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MP 7.01.28 Selective Posterior Rhizotomy for the Spasticity of Cerebral Palsy

Medical Policy
Section
Surgery
Original Policy Date
3/31/96
Last Review Status/Date
Reviewed by consensus/2:2003
Issue
2:2003
Return to Medical Policy Index

Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.


Description

Spastic cerebral palsy is the most common form of cerebral palsy and is manifested as hyperactive tendon reflexes, muscle hypertonia, and increased resistance to increasing velocity of muscle stretch. Spastic cerebral palsy is further defined according to the affected limbs; spastic hemiplegia involves the arm and leg on one side; spastic diplegia is characterized by lower extremity involvement primarily or exclusively; and spastic quadriplegia affects both arms and legs equally. Spastic diplegia is the most common type. When involving the lower extremities, the hypertonia induced by spasticity prevents normal standing, walking, or crawling.

Selective posterior (dorsal) rhizotomy is a surgical procedure that is intended to reduce spasticity by diminishing the number of afferent nerve transmissions to neuronal circuits that regulate the spinal stretch reflex. Either cervical or lumbar laminectomy is used to expose the appropriate spinal nerves. Either a predetermined percentage of the dorsal rootlets are severed or electromyographic responses to direct electrical stimulation may be used to identify specific nerve roots involved in spasticity-producing circuits. Selective posterior rhizotomy has been offered to patients in an attempt to increase ambulation, and in a smaller subset of patients without ambulatory potential, but whose severe spasticity limits adequate care and handling.


Policy

Selective dorsal rhizotomy may be considered medically necessary in the treatment of persons with cerebral palsy and associated severe spasticity interfering with gross motor function or adequate care.


Policy Guidelines

In general, dorsal rhizotomy should be limited to those patients who retain some ambulatory potential and to a smaller subset of patients without ambulatory potential, but whose severe spasticity limits adequate care.

Intensive outpatient physiotherapy for 3 to 6 months is typically offered as part of the postoperative treatment of patients. Benefits for physical therapy may be subject to contractual limitations.


Benefit Application

No applicable information


Rationale

A randomized clinical trial comparing posterior rhizotomy plus physiotherapy compared to physiotherapy alone has reported improved results among those treated surgically, suggesting that the improvement in motor function after surgery is more than can be explained by physiotherapy alone. (1) These results are consistent with the results of the many case series that have been reported over the years. (2,3) Methods of targeting which dorsal rootlets to sever is still evolving, with fewer and fewer rootlets being cut as experience is gained. Further study is needed to determine if selection of nerve rootlets for rhizotomy on the basis of patient responses to intraoperative electrical stimulation is any better than performing predetermined partial posterior rhizotomies. (4)

References:

  1. Steinbok P, Reiner AM, Beauchamp R et al. A randomized clinical trial to compare selective posterior rhizotomy plus physiotherapy with physiotherapy alone in children with spastic diplegic cerebral palsy. Dev Med Child Neurol 1997; 39(3):178-84.
  2. Peacock WJ, Staudt LA. Functional outcomes following selective posterior rhizotomy in children with cerebral palsy. J Neurosurg 1991; 74(3):380-5.
  3. Chicoine MR, Park TS, Kaufman BA. Selective dorsal rhizotomy and rates of orthopedic surgery in children with spastic cerebral palsy. J Neurosurg 1997; 86(1):34-9.
  4. Steinbok P, Gustavsson B, Kestle JR et al. Relationship of intraoperative electrophysiological criteria to outcome after selective functional posterior rhizotomy. J Neurosurg 1995;83(1):18-26.

A search of literature was completed through the MEDLINE database for the period of January 1992 through June 1997. The search strategy focused on references containing the following Medical Subject Headings:

– Cerebral Palsy
 
– Rhizotomy

 

Codes

Number

Description

CPT 

63185,63190 

Rhizotomy code range 

 

95860, 95861, 95863, 95864, 95866, 95867, 95868, 95869 

Electromyography (EMG) code range 

ICD-9 Procedure 

03.1 

Division of intraspinal nerve root 

 

93.08 

Electromyography 

ICD-9 Diagnosis 

343.0–343.9 

Infantile cerebral palsy code range 

HCPCS 

No code 

Type of Service 

Surgery 

Place of Service 

Inpatient 


Index

Cerebral palsy, selective posterior rhizotomy
Dorsal rhizotomy for spasticity in cerebral palsy
Rhizotomy, dorsal, for cerebral palsy
Rhizotomy, selective posterior, for cerebral palsy
Selective posterior rhizotomy for spasticity in cerebral palsy


Policy History

Date Action Reason
03/31/96 Add to Surgery section New policy
01/30/98 Replace policy Reviewed with changes; new indications
07/10/98 Replace policy Revised to correct typo
04/15/02 Replace policy Policy reviewed by consensus; new review date only
07/17/03 Replace policy Policy revised by consensus; policy unchanged; no further review scheduled


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