Medical Policy

Policy Num:       07.001.108
Policy Name:     Laminectomy
Policy ID:          [07.001.108]  [Ac / B / M+ / P-]  [7.01.145]

Last Review:       July 16, 2024
Next Review:       July 20, 2025
 

Related Policies:

07.001.173 Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers)
07.001.086 Image-Guided Minimally Invasive LumbarDecompression for Spinal Stenosis
07.001.102 LumbarSpinal Fusion

Laminectomy

summary

Description

Laminectomy is a surgical procedure in which a portion of the vertebra (the lamina) is removed to decompress the spinal cord. Removal of the lamina creates greater space for the spinal cord and the nerve roots, thus relieving compression on these structures. Laminectomy is typically performed to alleviate compression due to spinal stenosis or a space-occupying lesion.

Summary of Evidence

For individuals who have lumbar spinal stenosis and spinal cord or nerve root compression who receive lumbar laminectomy, the evidence includes randomized controlled trials (RCTs)and a systematic review of RCTs. Relevant outcomes are symptoms, functional outcomes, health status measures, quality of life, and treatment-related mortality and morbidity. In patients with spinal stenosis, there is sufficient evidence that laminectomy is more effective than nonoperative “usual care” in individuals with spinal stenosis who do not improve after 8 weeks of conservative treatment. The superiority of laminectomy is sustained through 8 years of follow-up. This conclusion applies best to individuals who do not want to undergo intensive, organized conservative treatment, or who do not have access to such a program. For individuals who want to delay surgery and participate in an organized program of physical therapy and exercise, early surgery with the combination of conservative initial treatment and delayed surgery in selected patients have similar outcomes at 2 years. From a policy perspective, this means that immediate laminectomy and intensive conservative care are both viable options. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have cervical spinal stenosis and spinal cord or nerve root compression who receive cervical laminectomy, the evidence includes systematic reviews and nonrandomized comparative studies. Relevant outcomes are symptoms, functional outcomes, health status measures, quality of life, and treatment-related mortality and morbidity. There is a lack of high-quality, comparative evidence for this indication, although what evidence there is offers outcomes similar to those for lumbar spinal stenosis. Given the parallels between cervical laminectomy and lumbar laminectomy, a chain of evidence can be developed that the benefit reported for lumbar laminectomy supports a benefit for cervical laminectomy. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have space-occupying lesion(s) of the spinal canal or nerve root compression who receive cervical, thoracic, or lumbar laminectomy, the evidence includes case series. Relevant outcomes are symptoms, functional outcomes, health status measures, quality of life, and treatment-related mortality and morbidity. Most case series are small and retrospective. They have reported that most patients with myelopathy experience improvements in symptoms or abatement of symptom progression after laminectomy. However, this uncontrolled evidence does not provide a basis to determine the efficacy of the procedure compared with alternatives. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Additional Information

The current standard of care, clinical input obtained in 2015, clinical practice guidelines, and the absence of alternative treatments all support the use of laminectomy for space-occupying lesions of the spinal canal. As a result, laminectomy may be considered medically necessary for patients with space-occupying lesions of the spinal cord.

Objective

The objective of this evidence review is to determine whether lumbar and cervical laminectomy improves the net health outcome for individuals with spinal stenosis or space-occupying lesion(s) of the spinal canal and spinal cord or nerve root compression.

Policy Statements

Cervical laminectomy may be 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

  • Persistent debilitating pain that is refractory to at least 6 weeks of conservative nonsurgical therapy (See Policy Guidelines section).

• Imaging studies (preferably magnetic resonance imaging) with findings of spinal cord compression, nerve root compression, and/ormyelographic changes, at a level corresponding to the patient's signs and symptoms.

Lumbar laminectomy may be considered medically necessary when ALL of the following conditions are 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 of spinal cord 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  investigational   for spinal stenosis when the above criteria are not met.

Laminectomy is considered investigational for all other indications.

Policy Guidelines

Cervical Myelopathy And/Or Cord Compression

Signs and symptoms of cervical myelopathy and/or cord compression include the following;

• 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 patient could not tolerate physical therapy, AND

• Evaluation and appropriate management of associated cognitive, behavioral, or addiction issues

• Documentation of patient 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 required for adequate decompression. Compression of the spine due to herniated disc is uncommon, and there are no standardized preoperative criteria to determine which patients 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 (eg, 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 patient'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 patient's diagnostic workup.

Coding

Please see the Codes table for details.

Benefit Application

BlueCard/National Account Issues

None.

Benefits are determined by the group contract, member benefit booklet, and/or individual subscriber certificate in effect at the time services were rendered. Benefit products or negotiated coverages may have all or some of the services discussed in this medical policy excluded from their coverage.

Background

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 2 levels above and below the site of maximal cord compression.^1,

There are numerous variations on the basic laminectomy procedure. It can be performed by minimally invasive techniques, which minimizes the extent of resection. Laminoplasty is a more limited procedure in which the lamina is cut but not removed, thus allowing expansion of the spinal cord. Foraminotomy and/or foramenectomy, which involve partial or complete removal of the facet joints, may be combined with laminectomy when the spinal nerve roots are compressed at the foramen. Spinal fusion is combined with laminectomy when the instability of the spine is present preoperatively, or if the procedure is sufficiently extensive to expect postoperative spinal instability.

Associated Disorders

The most common diagnosis treated with laminectomy is spinal stenosis. In spinal stenosis, the spinal canal (vertebral foramen) is narrowed, thus compressing the spinal cord. Narrowing of the spinal canal may be congenital or degenerative in origin. Other conditions that cause pressure on the spine and spinal nerve roots include those where a mass lesion is present (eg, tumor, abscess, other localized infection).

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.

Microendoscopic decompressive laminotomy is similar to laminotomy but uses endoscopic visualization. The position of the tubular working channel is confirmed by fluoroscopic guidance, and serial dilators (METRx™ lumbar endoscopic system, Medtronic) are used to dilate the musculature and expand the fascia. For microendoscopic decompressive laminotomy, an endoscopic curette, rongeur, and drill are used for the laminotomy, facetectomy, and foraminotomy. The working channel may be repositioned from a single incision for multilevel and bilateral dissections.

Adverse Events

Complications of laminectomy can include spinal cord and nerve root injuries, which occur at rates from 0% to 10%.^1, Worsening myelopathy and/or radiculopathy can occur in a small percentage of patients independent of surgical injuries. Worsening of symptoms is usually temporary, but in some cases has been permanent. Infection and bleeding can occur; hematomas following surgery often require reoperation if they are close to critical structures. Leakage of spinal fluid may occur and occasionally be persistent requiring treatment. Instability of the spine can result from extensive laminectomy involving multiple levels. This is usually an indication for spinal fusion as an adjunct to laminectomy, but if fusion is not performed, the instability may lead to progressive symptoms and additional surgery. Specific complication rates depend on the indication and location treated, surgical approach, and extent of surgery.

Regulatory Status

Laminectomy is a surgical procedure and, as such, is not subject to regulation by the U.S. Food and Drug Administration. Some of the instrumentation used during laminectomy may be subject to U.S. Food and Drug Administration approval.

RATIONALE

This evidence review was created in January 2015 and has been updated regularly with searches of the PubMed database. The most recent literature update was performed through May 5, 2024.

Evidence reviews assess the clinical evidence to determine whether the use of a technology improves the net health outcome. Broadly defined, health outcomes are length of life, quality of life, and ability to function including benefits and harms. Every clinical condition has specific outcomes that are important to patients and to managing the course of that condition. Validated outcome measures are necessary to ascertain whether a condition improves or worsens; and whether the magnitude of that change is clinically significant. The net health outcome is a balance of benefits and harms.

To assess whether the evidence is sufficient to draw conclusions about the net health outcome of a technology, 2 domains are examined: the relevance and the quality and credibility. To be relevant, studies must represent 1 or more intended clinical use of the technology in the intended population and compare an effective and appropriate alternative at a comparable intensity. For some conditions, the alternative will be supportive care or surveillance. The quality and credibility of the evidence depend on study design and conduct, minimizing bias and confounding that can generate incorrect findings. The randomized controlled trial (RCT) is preferred to assess efficacy; however, in some circumstances, nonrandomized studies may be adequate. Randomized controlled trials are rarely large enough or long enough to capture less common adverse events and long-term effects. Other types of studies can be used for these purposes and to assess generalizability to broader clinical populations and settings of clinical practice.

Promotion of greater diversity and inclusion in clinical research of historically marginalized groups (e.g., People of Color [African-American, Asian, Black, Latino and Native American]; LGBTQIA (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual); Women; and People with Disabilities [Physical and Invisible]) allows policy populations to be more reflective of and findings more applicable to our diverse members. While we also strive to use inclusive language related to these groups in our policies, use of gender-specific nouns (e.g., women, men, sisters, etc.) will continue when reflective of language used in publications describing study populations.

Population Reference No. 1

Spinal Stenosis

Lumbar Spinal Stenosis

Clinical Context and Therapy Purpose

The purpose of laminectomy in patients who have lumbar spinal stenosis is to provide a treatment option that is an alternative to or an improvement on existing therapies.

The following PICO was used to select literature to inform this review.

Populations

The relevant population of interest is patients with lumbar spinal stenosis.

Degenerative lumbar spinal stenosis is a condition in which there is diminished space available for the neural and vascular elements in the lumbar spine secondary to degenerative changes in the spinal canal. Symptomatic patients usually have radiating buttock and leg pain exacerbated by walking (neurogenic claudication) and relieved by leaning forward or sitting. Pain may be accompanied by numbness, tingling, or weakness in a foot or leg. The value of symptom questionnaires and specific physical examination signs in making the diagnosis of spinal stenosis is not clear. Patients with spinal stenosis may or may not have back pain. MRI is the preferred test to confirm spinal stenosis. Degenerative material such as hypertrophic ligamentum flavum or osteophytes, or disc herniation or bulging can cause spinal stenosis. However, it is a misconception that spinal stenosis is a progressive, “degenerative” disease. Most patients improve or remain stable over time without surgery.

Interventions

The therapy being considered is laminectomy.

Surgical decompression is an option for patients with lumbar spinal stenosis who do not have deformity or instability and have not responded to a course of conservative care. Laminectomy is a surgical procedure that removes a portion of a vertebra (the lamina) to decompress the spine. Removal of the lamina provides greater space for the spinal cord and the nerve roots, thus relieving compression on these structures.

Comparators

The following therapies and practices are currently being used to make decisions about laminectomy.

For patients with lumbar spinal stenosis, alternatives are conservative, nonsurgical care, including activity modification for at least 6 weeks, oral analgesics and/or anti-inflammatory medications, physical therapy, chiropractic manipulation, and epidural steroid injections.

Outcomes

The general outcomes of interest are symptoms, functional outcomes, health status measures, quality of life, treatment-related mortality, and treatment-related morbidity.

Outcome measures for back surgery are relatively well-established (see Table 1). Most studies used back and leg visual analog scores (VAS) or the Zurich Claudication Questionnaire to assess pain and the Oswestry Disability Index (ODI) to assess functional limitations related to back pain. Most studies also use a broader functional status index such as the Short Form (SF)-12 or SF-36, particularly the physical function subscale of SF-36. Throughout this report, we refer to a combination of pain and function measures as “Back and Leg Pain Measures.” Determining the minimal clinically important differences (MCID) for these measures is complex. The MCID for a given measure can depend on the baseline score or severity of illness, the method used to calculate MCID, and the times at which the scores are measured.^2, For these reasons, some investigators prefer to calculate a minimum detectable difference (MDD).^3,

Both short-term and long-term outcomes are important in evaluating back treatments. For example, for definitive back surgery, net benefit should take into account immediate (perioperative) adverse events; improvements in pain, neurological status, and function at 12 to 24 months as measured by the ODI, SF-36, Zurich Claudication Questionnaire, or VAS measures; and 5-year secondary surgery rates, which reflect longer-term complications, recurrences, and treatment failures. Less important, but still relevant outcomes are the frequency of sustained response and the eventual need for surgery.

Patient preferences are important in decision-making about elective back surgery.^4, In particular, to avoid the morbidity and risk of complications of the surgery, some patients may choose to prolong conservative treatments even if it means they have additional pain and functional limitation. Conversely, some patients will accept long-term outcomes of surgery similar to those of conservative therapy to get faster relief of symptoms and improvement in function.

In some trials, the epidural injection has been considered an event indicative of treatment failure. This is usually not appropriate. Instead, patient-reported outcomes should be measured at prespecified time intervals in all patients, whether or not they undergo injections or secondary procedures. When possible, trials should use explicit criteria for secondary surgeries or measure patient-reported outcomes just prior to secondary procedures so those implicit criteria for reoperation can be compared across studies.

Group means are commonly designated as primary outcome measures in spine studies. Variation in the calculation and definition of MCIDs makes it difficult to compare response rates across studies. Nevertheless, clinical trials should prespecify an MCID for ODI and, when used, the other measures in the table and report response rates in addition to group means.

Table 1. Patient-reported Outcome Measures for Back and Leg Pain

MDD:minimal detectable difference; MCID:Minimal clinically important difference. 

Study Selection Criteria

Methodologically credible studies were selected using the following principles:

• To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs;

• In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies;

• To assess longer-term outcomes and adverse events, single-arm studies that capture longer periods of follow-up and/or larger populations were sought;

• Consistent with a 'best available evidence approach,' within each category of study design, studies with larger sample sizes and longer durations were sought;

• Studies with duplicative or overlapping populations were excluded.

Review of Evidence

Surgical decompression is an option for patients with lumbar spinal stenosis who do not have deformity or instability and have not responded to a course of conservative care. Laminectomy for decompression is widely considered effective, but the precise net benefit compared with intensive, prolonged conservative therapy is uncertain.^5,

Systematic Reviews

A network meta-analysis of 34 RCTs by Wei et al (2021) compared surgical and non-surgical interventions for lumbar spinal stenosis.^6, Non-surgical interventions were not specified, and surgical interventions included decompression, decompression plus fusion, endoscopic decompression, interspinous process spacer device, laminectomy, laminotomy, minimally invasive decompression, and split spinous process decompression. Results demonstrated that there were no statistically significant differences between surgical and non-surgical interventions for changes in short-term and long-term disability. On the other hand, surgical interventions were superior to non-surgical interventions for the reduction of short-term and long-term pain. In the short-term, pain scores increased with non-surgical interventions versus laminectomy (mean difference, 17.75; 95% confidence interval [CI], 3.84 to 29.09), and in the long-term, pain scores were reduced with laminectomy versus non-surgical interventions (mean difference, -36.14; 95% CI, -45.18 to -37.32). Rank probabilities demonstrated that surgical interventions had a higher likelihood of being more effective at reducing short-term and long-term disability and pain when compared to non-surgical measures.

Randomized Controlled Trials

One of the 3 Spine Patient Outcomes Research Trial (SPORT) studies compared laminectomy to usual care in patients who had spinal stenosis and no spondylolisthesis and found advantages through 4 years of follow-up in clinical outcomes in patients who had surgery.^7, In SPORT, patients presented with at least 12 weeks of pseudoclaudication or radicular pain (central, lateral recesses, or neural foramina), and no spondylolisthesis or instability. The trial attempted to compare standard posterior laminectomy (88%) or decompression with fusion (11%) with usual care. Over 4 years, about two-thirds of patients underwent surgery. Overall, patients treated surgically had significantly greater improvement in pain, function, and disability through 2 years. At 4 years, 61% of patients in the surgery group and 32% in the non-operative group achieved a 15-point improvement in the ODI.

Lurie et al (2015) published a follow-up analysis of SPORT at 8 years.^8, At that time point, 55% of the original randomized cohort was available. Of available patients, 70% assigned to surgery and 52% assigned to medical care had undergone surgery. On intention-to-treat analysis, there were no differences in the primary outcomes. On the as-treated analysis, the differences for the SF-36 and ODI measures were statistically significant at 4-year follow-up, but not at the 6- to 8-year follow-up time points. These widely cited SPORT results rest on observational analyses comparing patients who received surgery at any time with those who did not. That is, so many patients assigned to usual care had surgery that the data had to be analyzed as an (observational) randomized cohort study instead of as an RCT. These analyses included patients who were randomized as well as those who were enrolled in a prospective, observational cohort study. Because of high crossover rates, intention-to-treat analyses were generally negative for the SPORT trials. In this light, SPORT is best seen as a comparison of early surgery with the combination of conservative initial treatment and delayed surgery in selected patients. The SPORT results do not imply that immediate surgery is superior to continued conservative therapy; rather, they indicate that patients who choose surgery at various times after 6 weeks do better—short- and long-term—than those who continue usual care. One other small randomized trial ^9,10, and older observational studies and studies based on large databases also support the long-term effectiveness and safety of laminectomy for spinal stenosis.^11,12,

Malmivaara et al (2007) conducted a small RCT in Finland evaluating 94 patients from 4 university hospitals.^10, Patients were randomized to laminectomy with or without fusion or to conservative therapy and followed for 2 years. All patients had lumbar spinal stenosis, persistent back pain for at least 6 months, and imaging studies demonstrating spinal stenosis at a level corresponding with the patient's symptoms. Crossover was allowed for progressive symptoms, and 4 of 44 patients assigned to nonoperative treatment underwent surgery over the 2-year follow-up. The primary outcome measures were ODI scores and VAS scores of leg pain and back pain (ranges, 0 to 10). At 2-year follow-up, the surgical group showed greater improvement on all 3 primary outcome measures. The mean difference in the ODI score was 7.8 points (95% CI, 0.8 to 14.9 points); the mean difference in VAS leg pain score was 1.51 points (95% CI, 0.25 to 2.77 points); and the mean difference in VAS back pain score was 2.13 points (95% CI, 0.98 to 3.28 points). There were 8 perioperative complications, 7 of which were injuries to the dural sac. An additional 4 complications occurred postoperatively (1 hematoma requiring reoperation, 1 respiratory distress due to pulmonary edema, 2 additional surgeries).

While immediate laminectomy is probably better than “usual care,” recent research is examining the effectiveness of organized approaches to conservative management versus decompression. In a RCT of 169 participants, surgical decompression (laminectomy) and a specific therapy program emphasizing physical therapy and exercise had similar outcomes.^13, The main inclusion criteria were (1) lumbar spinal stenosis and from 0 to 5 mm of slippage (spondylolisthesis); (2) considered by a surgeon to be a candidate for decompression surgery; and (3) willing to be randomized to decompression surgery or an intensive, organized program of nonsurgical therapy. Baseline ODI scores were comparable to those in the SPORT trial. A high proportion of patients assigned to nonsurgical care (57%) crossed over to surgery (in SPORT the proportion was 43%), but crossover from surgery to nonsurgical care was minimal.

The main implication of the trial results (Table 2) is that about one-third of patients who were deemed candidates for decompression surgery but instead entered an intensive program of conservative care achieved outcomes similar to those of a successful decompression. It should be noted that the trial results are most applicable to individuals who are interested in a prolonged nonsurgical option; the results are not generalizable to all patients who have spinal stenosis, particularly the subset who strongly prefer surgery. Another randomized trial of a specific physical therapy program versus laminectomy is currently underway in Sweden (see Appendix 2: Ongoing Studies.)

Table 2. Results of Delitto et al (2015) Randomized Trial^13,

CI: confidence interval; ODI: Oswestry Disability Index; PT: physical therapy; SF-36: 36-Item Short-Form Health Survey.1.SF-36 Physical Function Subscale. Success was defined as >0.5 SD improvement at 2 years.2. Includes reoperation of lumbar spine and other surgeries.

Jung et al (2020) conducted a smaller RCT evaluating surgical and non-surgical interventions in patients who were surgical candidates for lumbar spinal stenosis.^14, Patients were offered the option to be enrolled in a randomized (n=110) or observational (n=37) cohort. In the randomized cohort, 16 of 55 (29%) patients in the non-surgical treatment group and 38 of 55 patients (69%) in the surgical treatment group crossed over to the other treatment group. Results demonstrated that the non-surgical treatment group had less pain improvement and functional recovery through 12 months compared to the surgical treatment group. Patients who did not undergo surgery had significantly less improvement in the following scores compared to patients who underwent surgery: VAS for back pain (p<.001), EuroQol 5- Dimension utility index (p=.002), and EuroQol 5-Dimension VAS (p=.003). The between-group difference after 12 months did not reach statistical significance for VAS for leg pain and the Korean version of the ODI.

Section Summary: Lumbar Spinal Stenosis

For individuals who have lumbar spinal stenosis and spinal cord or nerve root compression who receive lumbar laminectomy, the evidence includes randomized controlled trials (RCTs) and a systematic review of RCTs. Relevant outcomes are symptoms, functional outcomes, health status measures, quality of life, and treatment-related mortality and morbidity. In patients with spinal stenosis, there is sufficient evidence that laminectomy is more effective than nonoperative “usual care” in individuals with spinal stenosis who do not improve after 8 weeks of conservative treatment. The superiority of laminectomy is sustained through 8 years of follow-up. This conclusion applies best to individuals who do not want to undergo intensive, organized conservative treatment, or who do not have access to such a program. For individuals who want to delay surgery and participate in an organized program of physical therapy and exercise, early surgery with the combination of conservative initial treatment and delayed surgery in selected patients have similar outcomes at 2 years. From a policy perspective, this means that immediate laminectomy and intensive conservative care are both viable options. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

Population Reference No. 2

Cervical Spinal Stenosis

Clinical Context and Therapy Purpose

The purpose of cervical laminectomy in patients who have cervical spinal stenosis is to provide a treatment option that is an alternative to or an improvement on existing therapies.

The following PICO was used to select literature to inform this review.

Populations

The relevant population of interest is patients with cervical spinal stenosis.

The most common diagnosis treated with laminectomy is spinal stenosis. In spinal stenosis, the spinal canal (vertebral foramen) is narrowed, thus compressing the spinal cord. Narrowing of the spinal canal may be congenital or degenerative in origin.

Interventions

The therapy being considered is cervical laminectomy.

Laminectomy is a surgical procedure that removes a portion of a vertebra (the lamina) to decompress the spine. Removal of the lamina provides greater space for the spinal cord and the nerve roots, thus relieving compression on these structures. Laminectomy is an inpatient procedure performed under general anesthesia. An incision is made over the affected region, and the 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 2 levels above and below the site of maximal cord compression

Comparators

The following therapies and practices are currently being used to make decisions about cervical laminectomy: conservative, nonsurgical care, including activity modification for at least 6 weeks, oral analgesics and/or anti-inflammatory medications, physical therapy, chiropractic manipulation, and epidural steroid injections.

Outcomes

The general outcomes of interest are symptoms, functional outcomes, health status measures, quality of life, treatment-related mortality, and treatment-related morbidity.

Both short-term and long-term outcomes are important in evaluating cervical spine treatments. For example, for definitive back surgery, net benefit should take into account immediate (perioperative) adverse events; improvements in pain, neurological status, and function at 1 to 24 months as measured by the ODI, SF-36, Zurich Claudication Questionnaire, or VAS measures; and 5-year secondary surgery rates, which reflect longer-term complications, recurrences, and treatment failures.

Additional physician-scored scales used to determine the severity of clinical symptoms in patients with cervical compressive myelopathy include the Nurick score (scored 0 to 5; higher scores represent more severe disease) and the Japanese Orthopaedic Association (JOA) scale (scored 0 to 18; lower scores represent more severe disease).

Study Selection Criteria

Methodologically credible studies were selected using the following principles:

• To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs;

• In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies.

• To assess longer term outcomes and adverse events, single-arm studies that capture longer periods of follow-up and/or larger populations were sought.

• Consistent with a 'best available evidence approach,' within each category of study design, studies with larger sample sizes and longer durations were sought;

• Studies with duplicative or overlapping populations were excluded.

Review of Evidence

Many of the studies of laminectomy for cervical spinal stenosis have included patients with either or both spondylosis or posterior longitudinal ligament ossification. Those that specifically address the posterior longitudinal ligament ossification are addressed separately.

Cervical Myelopathy

There are few controlled trials comparing laminectomy to conservative management for patients who had symptomatic cervical spinal stenosis. One small RCT (2002) was identified, comparing decompressive surgery with nonsurgical treatment in patients with mild or moderate cervical myelopathy.^15, The surgical techniques used were variations on laminectomy (ie, anterior decompression with fusion, corpectomy, laminoplasty); standard laminectomy was not used. Other published RCTs have compared various surgical techniques and therefore did not address the efficacy of surgery itself.^{16,17,18,19,20,21,22,}

Systematic Reviews

Some studies have compared laminectomy with alternative surgical approaches. A meta-analysis by Liu et al (2016) summarized studies comparing laminectomy plus fusion with laminoplasty for cervical compressive myelopathy.^23, Across the 23 studies meeting inclusion criteria, with 743 and 774 patients treated with laminectomy and laminoplasty and fusion, respectively, there were generally no significant differences in most clinical outcomes, although laminoplasty-treated patients had lower rates of C5 palsy (pooled odds ratio, 0.26; 95% CI, 0.15 to 0.44).

A 2017 meta-analysis with more restrictive selection criteria compared laminectomy plus fusion with expansive laminectomy for multiple-level cervical spondylotic myelopathy.^24, Reviewers included 10 studies - 2 prospective RCTs and 8 retrospective observational studies. For most clinical outcomes, there were no significant differences between groups, except a higher complication rate in the laminectomy plus fusion group.

A 2022 meta-analysis compared anterior cervical discectomy with fusion versus posterior decompression (laminectomy with fusion, laminectomy without fusion, or laminoplasty) in patients with multilevel degenerative cervical myelopathy spanning at least 2 levels without ossification of the posterior longitudinal ligament.^25, Reviewers included 19 studies, most of which were comparative, non-randomized studies. Results demonstrated that both surgical approaches achieved similar functional outcomes at the 1-year follow-up, as well as similar risk of complications and mortality.

Nonrandomized Comparative Studies

One small, prospective, nonrandomized, multicenter study (2000) evaluated surgical and nonsurgical treatments in 62 patients with cervical myelopathy. ^26,  Follow-up data were obtained for 43 (69%) of 62 patients, 20 of whom underwent surgery, and 23 of whom had nonsurgical treatment. Details on the specific types of surgery were sparse, though authors indicated that the primary procedure was posterior laminotomy or laminectomy with or without foraminotomy. Patients in the surgical group improved significantly on the overall functional status measure (worst pain rating) and average pain rating, while patients in the nonsurgical group only showed significant improvements in average pain rating. No between-group comparisons or complications were reported.

Cohort Studies

The AO Spine North America Prospective Multi-Center Study, a single-arm cohort study (2013), evaluated surgical decompression outcomes for cervical myelopathy.^27, The study enrolled 278 consecutive patients, presenting to 12 North American centers, with symptomatic cervical myelopathy, objective cord compression on MRI , and no evidence of lumbar spinal stenosis. The treating surgeon decided the specific surgical approach. Details on the approach were not reported, but approximately one-third of patients received laminectomy. At 1-year follow-up, there was a significant improvement on multiple measures of symptoms and functional status, including improvement on 7 of 8 SF-36 scales. Complications occurred in 18.7% of patients. The most common complications were postoperative dysphagia (3.6%), superficial infection (2.9%), and need for revision surgery (2.2%). Worsening myelopathic symptoms postoperatively developed in 3 patients, 2 of whom returned to baseline by 1 year.

A separate 2012 publication from the AO Spine study reported on short- and long-term surgical complications.^28, Perioperative complications occurred in 15.6% (47/302) of patients, the most common being minor cardiopulmonary events (3.0%), dysphagia (3.0%), and superficial wound infection (2.3%). Worsening of perioperative myelopathy occurred in 1.3% (n=4) of patients. Of patients who completed 2-year follow-up, late complications occurred in 4.4% (14/275), of which 6 were considered major.

A separate 2020 publication from the AO Spine study reported on clinical outcomes following laminectomy with fusion (n=186) versus laminectomy alone (n=22).^22, At 24 months after surgery, there were significant differences between surgical groups in favor of laminectomy with fusion based on the modified JOA scores (adjusted mean difference, -2.2; p=.001) and Nurick scores (adjusted mean difference, 0.90 p=.026); perioperative complications were similar between surgical groups (approximately 23% in each group; p=.879).

Ossification of the Posterior Longitudinal Ligament

Systematic Reviews

Yu et al (2020) reported on a systematic review and meta-analysis of studies comparing anterior cervical corpectomy with fusion, laminoplasty, and laminectomy with instrumented fusion in the treatment of ossification of the posterior longitudinal ligament (14 trials; N=877).^29, When considering comparisons to laminectomy with instrumented fusion, there were no statistically significant differences in JOA scores between anterior cervical corpectomy with fusion and laminectomy with instrumented fusion. With regards to complications, no significant differences were found when comparing laminectomy with instrumented fusion with anterior cervical corpectomy with fusion or laminoplasty. Cumulative ranking curves demonstrated that improvement in JOA score was most likely with anterior cervical corpectomy with fusion, followed by laminectomy with instrumented fusion. For the likelihood of complications, laminectomy with instrumented fusion ranked highest.

Singhatanadgige et al (2016) reported on a systematic review of studies comparing laminoplasty with laminectomy plus fusion in patients with ossification of the posterior longitudinal ligament leading to myelopathy.^19, Four studies were identified, 1 prospective and 3 retrospective cohort studies (N=334 patients; range 38 to 164 patients); the overall body of evidence was assessed using GRADE criteria. Follow-up ranged from 12 to 72 months. Outcomes were not pooled; primary outcomes were summarized. Myelopathy recovery rates did not differ significantly at 12 months in 2 studies. In 2 other retrospective studies, recovery rates were higher in the laminoplasty group (65.2%) than in the laminectomy plus fusion group (50.8%; p=reported as significant) in 1 study, but the opposite was reported in the other (25.1% vs. 43.5%). The 2 studies that reported on pain did not find differences between groups. All 4 studies that reported on the incidence of cranial nerve 5 palsy found that it was higher in patients treated with laminectomy with fusion (range, 9.6% to 25%) than laminoplasty (range, 0% to 8%). Reviewers concluded that their analysis did not establish the superiority of either procedure.

Randomized Controlled Study

Cao et al (2023) compared anterior cervical ossified posterior longitudinal ligament en bloc resection (ACOE) with posterior laminectomy and fusion with bone graft and internal fixation (PTLF) for the treatment of ossification of the posterior longitudinal ligament in an RCT conducted between July 2017 and July 2019.^30, The trial included 40 patients with a diagnosis of cervical ossification of the posterior longitudinal ligament and associated spinal cord compression involving less than 3 segments who failed to respond to conservative treatment. Results demonstrated the JOA score and recovery rate were significantly better in the ACOE group than in the PTLF group at 2 years postoperatively. The final JOA scores were 16.05 in the ACOE group and 14.89 in the PTLF group (p=0.004). The recovery rate was 68.10% in the ACOE group and 38.39% in the PTLF group (p=0.015).

Cohort Studies

Nakashima et al (2016) reported on the prospective, multicenter AO Spine study, which was designed to evaluate whether the underlying mechanism of disease (eg, cervical spondylotic myelopathy, posterior longitudinal ligament ossification) in degenerative cervical myelopathy has an impact on the outcomes of surgical decompression.^26, The study included 479 patients with symptomatic degenerative cervical myelopathy, of whom 135 (28.2%) had radiographic evidence of posterior longitudinal ligament ossification. Patients were treated at the discretion of their surgeons: anteriorly by cervical discectomy and/or corpectomy with fusion, or posteriorly by laminectomy with or without fusion or laminoplasty. At 2-year follow-up, there were no significant differences between groups in symptoms or functional outcomes.

A prospective study of 63 patients who underwent cervical decompressive surgery for ossification of the posterior longitudinal ligament was published by Kommu et al (2014).^27, Laminectomy was performed by 1 of 2 methods, either the anterior or posterior approach. The primary outcome measure was the Nurick Scale for myelopathy (score range, 0 to 5), with higher numbers representing more severe myelopathy. At 24-month follow-up, improvement in the Nurick Scale grade was reported for 54 (86%) of 63 patients, and mean Nurick grade improved from 2.82 at baseline to 2.03 at final follow-up (p<.05).

Lee et al (2016) published a retrospective study of 57 patients who underwent surgery for cervical myelopathy caused by ossification of the posterior longitudinal ligament and had at least 24 months of follow-up.^28, Three surgical variations were used: laminectomy alone, laminectomy plus fusion, and laminoplasty. Outcomes reported included radiographic evidence of cervical sagittal balance, Neck Disability Index, and VAS for pain. Progressive improvements were reported in radiographic and clinical outcomes over time in all groups. Progression of posterior longitudinal ligament ossification was seen more commonly in the group treated with laminectomy alone than with laminectomy plus fusion.

Section Summary: Cervical Spinal Stenosis

For cervical spinal stenosis, the evidence is more limited than for lumbar spinal stenosis, with no published RCTs comparing laminectomy to conservative, nonsurgical care. Some nonrandomized comparative evidence is available on the treatment of cervical spondylotic myelopathy with decompressive surgery versus nonsurgical management, but this evidence assesses spinal stenosis and other etiologies, and includes various techniques for decompression, without reporting on laminectomy separately. Single-arm studies have reported significant improvements in postsurgical pain and functional status but have not provided relevant evidence on the comparative efficacy of surgical versus nonsurgical management.

For individuals who have cervical spinal stenosis and spinal cord or nerve root compression who receive cervical laminectomy, the evidence includes RCTs and nonrandomized comparative studies. Relevant outcomes are symptoms, functional outcomes, health status measures, quality of life, and treatment-related mortality and morbidity. There is a lack of high-quality, comparative evidence for this indication, although what evidence there is offers outcomes similar to those for lumbar spinal stenosis. Given the parallels between cervical laminectomy and lumbar laminectomy, a chain of evidence can be developed that the benefit reported for lumbar laminectomy supports a benefit for cervical laminectomy. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

Population Reference No. 3

Space-Occupying Lesions of the Spinal Canal

Clinical Context and Therapy Purpose

The purpose of cervical, thoracic, or lumbar laminectomy in patients who have cervical, thoracic, or lumbar spinal stenosis or space-occupying lesion(s) of the spinal canal and spinal cord or nerve root compression is to provide a treatment option that is an alternative to or an improvement on existing therapies.

The following PICO were used to select literature to inform this review.

Populations

The relevant population of interest is patients with space-occupying lesion(s) of the spinal canal and spinal cord or nerve root compression

Conditions other than spinal stenosis that cause pressure on the spine and spinal nerve roots include those where a mass lesion is present (eg, tumor, abscess, other localized infection).

Interventions

The therapy being considered is cervical laminectomy.

Laminectomy is a surgical procedure that removes a portion of a vertebra (the lamina) to decompress the spine. Removal of the lamina provides greater space for the spinal cord and the nerve roots, thus relieving compression on these structures. 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 2 levels above and below the site of maximal cord compression

Comparators

The following practices are currently being used to make decisions about cervical laminectomy: resection and/or drainage alone without cervical laminectomy.

Outcomes

The general outcomes of interest are symptoms, functional outcomes, health status measures, quality of life, treatment-related mortality, and treatment-related morbidity.

Both short-term and long-term outcomes are important in evaluating back treatments. For example, for definitive back surgery, the net benefit should take into account immediate (perioperative) adverse events; improvements in pain, neurological status, and function at 12 to 24 months as measured by the ODI, SF-36, ZCQ, or VAS measures; and 5-year secondary surgery rates, which reflect longer-term complications, recurrences, and treatment failures.

Study Selection Criteria

Methodologically credible studies were selected using the following principles:

• To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs;

• In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies.

• To assess longer term outcomes and adverse events, single-arm studies that capture longer periods of follow-up and/or larger populations were sought.

• Consistent with a 'best available evidence approach,' within each category of study design, studies with larger sample sizes and longer durations were sought;

• Studies with duplicative or overlapping populations were excluded

Review of Evidence

For indications other than spinal stenosis, the evidence consists primarily of case reports and retrospective case series. Representative examples of the types of studies available for specific indications are provided next.

Neoplasms of the Spine

Systematic Review

Mo et al (2022) published a systematic review comparing laminectomy versus laminectomy with fixation for the treatment of intradural extramedullary tumors.^31, The review included 13 retrospective case series, 3 retrospective control cohorts, and 1 historic control case series. Results demonstrated that laminectomy increased the risk of postoperative sagittal instability compared to laminectomy with fixation (odds ratio, 1.81; p<.001). The risk of any adverse postoperative outcomes did not differ between procedures (p=.44)

A meta-analysis by Byvaltsev et al (2023) compared laminectomy versus laminoplasty in adult patients with primary spinal cord tumors of the cervical, thoracic, and lumbar spine.^32, A total of 7 retrospective, observational studies were included with a total of 540 patients. No significant differences were observed in the rate of total complications between groups (risk ratio [RR], 0.83; 95% CI, 0.50 to 1.38; p=.48); however, the laminoplasty group had a lower rate of spinal deformity (odds ratio [OR], 0.47; 95% CI, 0.27 to 0.84; p=.01) and reduced length of hospital stay (standardized mean difference, -0.68; 95% CI, -1.03 to -0.34; p=.0001).

Cohort study

Zong et al (2013) retrospectively evaluated 110 patients with extramedullary schwannomas treated surgically.^23, Three variations of laminectomy were used: laminectomy plus microscopic excision, hemilaminectomy plus microscopic excision, and laminectomy plus microscopic excision and pedicle screw fixation. The authors compared various surgical parameters across procedures, such as blood loss, operative time, and length of stay. No clinical outcomes were reported.

Case Series

Tredway et al (2006) reported on 6 patients with intradural spinal neoplasms (4 lumbar, 1 thoracic, 1 cervical) treated with laminectomy and dural resection by minimally invasive techniques.^24, The authors reported that all patients underwent successful resection without complications. On follow-up MRI , complete resection was seen in all cases, with no evidence of residual tumor.

Epidural Abscess

Case Series

Piccolo et al (1999) reported on a series of 5 patients with cervical epidural abscess treated with surgical drainage plus laminectomy or surgical drainage alone, depending on the degree of cervical spinal involvement. ^33,  Surgical outcome was poor in 1 of 2 patients treated with laminectomy, who had extensive disease spanning more than 3 vertebral segments.

Spinal Arachnoid Cysts

Case Series

El-Hajj et al (2023) reported on a series of 34 patients with intra- or extradural spinal arachnoid cysts treated with fenestration or excision. Surgical access was predominantly by laminectomy (82%), but a minority of patients were treated by laminotomy.^34, The median post-operative follow-up duration was 8 years. Patients had significant improvement from baseline in the American Spinal Injury Association Impairment Scale (p=.012) and modified Japanese Orthopedic Association scores (p=.005). At the longest available follow-up, patients reported significantly improved pain (p<.001), motor (p=.023), and sensory function (p<.001), but no improvement from baseline was noted for gait (p=.48) and bowel/bladder (p=.134) symptoms.

Section Summary: Space-Occupying Lesions of the Spinal Canal

The evidence evaluating the use of cervical, thoracic, or lumbar laminectomy to treat space-occupying lesion(s) of the spinal canal or nerve root compression consists of small and retrospective case series. These series have reported that most patients with myelopathy experience improvements in symptoms or abatement of symptom progression after laminectomy. However, this uncontrolled trial evidence does not provide a basis to determine the efficacy of the procedure compared with alternatives.

For individuals who have space-occupying lesion(s) of the spinal canal or nerve root compression who receive cervical, thoracic, or lumbar laminectomy, the evidence includes case series. Relevant outcomes are symptoms, functional outcomes, health status measures, quality of life, and treatment-related mortality and morbidity. Most case series are small and retrospective. They have reported that most patients with myelopathy experience improvements in symptoms or abatement of symptom progression after laminectomy. However, this uncontrolled evidence does not provide a basis to determine the efficacy of the procedure compared with alternatives. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

The current standard of care, clinical input obtained in 2015, clinical practice guidelines, and the absence of alternative treatments all support the use of laminectomy for space-occupying lesions of the spinal canal. As a result, laminectomy may be considered medically necessary for patients with space-occupying lesions of the spinal cord.

Supplemental Information

The purpose of the following information is to provide reference material. Inclusion does not imply endorsement or alignment with the evidence review conclusions.

Clinical Input From Physician Specialty Societies and Academic Medical Centers

While the various physician specialty societies and academic medical centers may collaborate with and make recommendations during this process, through the provision of appropriate reviewers, input received does not represent an endorsement or position statement by the physician specialty societies or academic medical centers, unless otherwise noted.

In response to requests, input was received from 2 specialty societies and 4 academic medical centers when this policy was in development in 2015. Input informed criteria for medical necessity for the indications of mass lesions and cervical laminectomy.

Practice Guidelines and Position Statements

Guidelines or position statements will be considered for inclusion in ‘Supplemental Information' if they were issued by, or jointly by, a US professional society, an international society with US representation, or National Institute for Health and Care Excellence (NICE). Priority will be given to guidelines that are informed by a systematic review, include strength of evidence ratings, and include a description of management of conflict of interest.

North American Spine Society

In 2011, the North American Spine Society (NASS) issued evidence-based guidelines on the diagnosis and treatment of degenerative lumbar spinal stenosis.^35, The guidelines stated that patients with mild symptoms of lumbar spinal stenosis are not considered surgical candidates; however, decompressive surgery was suggested to improve outcomes in patients 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. A 2013 update of this guideline from the Degenerative Lumbar Spinal Stenosis Work Group of the NASS notes the same recommendations.^36,

U.S. Preventive Services Task Force Recommendations

Not applicable.

Medicare National Coverage

There is no national coverage determination. In the absence of a national coverage determination, coverage decisions are left to the discretion of local Medicare carriers.

Ongoing and Unpublished Clinical Trials

A search of ClinicalTrials.gov in March 2024 did not identify any ongoing or unpublished trials that would likely influence this review.

References

1. Epstein NE. Laminectomy for cervical myelopathy. Spinal Cord. Jun 2003; 41(6): 317-27. PMID 12746738
2. Katz NP, Paillard FC, Ekman E. Determining the clinical importance of treatment benefits for interventions for painful orthopedic conditions. J Orthop Surg Res. Feb 03 2015; 10: 24. PMID 25645576
3. Parker SL, Mendenhall SK, Shau DN, et al. Minimum clinically important difference in pain, disability, and quality of life after neural decompression and fusion for same-level recurrent lumbar stenosis: understanding clinical versus statistical significance. J Neurosurg Spine. May 2012; 16(5): 471-8. PMID 22324801
4. Katz JN. Surgery for lumbar spinal stenosis: informed patient preferences should weigh heavily. Ann Intern Med. Apr 07 2015; 162(7): 518-9. PMID 25844999
5. Zaina F, Tomkins-Lane C, Carragee E, et al. Surgical versus non-surgical treatment for lumbar spinal stenosis. Cochrane Database Syst Rev. Jan 29 2016; 2016(1): CD010264. PMID 26824399
6. Wei FL, Zhou CP, Liu R, et al. Management for lumbar spinal stenosis: A network meta-analysis and systematic review. Int J Surg. Jan 2021; 85: 19-28. PMID 33253898
7. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical versus nonoperative treatment for lumbar spinal stenosis four-year results of the Spine Patient Outcomes Research Trial. Spine (Phila Pa 1976). Jun 15 2010; 35(14): 1329-38. PMID 20453723
8. Lurie JD, Tosteson TD, Tosteson A, et al. Long-term outcomes of lumbar spinal stenosis: eight-year results of the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976). Jan 15 2015; 40(2): 63-76. PMID 25569524
9. Slätis P, Malmivaara A, Heliövaara M, et al. Long-term results of surgery for lumbar spinal stenosis: a randomised controlled trial. Eur Spine J. Jul 2011; 20(7): 1174-81. PMID 21240530
10. Malmivaara A, Slätis P, Heliövaara M, et al. Surgical or nonoperative treatment for lumbar spinal stenosis? A randomized controlled trial. Spine (Phila Pa 1976). Jan 01 2007; 32(1): 1-8. PMID 17202885
11. Amundsen T, Weber H, Nordal HJ, et al. Lumbar spinal stenosis: conservative or surgical management?: A prospective 10-year study. Spine (Phila Pa 1976). Jun 01 2000; 25(11): 1424-35; discussion 1435-6. PMID 10828926
12. Atlas SJ, Keller RB, Wu YA, et al. Long-term outcomes of surgical and nonsurgical management of lumbar spinal stenosis: 8 to 10 year results from the maine lumbar spine study. Spine (Phila Pa 1976). Apr 15 2005; 30(8): 936-43. PMID 15834339
13. Delitto A, Piva SR, Moore CG, et al. Surgery versus nonsurgical treatment of lumbar spinal stenosis: a randomized trial. Ann Intern Med. Apr 07 2015; 162(7): 465-73. PMID 25844995
14. Jung JM, Hyun SJ, Kim KJ, et al. A prospective study of non-surgical versus surgical treatment for lumbar spinal stenosis without instability. J Clin Neurosci. Oct 2020; 80: 100-107. PMID 33099329
15. Kadanka Z, Mares M, Bednaník J, et al. Approaches to spondylotic cervical myelopathy: conservative versus surgical results in a 3-year follow-up study. Spine (Phila Pa 1976). Oct 15 2002; 27(20): 2205-10; discussion 2210-1. PMID 12394893
16. Fehlings MG, Wilson JR, Kopjar B, et al. Efficacy and safety of surgical decompression in patients with cervical spondylotic myelopathy: results of the AOSpine North America prospective multi-center study. J Bone Joint Surg Am. Sep 18 2013; 95(18): 1651-8. PMID 24048552
17. Huang M, Gao X, Cheng J, et al. Laminoplasty versus laminectomy and fusion for multilevel cervical compressive myelopathy: A meta-analysis. Medicine (Baltimore). Jun 2016; 95(23): e03588. PMID 27281067
18. Phan K, Scherman DB, Xu J, et al. Laminectomy and fusion vs laminoplasty for multi-level cervical myelopathy: a systematic review and meta-analysis. Eur Spine J. Jan 2017; 26(1): 94-103. PMID 27342611
19. Singhatanadgige W, Limthongkul W, Valone F, et al. Outcomes following Laminoplasty or Laminectomy and Fusion in Patients with Myelopathy Caused by Ossification of the Posterior Longitudinal Ligament: A Systematic Review. Global Spine J. Nov 2016; 6(7): 702-709. PMID 27781191
20. Ghogawala Z, Terrin N, Dunbar MR, et al. Effect of Ventral vs Dorsal Spinal Surgery on Patient-Reported Physical Functioning in Patients With Cervical Spondylotic Myelopathy: A Randomized Clinical Trial. JAMA. Mar 09 2021; 325(10): 942-951. PMID 33687463
21. Yoshii T, Tomizawa S, Hirai T, et al. Surgical Outcomes in Selective Laminectomy and Conventional Double-Door Laminoplasty for Cervical Spondylotic Myelopathy. Orthopedics. Jul 01 2020; 43(4): e311-e315. PMID 32501516
22. Kotter MRN, Tetreault L, Badhiwala JH, et al. Surgical Outcomes Following Laminectomy With Fusion Versus Laminectomy Alone in Patients With Degenerative Cervical Myelopathy. Spine (Phila Pa 1976). Dec 15 2020; 45(24): 1696-1703. PMID 32890295
23. Zong S, Zeng G, Xiong C, et al. Treatment results in the differential surgery of intradural extramedullary schwannoma of 110 cases. PLoS One. 2013; 8(5): e63867. PMID 23724010
24. Tredway TL, Santiago P, Hrubes MR, et al. Minimally invasive resection of intradural-extramedullary spinal neoplasms. Neurosurgery. Feb 2006; 58(1 Suppl): ONS52-8; discussion ONS52-8. PMID 16479629
25. Sattari SA, Ghanavatian M, Feghali J, et al. Anterior cervical discectomy and fusion versus posterior decompression in patients with degenerative cervical myelopathy: a systematic review and meta-analysis. J Neurosurg Spine. Feb 24 2023: 1-13. PMID 36840737
26. Nakashima H, Tetreault L, Nagoshi N, et al. Comparison of Outcomes of Surgical Treatment for Ossification of the Posterior Longitudinal Ligament Versus Other Forms of Degenerative Cervical Myelopathy: Results from the Prospective, Multicenter AOSpine CSM-International Study of 479 Patients. J Bone Joint Surg Am. Mar 02 2016; 98(5): 370-8. PMID 26935459
27. Kommu R, Sahu BP, Purohit AK. Surgical outcome in patients with cervical ossified posterior longitudinal ligament: A single institutional experience. Asian J Neurosurg. 2014; 9(4): 196-202. PMID 25685216
28. Lee CH, Jahng TA, Hyun SJ, et al. Expansive Laminoplasty Versus Laminectomy Alone Versus Laminectomy and Fusion for Cervical Ossification of the Posterior Longitudinal Ligament: Is There a Difference in the Clinical Outcome and Sagittal Alignment?. Clin Spine Surg. Feb 2016; 29(1): E9-15. PMID 25075990
29. Yu H, Li X, Chen S, et al. Comparative Effectiveness and Safety of Anterior Cervical Corpectomy with Fusion, Laminoplasty, and Laminectomy and Instrumented Fusion for Ossification of the Posterior Longitudinal Ligament: A Systematic Review and Network Meta-Analysis. J Invest Surg. Mar 2022; 35(3): 667-676. PMID 33472478
30. Cao B, Chen J, Yuan B, et al. Comparison of the outcome after anterior cervical ossified posterior longitudinal ligament en bloc resection versus posterior total laminectomy and fusion in patients with ossification of the cervical posterior longitudinal ligament: a prospective randomized controlled trial. Bone Joint J. Mar 15 2023; 105-B(4): 412-421. PMID 36924177
31. Mo K, Gupta A, Laljani R, et al. Laminectomy Versus Laminectomy with Fusion for Intradural Extramedullary Tumors: A Systematic Review and Meta-Analysis. World Neurosurg. Aug 2022; 164: 203-215. PMID 35487493
32. Byvaltsev V, Polkin R, Kalinin A, et al. Laminoplasty versus Laminectomy in the Treatment of Primary Spinal Cord Tumors in Adult Patients: A Systematic Review and Meta-analysis of Observational Studies. Asian Spine J. Jun 2023; 17(3): 595-609. PMID 36717092
33. Piccolo R, Passanisi M, Chiaramonte I, et al. Cervical spinal epidural abscesses. A report on five cases. J Neurosurg Sci. Mar 1999; 43(1): 63-7. PMID 10494668
34. El-Hajj VG, Singh A, Pham K, et al. Long-term outcomes following surgical treatment of spinal arachnoid cysts: a population-based consecutive cohort study. Spine J. Dec 2023; 23(12): 1869-1876. PMID 37604309
35. North American Spine Society. Evidence-based clinical guidelines for multidisciplinary spine care. Diagnosis and treatment of lumbar spinal stenosis. 2011. Available at: https://www.spine.org/Portals/0/assets/downloads/ResearchClinicalCare/Guidelines/LumbarStenosis.pdf. Accessed May 6, 2024.
36. Kreiner DS, Shaffer WO, Baisden JL, et al. An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (update). Spine J. Jul 2013; 13(7): 734-43. PMID 23830297

CODES

Applicable Modifiers

As per correct coding guidelines

Policy History