Blue Cross of Idaho
Lumbar Spinal Surgery Pre-authorization Guidelines

Subject       Lumbar Laminectomy, Hemi-Laminectomy, Diskectomy

Next Review    10/2008

Description

Back pain, with and without radicular symptoms, is one of the most common complaints for which members seek medical care. This set of diagnoses is one of the highest direct healthcare cost categories and significantly impacts indirect costs to employers significantly due to lost work days and work-related claims.

Permanent disability is a common outcome of back injury and pain. One study¹ indicated that workers with back complaints who are off work over six months have only a 50% possibility of ever returning to productive employment. If they are off work over one year this possibility drops to 25%, and if more than two years, it is almost nil.

There is also significant geographic variability in the treatment of back pain and radiculopathy. According to the Dartmouth Atlas of Healthcare, patients in Idaho are four times more likely to undergo back surgery than patients in regions with the lowest rates with no difference in outcomes.

To improve communication related to authorization for lumbar spinal surgery, we have separated the guideline into two categories:

1. Surgery related to the treatment of sciatica or other nerve root impingements where primary intervention is related to removal of an offending herniated disk.
2. Surgery related to mechanical and anatomical abnormalities for which spinal fusion may be the appropriate treatment.

These guidelines do not apply to patients with traumatic spinal fractures or dislocations, primary infections, or neoplasms of the spine.

Seventy-five percent of patients with sciatica will have resolution of their symptoms within three months without surgery.² A recent study appropriately looked at patients who had no resolution of sciatica in 6 - 12 weeks.³ The study threats included significant crossover between the surgical and conservative treatment arms. Relief from leg pain was faster for patients treated surgically than for patients treated conservatively. The maximal differences in pain on the visual-analog scale were only 20mm on a 100mm scale, however. The Roland-Morris Disability Index did not meet the four-point change that defines a clinically significant difference that would allow a conclusion of benefits of surgery over conservative care. Patients undergoing surgery after receiving 18 weeks of conservative treatment, however, had the same relief as those undergoing surgery with two weeks of conservative care. Lateral transflaval microdiscectomies were performed and no patient underwent fusion. The one-year outcomes were similar for patients assigned to early surgery and those assigned to conservative treatment with eventual surgery needed.

Clearly, patients presenting with cauda equina syndrome, muscle paralysis, or insufficient strength to move against gravity may be candidates for surgical treatment. Other circumstances that warrant surgical consideration include the occurrence of another episode of symptoms similar to those of the current episode during the previous 12 months, previous spine surgery, bony stenosis, spondylolisthesis, pregnancy or severe coexisting disease.

In the absence of these circumstances, please attempt conservative treatment and inform the patient of similar outcomes with conservative treatment.

Policy

General Requirements for Lumbar Laminectomy, Hemi-Laminectomy and Diskectomy: In the absence of red flag symptoms or progressive neurological symptoms or signs, members presenting with low back pain should undergo conservative therapy, which may include the use of anti-inflammatory medications, aggressive physical therapy with home exercise program, activity modification, physical reconditioning or facet or epidural injections. A patient should undergo at least 12 weeks of conservative management for symptomatic herniations or nerve root impingement.

1. The requesting surgeon should have personally evaluated the patient on at least two occasions prior to requesting surgery. As part of initial evaluation, there should be a functional assessment such as the SF-36 and/or Oswestry Disability Index. If the mental health component of the SF-36 indicates concern (usually scores less than 40), clinical psychological or psychiatric assessment should occur. This assessment should focus on helping the requesting surgeon identify specific psychological risk factors (chronic pain syndrome, depression) that may be barriers to successful treatment and/or recovery following surgery.
2. All members should be screened for medical co-morbidities and undergo thorough medical clearance as indicated.
3. Because of the high risk of pseudoarthrosis, a smoker anticipating a spinal fusion should undergo counseling and adhere to a smoking-cessation program that results in abstinence from smoking for at least six weeks prior to elective surgery.
4. Pre-authorization is required for elective procedures and physicians should submit requests to Blue Cross of Idaho's Medical Management Department at least two weeks prior to the anticipated date of an elective surgery.
5. The minimal documents necessary to accurately and expeditiously complete pre-authorization requests for spinal fusion are:

Clinical Guideline for Surgery of Entrapment of a Single Lumbar Nerve Root

References:

1. (McGill, C.M. Industrial back problems.  Journal of Occupational Medicine, 10, 1740-1748) 1968.
2. Paul, W.C. et al. Surgery vs. prolonged conservative treatment for sciatica. NEJM 2007; 356:2245-56
3. Vrooman PCAS, de Krom MCTFM, Knotteraus JA, Predicting the outcome of sciatica at short-term follow-up. Br J. Gen Pract 2002;52:119-23