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All An analysis of bmp lumber co reasonable sources of pain have been ruled out; and Presence of thoracic pain secondary to nerve root or spinal cord compression with findings of weakness, myelopathy, or sensory deficit; and Imaging studies e. Spinal fracture, dislocation associated with mechanical instabilitylocked facets, or displaced fracture fragment confirmed by imaging studies e.
Aetna considers cervical spinal fusion medically necessary for any of the following: Cervical kyphosis associated with cord compression; or Symptomatic pseudarthrosis non-union of prior fusionwhich is associated with radiological e.
The deformity prohibits forward gaze; or The deformity is associated with severe neck pain, difficulty ambulating, and interference with activities of daily living; or Documented progression of the deformity.
Aetna considers thoracic spinal fusion medically necessary for any of the following: Scoliosis confirmed by imaging studies, with Cobb angle greater than 40 degrees in skeletally immature children and adolescents, or Cobb angle greater than 50 degrees associated with functional impairment in skeletally mature adults; or Thoracic kyphosis resulting in spinal cord compression, or kyphotic curve greater than 75 degrees that is refractory to bracing; or Symptomatic pseudarthrosis non-union of prior fusionwhich is associated with radiological e.
Decompression is performed in an area of segmental instability as manifested by gross movement on flexion-extension radiographs; or Decompression coincides with an area of significant degenerative instability e. Aetna considers lumbar spinal fusion medically necessary for any of the following: Adult scoliosis confirmed by imaging studies, with Cobb angle greater than 50 degrees associated with functional impairment in skeletally mature adults; or Adult kyphosis or pseudarthrosis non-union of prior fusionwhich is associated with radiological e.
Aetna considers cervical and lumbar laminectomy and cervical fusion experimental and investigational for all other indications not listed above as medically necessary because of insufficient evidence of its effectiveness for these indications.
The requirement for a trial of conservative measures may be waived in the following situations: Certain fusion procedures are considered experimental and investigational: The initial evaluation of patients with LBP involves ruling out potentially serious conditions such as infection, malignancy, spinal fracture, or a rapidly progressing neurologic deficit suggestive of the cauda equina syndrome, bowel or bladder dysfunction, or weakness, which suggest the need for early diagnostic testing.
Patients without these conditions are initially managed with conservative therapy. Spondylolisthesis refers to the forward slippage of one vertebral body with respect to the one beneath it. This most commonly occurs at the lumbosacral junction with L5 slipping over S1, but it can occur at higher levels as well.
It is classified based on etiology into 5 types: The most common grading system for spondylolisthesis is the Meyerding grading system for severity of slippage, which categorizes severity based upon measurements on lateral X-ray of the distance from the posterior edge of the superior vertebral body to the posterior edge of the adjacent inferior vertebral body.
The distance is then reported as a percentage of the total superior vertebral body length see appendix. For patients 50 years of age and older or those whose findings suggest systemic disease, plain radiography and simple laboratory tests can almost completely rule out underlying systemic diseases.
Advanced imaging should be reserved for patients who are considering surgery or those in whom systemic disease is strongly suspected. Conservative care without immediate imaging is also considered appropriate for patients with radiculopathy, as long as symptoms are not bilateral or associated with urinary retention.
For acute low back pain, the only therapy with good evidence of efficacy is superficial heat. Such conservative treatments are seldom applied in a comprehensive, well-organized rehabilitation program, although some such programs do exist.
Conservative treatments are usually tried for at least 6 to 12 months before surgery for any form of lumbar fusion is considered. Several reviews of these therapies noted that there is no evidence about the effectiveness of any of these therapies for low back or radicular pain beyond about 6 weeks.
The other indications for lumbar fusion focus on improvement in axial lumbar pain i. These indications include lumbar instability, such as degenerative lumbar scoliosis, spondylolisthesis for axial pain alone, and for less common problems, such as discitis, lumbar flat back syndrome, neoplastic bone invasion and collapse, and chronic fractures, such as osteoporotic fractures which develop into burst fractures over time.
The assessment concluded that, "The evidence for lumbar spinal fusion does not conclusively demonstrate short-term or long-term benefits compared with non-surgical treatment, especially when considering patients over 65 years of age, for degenerative disc disease; for spondylolisthesis, considerable uncertainty exists due to lack of data, particularly for older patients.
The guidance stated that one of the following treatment options should be offered to the patient: The guidance stated "[t]here is evidence that manual therapy, exercise and acupuncture individually are cost-effective management options compared with usual care for persistent non-specific low back pain.
The cost implications of treating people who do not respond to initial therapy and so receive multiple back care interventions are substantial. It is unclear whether there is added health gain for this subgroup from either multiple or sequential use of therapies. An MRI is appropriate only for people who have failed conservative care, including a combined physical and psychological treatment program, and are considering a referral for an opinion on spinal fusion.
However, it is unclear if methods for identifying specific anatomic sources of back pain are accurate, and effectiveness of some interventional therapies and surgery remains uncertain or controversial. The APS guideline stated that, in patients with chronic non-radicular LBP, provocative discography is not recommended as a procedure for diagnosing LBP strong recommendation, moderate-quality evidence Chou et al, The guideline recommended that shared decision-making regarding surgery for non-specific LBP include a specific discussion about intensive interdisciplinary rehabilitation as a similarly effective option, the small to moderate average benefit from surgery versus non-interdisciplinary non-surgical therapy, and the fact that the majority of such patients who undergo surgery do not experience an optimal outcome defined as minimum or no pain, discontinuation of or occasional pain medication use, and return of high-level function Chou et al, Compared with non-interdisciplinary, non-surgical therapy, average benefits are small for function points on a point scale and moderate for improvement in pain points on a point scale.
Furthermore, more than half of the patients who undergo surgery do not experience an "excellent" or "good" outcome i. Instrumented fusion is associated with enhanced fusion rates compared with non-instrumented fusion, but insufficient evidence exists to determine whether instrumented fusion improves clinical outcomes, and additional costs are substantial.
In addition, there is insufficient evidence to recommend a specific fusion method anterior, posterolateral, or circumferentialthough more technically difficult procedures may be associated with higher rates of complications.CoCreateInstance "!!CO:D"-cannot be got or checked for all Commanders.
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