Purpose
This guideline outlines the key surgical treatments and indications for common thoracic spinal disorders and is a consensus document based upon the best available evidence. Spine surgery is a complex area of medicine, and this document breaks out the clinical indications by surgical type.

This guideline does not address spinal deformity surgeries or the clinical indications for spinal deformity surgery.

Scope
Spinal surgeries should be performed only by those with extensive and specialized surgical training (neurosurgery, orthopedic surgery). Choice of surgical approach is based on anatomy, pathology, and the surgeon's experience and preference.

Instrumentation, bone formation or grafting materials, including biologics, should be used at the surgeon’s discretion; however, use should be limited to FDA approved indications regarding the specific devices or biologics.

BACKGROUND
Thoracic Decompression with or without fusion
Thoracic disc herniation with or without nerve root compression is usually treated conservatively (non-surgically). A back brace may be worn to provide support and limit back motion. Injection of local anesthetic and steroids around the spinal nerve (spinal nerve blocks) may be effective in relieving radicular pain. As symptoms subside, activity is gradually increased. This may include physical therapy and/or a home exercise program. Preventive and maintenance measures (e.g., exercise, proper body mechanics) should be continued indefinitely. Job modification may be necessary to avoid aggravating activities.

Simple laminectomy is rarely used in the treatment of thoracic disc herniation because of the high risk of neurologic deterioration and paralysis. Excision of the disc (discectomy) may be performed via several different surgical approaches –anteriorly, laterally, or transpedicular. Fusion should be performed only if surgery causes instability in the spinal column. Many newer techniques do not usually destabilize the thoracic spine.

Policy
INDICATIONS
All requests for thoracic spine surgery will be reviewed on a case-by-case basis. The following criteria must be met for consideration.

Decompression Surgery Only

• Positive clinical findings of myelopathy with evidence of progressive neurologic deficits consistent with worsening spinal cord compression – immediate surgical evaluation is indicated. Symptoms may include any of the following ^(1,2):
  • Lower extremity weakness
  • Unsteady gait related to myelopathy/balance or generalized lower extremity weakness
  • Disturbance with coordination
  • Hyperreflexia
  • Positive Babinski sign
  • Clonus; OR
• Progressive neurological deficit (motor deficit, bowel or bladder dysfunction) or lower extremity weakness or paralysis with corresponding evidence of spinal cord compression on a magnetic resonance imaging (MRI) or computed tomography (CT) scan images – immediate surgical evaluation is indicated; OR
• When All of the following criteria are met:
  • Persistent or recurrent symptoms/pain with functional limitations that are unresponsive to at least 6 consecutive weeks in the last 6 months of documented, physician-directed appropriate conservative treatment to include at least 2 of the following:
    • Analgesics, steroids, and/or NSAIDs
    • Structured program of physical therapy
    • Structured home exercise program prescribed by a physical therapist, chiropractic provider or physician
    • Epidural steroid injections and/or selective nerve root block; AND
  • Imaging studies confirm the presence of spinal cord or spinal nerve root compression at the level corresponding with the clinical findings (MRI or CT)

Thoracic Decompression with Fusion Surgery

• Deformity cases–please refer to CAM 399 for Deformity Surgery; OR
• For myelopathy or radiculopathy secondary to cord or root compression (see criteria described above) satisfying the indications for decompressive surgery requiring extensive decompression that results in destabilization of the thoracic spine

NOTE: There is no current evidence base to support fusion in the thoracic spine for degenerative disease without significant neurological compression or significant deformity as outlined above.

Relative Contraindications for Spine Surgery
NOTE: Cases may not be approved if the below contraindications exist:

• Medical contraindications to surgery (e.g., osteoporosis; infection of soft tissue adjacent to the spine, whether or not it has spread to the spine; severe cardiopulmonary disease; anemia; malnutrition and systemic infection) ^(3,4,5)
• Psychosocial risk factors. It is imperative to rule out non-physiologic modifiers of pain presentation or non-operative conditions mimicking radiculopathy or instability (e.g., peripheral neuropathy, piriformis syndrome, myofascial pain, sympathetically mediated pain syndromes, sacroiliac dysfunction, psychological conditions, etc.) prior to consideration of elective surgical intervention.^(5,6) Individuals with clinically significant depression or other psychiatric disorders being considered for elective spine surgery will be reviewed on a case-by-case basis and the surgery may be denied for risk of failure.
• Active Tobacco or Nicotine use prior to fusion surgery. Individuals must be free from smoking and/or nicotine use for at least six weeks prior to surgery and during the entire period of fusion healing.^(7,8)
• Morbid obesity. Contraindication to surgery in cases where there is significant risk and concern for improper post-operative healing, post-operative complications related to morbid obesity, and/or an inability to participate in post-operative rehabilitation.^(9,10) These cases will be reviewed on a case-by-case basis and may be denied given the risk of failure.

NOTE: Cases of severe myelopathy and progressive neurological dysfunction may require surgery despite these general contraindications.

References:

1. Li Z, Ren D, Zhao Y, Hou S, Li L et al. Clinical characteristics and surgical outcome of thoracic myelopathy caused by ossification of the ligamentum flavum: a retrospective analysis of 85 cases. Spinal Cord. 2016; 54: 188-196. 10.1038/sc.2015.139.  
2. Wang H, Ma L, Xue R, Yang D, Wang T et al. The incidence and risk factors of postoperative neurological deterioration after posterior decompression with or without instrumented fusion for thoracic myelopathy. Medicine. 2016; 95: e 5519. 10.1097 /MD.0000000000005519.
3. Puvanesarajah V, Shen F, Cancienne J, Novicoff W, Jain A et al. Risk factors for revision surgery following primary adult spinal deformity surgery in patients 65 years and older. J Neurosurg Spine. 2016; 25: 486-493. 10.3171/2016.2.Spine151345. 
4. Varshneya K, Jokhai R, Fatemi P, Stienen M, Medress Z et al. Predictors of 2-year reoperation in Medicare patients undergoing primary thoracolumbar deformity surgery. J Neurosurg Spine. 2020; 1-5. 10.3171/2020.5.Spine191425. 
5. Rajaee S, Kanim L, Bae H. National trends in revision spinal fusion in the USA: patient characteristics and complications. Bone Joint J. 2014; 96-b: 807-816. 10.1302/0301-620x.96b6.31149. 
6. North American Spine Society. Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis. NASS. 2011; https://www.spine.org/Portals/0/Assets/Downloads/ResearchClinicalCare/Guidelines/LumbarStenosis.pdf. 
7. Jackson 2nd K, Devine J. The Effects of Smoking and Smoking Cessation on Spine Surgery: A Systematic Review of the Literature. Global Spine J. 2016; 6: 695-701. 10.1055/s-0036-1571285. 
8. Nunna R, Ostrov P, Ansari D, Dettori J, Godolias P et al. The Risk of Nonunion in Smokers Revisited: A Systematic Review and Meta-Analysis. Global Spine J. 2022; 12: 526-539. 10.1177/21925682211046899. 
9. Feeley A, McDonnell J, Feeley I, Butler J. Obesity: An Independent Risk Factor for Complications in Anterior Lumbar Interbody Fusion? A Systematic Review. Global Spine J. 2022; 12: 1894-1903. 10.1177/21925682211072849. 
10. Cofano F, Perna G, Bongiovanni D, Roscigno V, Baldassarre B et al. Obesity and Spine Surgery: A Qualitative Review About Outcomes and Complications. Is It Time for New Perspectives on Future Researches?. Global Spine J. 2022; 12: 1214-1230. 10.1177/21925682211022313.

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

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