Laminectomy

Section: Surgery
Effective Date: May 01, 2020
Last Reviewed: March 16, 2020

Description

Laminectomy

Laminectomy is an inpatient procedure performed under general anesthesia. An incision is made in the back over the affected region, and the back muscles are dissected to expose the spinal cord. The lamina is then removed from the vertebral body, along with any inflamed or thickened ligaments that may be contributing to compression. Following resection, the muscles are reapproximated and the soft tissues sutured back into place. The extent of laminectomy varies, but most commonly extends two levels above and below the site of maximal cord compression.

Surgical Variations

Hemilaminotomy and laminotomy, sometimes called laminoforaminotomy, are less invasive than a laminectomy. These procedures focus on the interlaminar space, where most of the pathologic changes are concentrated, minimizing resection of the stabilizing posterior spine. A laminotomy typically removes the inferior aspect of the cranial lamina, the superior aspect of the subjacent lamina, the ligamentum flavum, and the medial aspect of the facet joint. Unlike laminectomy, laminotomy does not disrupt the facet joints, supra- and interspinous ligaments, a major portion of the lamina, or the muscular attachments. Muscular dissection and retraction are required to achieve adequate surgical visualization.

Criteria

Cervical laminectomy maybe considered medically necessary when ALL of the following conditions are met:

  • Spinal cord or nerve root compression due to one of the following conditions:
    • Spinal stenosis (with or without spondylolisthesis)
    • Ossification of the posterior longitudinal ligament or the yellow ligament; or hypertrophy of the ligamentumflavum.
  • Signs and/or symptoms that meet at least one of the following criteria:
    • Neurologic deficits that are rapidly progressive; OR
    • Symptoms of cervical myelopathy (see Policy Guidelines section) or cervical cord compression (with or without radiculopathy); OR
    • Persistentdebilitating pain that is refractory to at least6weeks of conservative nonsurgical therapy (See Policy Guidelines section).
  • Imaging studies (preferably magnetic resonance imaging) with findings of spinal cord compression, nerve root compression,and/ormyelographicchanges, at a level corresponding to the patient's signs and symptoms.

Lumbar laminectomy maybe considered medically necessary when ALL of the following conditionsare met:

  • Spinal cord or nerve root compression due to spinal stenosis (with or without spondylolisthesis);
  • Signs and/or symptoms that meet at least one of the following criteria:
    • Neurologic deficits that are rapidly progressive; OR
    • Neurologic claudication that is persistent and refractory to at least 6 weeks of conservative nonsurgical therapy (see Policy Guidelines section); OR
    • Persistent debilitating pain that is refractory to at least 6 weeks of conservative nonsurgical management (see Policy Guidelines section).
  • Imaging studies (preferably magnetic resonance imaging) with findings ofspinalcord or nerve root compression, at a level corresponding to the patient's signs and symptoms.

Laminectomy (cervical, thoracic, lumbar) may be considered medically necessary for space-occupying lesions of the spinal cord and/or spinal canal.

  • Primary or metastatic tumors
  • Abscesses or other localized infections.

Laminectomy (cervical or lumbar) is not medically necessary for spinal stenosis when the above criteriaare not met.

Laminectomy is considered investigational for all other indications.

Policy Guidelines

Cervical Myelopathy And/Or Cord Compression

Signs and symptoms of cervical myelopathyand/orcord compression include the following (Epstein, 2003):

  • Difficulty with fine movements of the hand and upper extremity
  • Incoordination of the hand and upper extremity
  • Atrophy of the thenar and hypothenar eminence
  • Diffuse hyperreflexia and bilateral Babinski responses
  • Decreased sensation, vibratory sense, and proprioception at a level of C5 or below
  • Inability to perform tandem walk
  • Bowel and bladder incontinence.

Conservative nonsurgical therapy for the duration specified should include the following:

  • Use of prescription strength analgesics for several weeks at a dose sufficient to induce a therapeutic response
    • Analgesics should include anti-inflammatory medications with or without adjunctive medications such as nerve membrane stabilizers or muscle relaxants AND
  • Participation in at least 6 weeks of physical therapy (including active exercise) or documentation of why the individual could not tolerate physical therapy, AND
  • Evaluation and appropriate management of associated cognitive, behavioral, or addiction issues
  • Documentation of individual compliance with the preceding criteria.

Persistent debilitating pain is defined as:

  • Significant level of pain on a daily basis as measured as a visual analog scale score of 4 or greater; AND
  • Pain on a daily basis that has a documented impact on activities of daily living despite optimal conservative nonsurgical therapy as outlined above and appropriate for the individual.

Laminectomy may occasionally be performed for the sole indication of radiculopathy due to herniated disc. In these cases, discectomy alone is not sufficient to relieve compression on vital structures, and laminectomy is requiredfor adequate decompression. Compression of the spine due to herniated disc is uncommon, and there are no standardized preoperative criteria to determine which individuals may require laminectomy in addition to discectomy.

The following procedures can be considered alternatives to laminectomy for decompression of the spinal cord. The specific indications for these alternative procedures are not standardized, and the evidence is insufficient to determine the effectiveness of these procedures compared with laminectomy.

  • Hemilaminectomy
  • Laminotomy
  • Foraminotomy.

Medical necessity is established by documentation of medical history, physical findings, and diagnostic imaging results that demonstrate spinal nerve compression and support the surgical intervention. Documentation in the medical record must clearly support the medical necessity of the surgery and include medical history, physical examination, and diagnostic testing.

Medical History

  • Assessment of comorbid physical and psychological health conditions (e.g. morbid obesity, current smoking, diabetes, renal disease, osteoporosis, severe physical deconditioning)
  • History of back surgery, including minimally invasive back procedures
  • Prior trial, failure, or contraindication to conservative medical/nonoperative interventions that may include but are not limited to the following:
    • Activity modification for at least 6 weeks
    • Oral analgesics and/or anti-inflammatory medications
    • Physical therapy
    • Chiropractic manipulation
    • Epidural steroid injections.

Physical Examination

  • Clinical findings including the individual's stated symptoms and duration.

Diagnostic Testing

  • Radiologist's report of a magnetic resonance image or computerized tomography scan with myelogram of the spine within the past 6 months showing a spine abnormality
  • Report of the selective nerve root injection results, if applicable to the individual's diagnostic workup.

Procedure Codes

63001 63005 63015 63017 63270 63272 63275
63277 63280 63282 63285 63287

Diagnosis Codes

C72.0 C79.40 G06.1 M48.00 M48.01 M48.02 M48.03
M48.04 M48.05 M48.06 M48.061 M48.062 M48.07 M48.08
M48.8X1 M48.8X2 M48.8X3 M48.8X4 M48.8X5 M48.8X6 M48.8X7
M48.8X8 M48.8X9

Professional Statements and Societal Positions Guidelines

Practice Guidelines and Position Statements

The North American Spine Society issued evidence-based guidelines (2011) on the diagnosis and treatment of degenerative lumbar spinal stenosis.The guidelines stated that individuals with mild symptoms of lumbar spinal stenosis are not considered surgical candidates; however, decompressive surgery was suggested to improve outcomes in individuals with moderate-to-severe symptoms of lumbar spinal stenosis (grade B recommendation). The Society also indicated that current evidence was insufficient to recommend for or against the placement of interspinous process spacing devices to treat spinal stenosis.

Excerpts from the North American Spine Society Coverage Recommendations

Laminectomy
1. Spinal Stenosis (including recurrent spinal stenosis, congenital stenosis, stenosis associated with achondroplasia) meeting the following criteria:

a. signs and symptoms of neurogenic claudication or radiculopathy correlated with imaging:
b. at least 6 weeks of nonoperative treatment
c. the following can mitigate the need for initial nonoperative trial

i. severity of symptoms causes forced bed rest
ii. stenosis results in functionally limiting motor weakness (e.g., foot drop)
iii. progressive neurological deficit

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