primary reconstruction remains to be defined, nerve transfers have been found to be effective and useful in specific clinical circumstances including late presentation, isolated deficits, failed primary reconstruction, and multiple nerve root avulsions. In the case of NBPP more severe than Erb palsy, nerve transfers alone were inadequate to address all of the deficits and should only be considered as adjuncts if maximal re-innervation is to be achieved. The authors concluded that surgeons who commit to care of infants with NBPP need to avoid an over-reliance on nerve transfers and should also have the capability and inclination for brachial plexus exploration and nerve graft reconstruction.

An UpToDate review on “Brachial plexus syndromes” (Bromberg, 2015) states that “Management of neonatal brachial plexus palsy is controversial. A period of physical therapy and observation for evidence of recovery is often employed. Surgical intervention is advocated in select cases if functional recovery does not ensue in 3 to 9 months, but there is no consensus regarding the utility or timing of surgery. Early referral to a center with expertise in the management of NBPP may improve outcomes”.

CPT Codes / HCPCS Codes / ICD-9 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:
Triangle Tilt Surgery:
No specific code
Mod-Quad Procedure:
No specific code
Neurolysis:
CPT codes covered if selection criteria are met:
64713 Neuroplasty, major peripheral nerve, arm or leg, open; brachial plexus
ICD-10 codes covered if selection criteria are met:
D21.0 Benign neoplasm of connective and other soft tissue of head, face and neck
D21.10 - D21.12 Benign neoplasm of connective and other soft tissue of upper limb, including shoulder
G54.0 Brachial plexus disorders
P14.3 Other brachial plexus birth injury
S14.3xx+ Injury of brachial plexus
Dorsal root entry zone (DREZ) coagulation :
CPT codes covered if selection criteria are met: :
63170 Laminectomy with myelotomy (eg, Bischof or DREZ type), cervical, thoracic, or thoracolumbar
64640 Destruction by neurolytic agent; other peripheral nerve or branch
ICD-10 codes covered if selection criteria are met:
S14.3xx+ Injury of brachial plexus [brachial plexus avulsion]
Computer-assisted dorsal root entry zone (CA-DREZ) coagulation:
CPT codes not covered for indications listed in the CPB :
+20985 Computer-assisted surgical navigational procedure for musculoskeletal procedures, image-less (List separately in addition to code for primary procedure)


The above policy is based on the following references:

    Brachial Neuroplasty

    1. Bradley: Neurology in Clinical Practice. Fifth Edition. 2008.
    2. Browner: Skeletal Trauma. Fourth Edition. 2008.
    3. Canale & Beaty: Campbell's Operative Orthopaedics. Eleventh Edition. 2007.
    4. Frontera: Essentials of Physical Medicine and Rehabilitation. Second Edition. 2008.
    5. Kliegman: Nelson Textbook of Pediatrics. Eighteenth Edition. 2007.
    6. Krishnan KG, Martin KD, Schackert G. Traumatic lesions of the brachial plexus: An analysis of outcomes in primary brachial plexus reconstruction and secondary functional arm reanimation. Neurosurgery. 2009;62(4):873-885; discussion 885-8866.
    7. Shin AY, Spinner RJ, Steinmann SP, Bishop AT. Adult traumatic brachial plexus injuries. J Am Acad Orthop Surg. 2005;13(6):382-396.
    8. Ali ZS, Bakar D, Li YR, et al. Utility of delayed surgical repair of neonatal brachial plexus palsy. J Neurosurg Pediatr. 2014;13(4):462-470.
    9. Tse R, Kozin SH, Malessy MJ, Clarke HM. International Federation of societies for surgery of the hand committee report: The role of nerve transfers in the treatment of neonatal brachial plexus palsy. J Hand Surg Am. 2015;40(6):1246-1259.
    10. Bromberg MR. Brachial plexus syndromes. UpToDate Inc., Waltham, MA. Last reviewed August 2015.

    Computer-Assisted Dorsal Root Entry Zone (CA-DREZ) Microcoagulation:

    1. Daroff: Bradley's Neurology in Clinical Practice. Sixth Edition. 2012.
    2. Edgar RE, Best LG, Quail PA, Obert AD. Computer-assisted DREZ microcoagulation: Posttraumatic spinal deafferentation pain. J Spinal Disord. 1993;6(1):48-56.
    3. Thomas DG, Jones SJ. Dorsal root entry zone lesions (Nashold’s procedure) in brachial plexus avulsion. Neurosurgery. 1984;15(6):966-968.

    Dorsal Root Entry Zone (DREZ) Coagulation:

    1. Friedman AH, Nashold BS Jr, Bronec PR. Dorsal root entry zone lesions for the treatment of brachial plexus avulsion injuries: A follow-up study. Neurosurgery. 1988;22(2):369-373.
    2. Prestor B. Microsurgical junctional DREZ coagulation for treatment of deafferentation pain syndromes. Surg Neurol. 2001;56(4):259-265.
    3. Samii M, Bear-Henney S, Ludemann W, et al. Treatment of refractory pain after brachial plexus avulsion with dorsal root entry zone lesions. Neurosurgery. 2001;48(6):1269-1277.
    4. Schwartz: Principles of Surgery. Seventh Edition. 1999.
    5. Sindou MP, Blondet E, Emery E, Mertens P. Microsurgical lesioning in the dorsal root entry zone for pain due to brachial plexus avulsion: A prospective series of 55 patients. J Neurosurg. 2005;102(6):1018-1028.
    6. Townsend: Sabiston Textbook of Surgery. Seventeenth Edition. 2004.
    7. Thomas DG, Jones SJ. Dorsal root entry zone lesions (Nashold’s procedure) in brachial plexus avulsion. Neurosurgery. 1984;15(6):966-968.

    Soft Tissue Reconstruction Procedures:

    1. Nath RK, Amrani A, Melcher SE, et al. Surgical normalization of the shoulder joint in obstetric brachial plexus injury. Ann Plast Surg. 2010;65(4):411-417.
    2. Louden EJ, Broering CA, Mehlman CT, et al. Meta-analysis of function after secondary shoulder surgery in neonatal brachial plexus palsy. J Pediatr Orthop. 2013;33(6):656-663.


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