|MP 8.01.18||Lysis of Epidural Adhesions|
|Original Policy Date
|Last Review Status/Date
Reviewed with literature search/12:2014
|Return to Medical Policy Index|
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.
Epidural fibrosis with or without adhesive arachnoiditis most commonly occurs as a complication of spinal surgery and may be included under the diagnosis of "failed back surgery syndrome." Both result from manipulation of the supporting structures of the spine. Epidural fibrosis can occur in isolation, but adhesive arachnoiditis is rarely present without associated epidural fibrosis. Arachnoiditis is most frequently seen in patients who have undergone multiple surgical procedures.
Both conditions are related to inflammatory reactions that result in the entrapment of nerves within dense scar tissue, increasing the susceptibility of the nerve root to compression or tension. The condition most frequently involves the nerves within the lumbar spine and cauda equina. Signs and symptoms indicate the involvement of multiple nerve roots and include low back pain, radicular pain, tenderness, sphincter disturbances, limited trunk mobility, muscular spasm or contracture, and motor sensory and reflex changes. Typically, the pain is characterized as constant and burning. In some cases, the pain and disability are severe, leading to analgesic dependence and chronic invalidism.
Lysis of epidural adhesions, using fluoroscopic guidance, with epidural injections of hypertonic saline in conjunction with corticosteroids and analgesics, has been investigated as a treatment option. Theoretically, the use of hypertonic saline results in a mechanical disruption of the adhesions. It may also function to reduce edema within previously scarred and/or inflamed nerves. Finally, manipulating the catheter at the time of the injection may disrupt adhesions. Spinal endoscopy has been used to guide the lysis procedure but the procedure is more commonly performed percutaneously using epidurography to guide catheter placement and identify nonfilling adhesions that indicate epidural scarring. Using endoscopy guidance, a flexible fiberoptic catheter is inserted into the sacral hiatus, providing 3-D visualization to steer the catheter toward the adhesions, to more precisely place the injectate in the epidural space and onto the nerve root. Various protocols for lysis have been described; in some situations, the catheter may remain in place for several days for serial treatment sessions.
Endoscopic epidurolysis is also being investigated for the treatment of degenerative chronic low back pain, including spondylolisthesis, stenosis, and hernia associated with radiculopathy. Along with mechanical adhesiolysis, hyaluronidase, ciprofloxacin and ozone have been applied.
Catheter-based techniques for lysis of epidural adhesions, with or without endoscopic guidance, are considered investigational. Techniques used either alone or in combination include mechanical disruption with a catheter and/or injection of hypertonic solutions with corticosteroids, analgesics, or hyaluronidase.
The following CPT codes specifically identify the injection of hypertonic saline, which may be performed over the course of multiple or single days.
62263: Percutaneous lysis of epidural adhesions using solution injection (e.g., hypertonic saline, enzyme) or mechanical means (e.g., catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 2 or more days
62264; as above but limited to 1 day only
Note: As noted here, the protocols for lysis of epidural adhesions vary. Some institutions may perform lysis of epidural adhesions as an in-patient procedure, performed in multiple sessions over a course of several days through an indwelling catheter. In the descriptor of the CPT book, it is noted that CPT code 62263 describes the percutaneous insertion and removal of an epidural catheter and that code 62263 is not reported for each adhesiolysis treatment, but should be reported once to describe the entire series of injection/infusion spanning 2 or more treatment days.
In 2003, the following CPT code was introduced to describe lysis of adhesions with endoscopic guidance:
0027T: Endoscopic lysis of epidural adhesions with direct visualization using mechanical means (e.g., spinal endoscopic catheter system) or solution injection (e.g., normal saline)
Code 0027T was deleted 12/31/08. Endoscopic lysis of epidural adhesions should now be coded using miscellaneous code 64999.
There is instruction following CPT code 77003 in the CPT book that states 62263 and 62264 include fluoroscopic guidance and localization.
BlueCard/National Account Issues
Lysis of epidural adhesions using hypertonic saline may be offered as one component of a multi-modality pain management program.
This policy was originally created in 1998 and updated regularly with searches of the MEDLINE database. The most recent literature search was performed for the period of November 8, 2013, through November 17, 2014. Following is a summary of the literature to date.
The evidence for lysis of epidural adhesions consists of single-center trials, most of them from a single U.S. pain management group. A number of systematic reviews of these trials have been identified for updates of this policy. A 2005 review article(1) focused on 3 randomized studies by Heavner and Manchikanti and concluded that there was moderate-to-strong evidence of the effectiveness of percutaneous adhesiolysis. A 2007 update of that review also concluded that there was strong evidence for short-term and moderate evidence of long-term effectiveness of percutaneous adhesiolysis and spinal endoscopy.(2) Applying the U.S. Preventive Services Task Force (USPSTF) criteria, a 2012 update of the review found fair evidence that percutaneous adhesiolysis is effective in relieving low back and/or leg pain caused by either post lumbar surgery syndrome or spinal stenosis.(3) Complications were considered to be minimal.
In a 2008 paper, Racz et al concluded, based on the literature (randomized trials and case series) and expert opinion, that evidence was strong for short-term (3 months) efficacy and moderate for long-term (>3 months) efficacy.(4) Two systematic reviews were published in 2009; one focused on endoscopic adhesiolysis and the other on the percutaneous method. Hayek et al concluded that, based on level II-1
or II-2 evidence (1 randomized trial, 5 observational studies), endoscopic adhesiolysis provides short- and long-term relief of pain based on the USPSTF criteria.(5) Epter with Hayek and others concluded that there is level-I or -II evidence (3 randomized trials, 4 observational studies) for percutaneous adhesiolysis.(6) The latest systematic review on endoscopic adhesiolysis was published in 2013 by Helm et al. The authors included 1 randomized controlled trial (RCT) and 3 observational studies in the review and noted there is a limited amount of literature available on endoscopic adhesiolysis.(7) Despite limitations in available evidence, using USPSTF quality of evidence criteria, the authors concluded there is fair evidence that spinal endoscopic adhesiolysis is effective in reducing chronic low back and/or leg pain in post lumbar surgery syndrome in both the short and long term (>12 months).
The primary studies cited in these reviews were reviewed individually for this policy (see following sections).
Percutaneous Lysis of Adhesions Without Spinal Endoscopy
In 2013, Gerdesmeyer et al reported on a randomized, double-blind, placebo-controlled trial on percutaneous epidural lysis of adhesions for chronic lumbar radicular pain at 4 participating treatment centers.(8) Of 381 patients screened, 90 patients were randomized in permuted blocks of 4 to 8 to adhesiolysis or placebo. Eligible patients had chronic lumbosacral radicular pain after disc protrusion or after failed back surgery and at least 4 months of unsuccessful conservative treatment. Patients in both groups received injections on each of 3 days and physical therapy after the series of injections. In the adhesiolysis group, the day 1 injection consisted of 10 mL saline with 150 U/mL hyaluronidase, plus 10 mL saline with 40 mg triamcinolone and 2 mL of 0.25% bupivacaine; this initial injection was followed by day 2 and 3 injections of saline with anesthetic. The placebo group received saline injections each of the 3 days through a catheter placed over the affected area but not into the spinal canal. Five patients were not able to complete the trial due to 1 punctured dura, 1 catheter displacement, and 3 required surgeries. After 3 months, the Oswestry Disability Index (ODI) score significantly improved in the adhesiolysis group
(55.3±11.6 to 26.4±10.8) compared with the placebo group (55.4±11.5 to 41.8±14.6; p<0.01). After 3 months, the visual analog scale (VAS) score was also significantly improved in the adhesiolysis group (6.7±1.1 to 2.9±1.9) compared with the placebo group (6.7±1.1 to 4.8±2.2; p<0.01]). The ODI and VAS scores remained significantly more improved in the adhesiolysis group than the control group at 6 and 12 months. In the adhesiolysis group, more patients experienced pain during the intervention and transient neurologic deficits (numbness, paralysis, motor weakness) after the intervention than the control group (34 vs 20 and 42 vs 6, respectively). All of the neurologic deficits resolved during hospitalization. Limitations of this study include failure to place the catheter near the anterolateral epidural space of the
targeted pathology, the unknown effect of each component of treatment, and the absence of magnetic resonance imaging after treatment. The large placebo effect seen in this study also brings into question whether placement of the catheter in the subcutaneous tissue produces a beneficial effect.
Two 2009 papers by Manchikanti et al(9,10) report 1-year outcomes of 2 comparative effectiveness RCTs. Patients in 1 trial had failed back surgery syndrome (planned enrollment, 200 patients), and patients in the other had chronic low back pain (planned enrollment, 120 patients). The reason for reporting preliminary results is not given, but the authors note that, in the larger study of patients with failed back surgery, having 60 patients in each group was determined to be adequate, and there are no controlled trials of patients receiving lysis of epidural adhesions for back pain related to spinal stenosis reported in the literature. The comparator in both trials was epidural corticosteroid injection. In both studies, the procedure in the intervention group included epidurography, introduction of the Racz catheter to the level of defect, adhesiolysis and/or targeted catheter positioning, repeat epidurography with confirmation of ventral and lateral filling, and injection of lidocaine, all performed in the operating room, followed by transfer to the recovery room and injection of 10% sodium chloride solution and injection of betamethasone. The control group received epidurography, introduction of the catheter up to S3 or S2, repeat epidurography, injection of lidocaine in the operating room, and injection of normal saline and betamethasone in the recovery room. For the patients with failed back surgery, significant pain relief, as defined by a greater than 50% reduction in VAS, was achieved by 73% of patients in the lysis group compared with 12% in the control group (p<0.001). For patients with spinal stenosis, there were no outcomes reported at the time of publication. In the 2-year follow-up report on the study with 120 patients treated for chronic low back pain, Manchikanti et al reported 82% of patients receiving adhesiolysis had significant improvement in functional status and relief of pain of at least 50% compared with only 5%improvement in the epidural corticosteroid injection group.(11) If patients had improved functioning and pain reductions of at least 50% for at least 3 months following adhesiolysis, repeat adhesiolysis was permitted. Patients in the adhesiolysis group received an average of 6.4 adhesiolysis procedures while patients in the epidural corticosteroid injection group averaged 2.4 procedures over the 2-year period.
A number of limitations are apparent in these studies. Efficacy of the comparator, epidural corticosteroid injection, has not been clearly demonstrated.(12) The injection site in the control group may have had some impact on outcomes. Additionally, in the chronic low back pain study, patients were not excluded from the comparator group if they previously failed caudal epidural injections in an effort to reduce placebo effects, which may also impact outcomes.(11) Losses to follow-up in the control groups were large in both studies (10/60 at 6 months, 43/60 at 12 months, 52/60 at 2 years in the failed back surgery study; 10/25 at 6 months, 18/25 at 12 months in the spinal stenosis study). There were few dropouts in the intervention groups. Thus, differential loss in follow-up is a major concern. Patients received additional treatments if needed (criteria for repeat treatment not given), and the type of treatment was based on the response to the previous injections, either after unblinding or without unblinding. Once unblinded, patients were considered withdrawn from the study. If the patient chose not to be unblinded, the prior treatment was repeated as assigned. Physicians performing procedures could not be blinded to treatment group but did not know which patients were participating in the studies. It is not reported if patients were asked which treatment they thought they received. Finally, several other case series have been reported, but without a control group, the independent contribution of the lysis cannot be assessed.
In 2004, Manchikanti et al published the results of a trial that randomized 75 patients to 1 of 3 groups, either a control group consisting of catheterization without adhesiolysis, or to adhesiolysis with or without additional hypertonic saline.(13) All patients received epidural injections of local anesthetic and corticosteroids. Patient selection criteria included a history of chronic low back pain of at least 2 years that had failed conservative treatment, including epidural corticosteroid injections. Outcomes were assessed at 3, 6, and 12 months based on a VAS, ODI, work status, opioid intake, range of motion, and psychological examination. Unblinding was allowed at 3 months, based on treatment response, followed by crossover to another treatment group. It is not clear from the published article how this assessment was made. In the control group, 6 of the 25 patients were unblinded at 3 months, and 18 of the 25 patients were unblinded at 18 months. Once patients were unblinded, they were considered withdrawn and no subsequent data were collected, and the results of their last assessment were carried forward to the next assessment. For example, if a patient was unblinded at 3 months, the same outcomes were reported at 6 and 12 months. Therefore, this discussion will focus on the 3-month outcomes.
Significant differences in pain relief, ODI, and range of motion were noted between the 2 treatment groups and the control group. For example, the mean VAS score did not significantly improve in the control group, dropping from 8.9 to 7.7, while in the treatment groups the VAS dropped from 8.8 to 4.6. A total of 40% of the control group had no response with the first treatment, compared with only 16% in the adhesiolysis group. At 3 months, no patient in the control group reported significant relief, defined as at least 50% relief, while at least 64% of patients in the treatment group reported significant relief. While this study was adequately designed and did report positive results, its small size and the fact that it is a single institution study limits interpretation. The dramatic effect reported in this study should be confirmed in a larger multi-institutional study.
One controlled trial included 45 patients who were randomized to receive either a 1- or a 3-day course of lysis of epidural adhesions. The methodologic strength of this trial is uncertain because details of the randomization and treatment protocols are not provided, and it is not clear what, if any, randomization took place.(14) The trial also included a conservatively treated control group of 15 patients composed of
patients who either refused the treatment option or whose insurance refused to pay. Although the study did not provide details on how pain relief was evaluated, describing only a verbal 10-point pain scale, the study concluded that a total of 97% of the treatment group with 1 to 3 injections reported at least 50% pain relief at 3 months, which fell to 93% at 6 months, and 47% at 1 year. There was no significant improvement in the control group. However, the lack of a placebo control and the obvious bias of the control group limit interpretation of these findings. Another study compared the use of 0.9% saline solution versus 10% saline solution but did not control other aspects of the pain management program.(15)
Serious adverse events from epidural lysis have been reported.(16) In 2012, Manchikanti et al reported on a prospective observational study of complications in 10,000 fluoroscopically directed epidural injections, including more than 800 cases treated by percutaneous adhesiolysis at their institution.(17) Measured outcomes included intravascular entry of the needle, profuse bleeding, local bleeding, local hematoma, bruising, dural puncture and headache, nerve root or spinal cord irritation, infection, numbness, postoperative soreness, and increased pain. There was intravascular entry in 11.6% of cases, return of blood in 3.6%, transient nerve root irritation in 1.9%, and dural puncture in 1.8% of adhesiolysis cases. Other complications occurred in less than 1% of cases. There were no major complications in this cohort.
A randomized, single-blinded trial compared epidural lysis with physical therapy in 99 patients with chronic low back pain.(18) Inclusion criteria were radicular pain with a corresponding nerve-root compressing substrate and included patients with disc protrusion and herniation, as well as epidural fibrosis. The authors did not present the results according to these separate indications. Therefore, for purposes of this policy, the study results cannot be evaluated.
Several small RCTs report benefits for epidural lysis of adhesions compared with placebo treatment. The interpretation of these trials is limited by differences in patients, populations, and treatment protocol. The treatment for lysis of adhesions varied in the use of mechanical disruption, the type of lytic medications used, and the number of injections given. There is also a large effect seen in the placebo group, raising questions about whether some component of the placebo treatment may be therapeutic. Larger trials with standardized treatment protocols would be helpful in determining whether specific treatment protocols have beneficial effects in specific patient populations.
Percutaneous Lysis of Adhesions With Spinal Endoscopy
In 2003, a new category III CPT code was introduced to describe lysis of epidural lesions using endoscopic guidance. One small RCT was identified in 2003 by Manchikanti et al. Twenty-three patients with back pain of greater than 6 months in duration were randomized to receive either spinal endoscopy followed by injection of local anesthetic or corticosteroid (control group) or the above procedure with the addition of lysis of adhesions with normal saline and mechanical disruption with the fiberoptic endoscope.(19) The trial was double-blinded. Patient selection criteria included failure of conservative management, including failure of prior attempts at lysis of adhesions using hypertonic saline. The principal outcomes included changes in VAS and ODI scores at 6 months. In the control group, the mean VAS score dropped from 8.7 at baseline to 7.6 at 6 months, while the scores in the intervention group dropped from 9.2 at baseline to 5.7 at 6 months. The difference between the control and the intervention groups was statistically significant. There was also a significant difference between the 2 groups in the percentage of patients experiencing at least a 50% reduction in pain. Blinding appeared to be successful as 6 of the 16 patients in the control group believed they were in the intervention group, and 8 of 23 patients in the intervention group believed they were in the control group. While this study reports promising results, its small size limits interpretation.
In 2011, Di Donato et al reported 48-month follow-up from a prospective case series of 234 patients with chronic low back pain due to failed back surgery syndrome, spondylolisthesis, stenosis, or hernia.(20) In addition to mechanical removal of adherences, targeted ozone, hyaluronidase, and ciprofloxacin were applied. Efficacy was prospectively evaluated by an independent investigator at 1 week and 3, 6, 12, 24, 36, and 48 months. Significant improvements in VAS and ODI scores were reported throughout the 48-month follow-up. Adverse events included 32 patients (13.7%) who had sacralpain lasting at least 2 weeks and 13 patients (5.5%) who experienced a nonpainful paresthesia and subsequently underwent surgical intervention. This study has a number of limitations, including the lack of information on the number of patients available for long-term follow-up and the lack of a control group.
Two additional articles by Manchikanti et al were identified that retrospectively examined the outcomes of patients who underwent lysis with (n=120) or without (n=60) adjunctive endoscopy.(21,22) As these articles are authored by the same investigator, it is likely that they include overlapping patients. However, these studies did not include a control group, and thus scientific conclusions regarding the contribution of
endoscopy are not possible.
Ongoing and Unpublished Clinical Trials
An online search of ClinicalTrials.gov on November 10, 2014, identified 2 ongoing studies that are no longer recruiting patients. Both studies are randomized trials, have completion dates listed as January 2014 and are led by Dr. Manchikanti. No publications are listed from these ongoing studies. In 1 study, percutaneous adhesiolysis will be compared with caudal epidural steroid injections for chronic low back and/or lower-extremity pain in patients without post lumbar surgery syndrome or spinal stenosis (NCT01053273). In the other study, percutaneous adhesiolysis with 10% sodium chloride solution or a steroid will be compared in 240 patients with post lumbar surgery syndrome (NCT01053572).
Summary of Evidence
Lysis of epidural adhesions involves passage of a catheter endoscopically or percutaneously under fluoroscopic guidance into the epidural space to break up adhesions and reduce pain and inflammation. The evidence for lysis of epidural adhesions with or without endoscopy is limited to a small number of randomized controlled trials with methodologic weaknesses, many from the same center. The trials vary in population, treatment, and the protocols used for lysis. These trials report benefits on pain and standardized patient-reported outcome measures compared with placebo. However, this evidence is insufficient to establish the safety and effectiveness of epidural lysis compared with placebo and alternative procedures. Larger, high-quality, controlled studies with standardized treatment protocols, and from independent research groups are needed to corroborate the currently available trials. Thus, lysis of epidural adhesions is considered investigational.
Practice Guidelines and Position Statements
The American Society of Interventional Pain Physicians updated its practice guidelines on the management of chronic spinal pain in 2013.(23) The guideline states that “for lumbar percutaneous adhesiolysis, the evidence is fair in managing chronic low back and lower extremity pain secondary to post surgery syndrome and spinal stenosis.” Percutaneous adhesiolysis is recommended “after failure of conservative management of physical therapy, chiropractic, drug therapy, structured exercise program, and fluoroscopically directed epidural injections.” The guideline also states spinal epidural endoscopic adhesiolysis is not discussed because there is limited evidence and the procedure is rarely used. The studies cited in the guideline have been reviewed for this policy.
The American Pain Society clinical practice guideline on Interventional Therapies, Surgery, and Interdisciplinary Rehabilitation for Low Back Pain, published in 2009, does not include a discussion or conclusion on adhesiolysis, and stated that “for other interventions or specific clinical circumstances, the panel found insufficient evidence from randomized controlled trials to reliably judge benefits or harms.”(24)
U.S. Preventive Services Task Force Recommendations
Medicare National Coverage
There is no national coverage determination (NCD). In the absence of an NCD, coverage decisions are left to the discretion of local Medicare carriers.
- Chopra P, Smith HS, Deer TR et al. Role of adhesiolysis in the management of chronic spinal pain: a systematic review of effectiveness and complications. Pain Physician 2005; 8(1):87-100. PMID 16850047
- Trescot AM, Chopra P, Abdi S, et al. Systematic review of effectiveness and complications of adhesiolysis in the management of chronic spinal pain: an update. Pain Physician. Jan 2007;10(1):129-146. PMID 17256027
- Helm Ii S, Benyamin RM, Chopra P, et al. Percutaneous adhesiolysis in the management of chronic low back pain in post lumbar surgery syndrome and spinal stenosis: a systematic review. Pain Physician. Jul-Aug 2012;15(4):E435-462. PMID 22828693
- Racz GB, Heavner JE, Trescot A. Percutaneous lysis of epidural adhesions--evidence for safety and efficacy. Pain Pract. Jul-Aug 2008;8(4):277-286. PMID 18503627
- Hayek SM, Helm S, Benyamin RM, et al. Effectiveness of spinal endoscopic adhesiolysis in post lumbar surgery syndrome: a systematic review. Pain Physician. Mar-Apr 2009;12(2):419-435. PMID 19305488
- Epter RS, Helm S, 2nd, Hayek SM, et al. Systematic review of percutaneous adhesiolysis and management of chronic low back pain in post lumbar surgery syndrome. Pain Physician. Mar-Apr 2009;12(2):361-378. PMID19305485
- Helm S, Hayek SM, Colson J, et al. Spinal endoscopic adhesiolysis in post lumbar surgery syndrome: an update of assessment of the evidence. Pain Physician. Apr 2013;16(2 Suppl):SE125-150. PMID 23615889
- Gerdesmeyer L, Wagenpfeil S, Birkenmaier C, et al. Percutaneous epidural lysis of adhesions in chronic lumbar radicular pain: a randomized, double-blind, placebo-controlled trial. Pain Physician. May-Jun 2013;16(3):185-196. PMID 23703406
- Manchikanti L, Cash KA, McManus CD, et al. The preliminary results of a comparative effectiveness evaluation of adhesiolysis and caudal epidural injections in managing chronic low back pain secondary to spinal stenosis: a randomized, equivalence controlled trial. Pain Physician. Nov-Dec 2009;12(6):E341-354. PMID 19935991
- Manchikanti L, Singh V, Cash KA, et al. A comparative effectiveness evaluation of percutaneous adhesiolysis and epidural steroid injections in managing lumbar post surgery syndrome: a randomized, equivalence controlled trial. Pain Physician. Nov-Dec 2009;12(6):E355-368. PMID 19935992
- Manchikanti L, Singh V, Cash KA, et al. Assessment of effectiveness of percutaneous adhesiolysis and caudal epidural injections in managing post lumbar surgery syndrome: 2-year follow-up of a randomized, controlled trial. J Pain Res. 2012;5:597-608. PMID 23293536
- Staal JB, de Bie RA, de Vet HC, et al. Injection therapy for subacute and chronic low back pain: an updated Cochrane review. Spine (Phila Pa 1976). Jan 1 2009;34(1):49-59. PMID 19127161
- Manchikanti L, Rivera JJ, Pampati V, et al. One day lumbar epidural adhesiolysis and hypertonic saline neurolysis in treatment of chronic low back pain: a randomized, double-blind trial. Pain Physician. Apr 2004;7(2):177-186. PMID 16868590
- Manchikanti L, Pampati V, Fellows B, et al. Role of one day epidural adhesiolysis in management of chronic low back pain: a randomized clinical trial. Pain Physician. Apr 2001;4(2):153-166. PMID 16902688
- Heavner JE, Racz GB, Raj P. Percutaneous epidural neuroplasty: prospective evaluation of 0.9% NaCl versus 10% NaCl with or without hyaluronidase. Reg Anesth Pain Med. May-Jun 1999;24(3):202-207. PMID 10338168
- Wagner KJ, Sprenger T, Pecho C, et al. [Risks and complications of epidural neurolysis -- a review with case report]. Anasthesiol Intensivmed Notfallmed Schmerzther. Apr 2006;41(4):213-222. PMID 16636945
- Manchikanti L, Malla Y, Wargo BW, et al. A prospective evaluation of complications of 10,000 fluoroscopically directed epidural injections. Pain Physician. Mar-Apr 2012;15(2):131-140. PMID 22430650
- Veihelmann A, Devens C, Trouillier H, et al. Epidural neuroplasty versus physiotherapy to relieve pain in patientswith sciatica: a prospective randomized blinded clinical trial. J Orthop Sci. Jul 2006;11(4):365-369. PMID 16897200
- Manchikanti L, Rivera JJ, Pampati V, et al. Spinal endoscopic adhesiolysis in the management of chronic low back pain: a preliminary report of a randomized, double-blind trial. Pain Physician. Jul 2003;6(3):259-267. PMID 16880869
- Di Donato A, Fontana C, Pinto R, et al. The effectiveness of endoscopic epidurolysis in treatment of degenerative chronic low back pain: a prospective analysis and follow-up at 48 months. Acta Neurochir Suppl. 2011;108:67-73. PMID 21107940
- Manchikanti L, Pampati V, Bakhit CE, et al. Non-endoscopic and endoscopic adhesiolysis in post-lumbar laminectomy syndrome: a one-year outcome study and cost effectiveness analysis. Pain Physician. Oct 1999;2(3):52-58. PMID 16906216
- Manchikanti L, Pakanati RR, Pampati V. The value and safety of epidural endoscopic adhesiolysis. Am J Anesthesiol. 2000;27(5):275-279.
- Manchikanti L, Abdi S, Atluri S, et al. An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain Physician. Apr 2013;16(2 Suppl):S49-283. PMID 23615883
- Chou R, Loeser JD, Owens DK, et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine (Phila Pa 1976). May 1 2009;34(10):1066-1077. PMID 19363457
|CPT||See Policy Guidelines|
|ICD-9 Procedure||03.6||Lysis of adhesions of spinal cord and nerve roots|
|ICD-9 Diagnosis||349.0-349.9||Other and unspecified disorders of the nervous system (code range)|
|HCPCS||J7130||Hypertonic saline solution, 50 or 100 mEq, 20 cc vial|
|ICD-10-CM (effective 10/1/15)||Investigational for all relevant diagnoses|
|G96.8||Other specified disorders of central nervous system|
|G96.9||Disorder of central nervous system unspecified|
|G97.1||Other reaction to spinal and lumbar puncture|
|G98.8||Other disorders of the nervous system|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|00NW3ZZ, 00NW4ZZ||Surgical, central nervous system, release, cervical spinal cord, code by approach (percutaneous or percutaneous endoscopic)|
|00NX3ZZ, 00NX4ZZ||Surgical, central nervous system, release, thoracic spinal cord, code by approach (percutaneous or percutaneous endoscopic)|
|00NY3ZZ, 00NY4ZZ||Surgical, central nervous system, release, lumbar spinal cord, code by approach (percutaneous or percutaneous endoscopic)|
|Type of Service||Therapy|
|Place of Service||Inpatient
Hypertonic Saline Injections
Injections, Epidural, Hypertonic Saline
Lysis of Epidural Adhesions
|11/01/98||Add to Therapy section||New policy|
|11/01/99||Replace policy||New CPT code; policy unchanged|
|07/12/02||Replace policy||Policy updated; policy statement unchanged|
|4/29/03||Replace policy||Policy updated and revised; CPT codes added, include discussion of endoscopic guidance; policy statement revised to address endoscopic guidance|
|12/17/03||Replace policy||Policy updated; new references added. No change in policy statement|
|07/15/04||Replace policy||Policy reviewed with literature search. No change in policy statement|
|06/27/05||Replace policy||Policy reviewed with literature search; no change in policy statement, reference numbers 8, 9, and 14-17 added|
|7/20/06||Replace policy||Policy reviewed with literature search; no change in policy statement, reference number 18 added. Policy guidelines section updated regarding inclusion of fluoroscopy in the CPT codes for the procedures|
|08/02/07||Replace policy||Policy updated with literature search; no change in policy statement, reference numbers 19-22 added|
|02/12/09||Replace policy||Policy updated with literature review, reference number 23 added. No change in policy statement|
|03/11/10||Replace policy||Policy updated with literature review, reference numbers 4, 5, 14 – 17 added, prior references renumbered and some removed. No change in policy statement|
|12/9/10||Replace policy - coding update only||ICD-10 codes added to policy|
|03/10/11||Replace policy||">Policy updated with literature review, reference number 18 added, no change in policy statement|
|12/08/11||Replace policy||Policy updated with literature review through September 2011, reference added and references reordered, no change in policy statement|
|12/13/12||Replace Policy||Policy updated with literature review through October 2012, references 3 and 11 added and references reordered, policy statement unchanged|
|12/12/13||Replace policy||Policy updated with literature review through November 8, 2013. Rationale section rearranged. References 7-8, 11, and 23 added, and previous reference 23 removed. Policy statement unchanged|
|12/11/14||Replace policy||Policy updated with literature review through November 17, 2014, No references added, policy statement unchanged.|