La. Admin. Code tit. 40 § I-2023

Current through Register Vol. 50, No. 9, September 20, 2024

Section I-2023 - Therapeutic Procedures-Operative

A. All operative interventions must be based upon positive correlation of clinical findings, clinical course, and diagnostic tests. A comprehensive assimilation of these factors must lead to a specific diagnosis with positive identification of pathologic condition(s). It is imperative to rule out non-physiologic modifiers of pain presentation or non-operative conditions mimicking radiculopathy or instability (e.g., peripheral neuropathy, piriformis syndrome, myofascial pain, scleratogenous or sympathetically mediated pain syndromes, sacroiliac dysfunction, psychological conditions, etc.) prior to consideration of elective surgical intervention.

B. Operative treatment is indicated when the natural history of surgically treated lesions is better than the natural history for non-operatively treated lesions. All patients being considered for surgical intervention should first undergo a comprehensive neuro-musculoskeletal examination to identify mechanical pain generators that may respond to non-surgical techniques or may be refractory to surgical intervention.

C. While sufficient time allowances for non-operative treatment are required to determine the natural cause and response to non-operative treatment of low back pain disorders, timely decision making for operative intervention is critical to avoid de-conditioning and increased disability (exclusive of "emergent" or urgent pathology such as cauda equina syndrome or associated rapidly progressive neurologic loss).

1. In general, if the program of non-operative treatment fails, operative treatment is indicated when:

a. Improvement of the symptoms has plateaued and the residual symptoms of pain and functional disability are unacceptable at the end of 6 to 12 weeks of active treatment, or at the end of longer duration of non-operative programs for debilitated patients with complex problems; and/or

b. Frequent recurrences of symptoms cause serious functional limitations even if a non-operative active treatment program provides satisfactory relief of symptoms, and restoration of function on each recurrence.

c. Mere passage of time with poorly guided treatment is not considered an active treatment program.

2. Referral for surgical evaluation and treatment. Consultation should be made to an appropriate surgical specialist for surgical evaluation and treatment when operative treatment is considered.

a. The decision and recommendation for operative treatment, and the appropriate informed consent should be made by the operating surgeon.

b. Prior to surgical intervention, the patient and treating physician should identify functional operative goals and the likelihood of achieving improved ability to perform activities of daily living or work activities and the patient should agree to comply with the pre- and post-operative treatment plan and home exercise requirements. The patient should understand the length of partial and full disability expected post-operatively.

D. Surgical workup and implementation for simple decompression of patients with herniated nucleus pulposus and sciatica should occur within 6 to 12 weeks after injury at the latest, within the above stated contingencies. For patients with true, refractory mechanical low back pain in whom fusion is being considered, it is recommended that a decisive commitment to surgical or non-surgical interventions occur within 5 months following injury, at the latest.

E. Spinal decompression surgeries and fusion have re-operation rates of approximately 10 percent or more over the following five years. Re-operation is indicated only when the functional outcome following the re-operation is expected to be better, within a reasonable degree of certainty, than the outcome of other non-invasive or less invasive treatment procedures. "Functional outcomes" refer to the patient's ability to improve functional tolerances such as sitting, standing, walking, strength, endurance, and/or vocational status. While timely surgical decision-making is critical to avoid de-conditioning and increased disability, a time limited trial of reconditioning should be tried prior to re-operation. Re-operation has a high rate of complications and failure and may lead to disproportionately increased disability.

F. Every post-operative patient should be involved in an active treatment program. (Refer to Therapeutic Procedures-Non-Operative. Interdisciplinary interventions should be strongly considered post-operatively in any patient not making functional progress within expected time frames. (Refer to Interdisciplinary Programs) Return to work restrictions should be specific according to the recommendations in Return to Work. Most non-fusion surgical patients can return to a limited level of duty between 3 to 6 weeks. Full activity is generally achieved between 6 weeks to 6 months depending on the procedure and healing of the individual.

G. Lumbar Operative Procedures and Conditions:

1. Discectomy

a. Description: To enter into and partially remove the disc.

b. Complications. Appropriate medical disclosures should be provided to the patient as deemed necessary by the physician.

c. Surgical Indications. To include all of the following: Primary radicular symptoms, radiculopathy on exam, correlating imaging study, and failure of non-surgical care. There is good evidence that surgery provides initial improvement of radicular symptoms with respect to chronic low back pain. There is conflicting evidence that the long-term outcome differs from that of the natural history of healing.

d. Operative Treatment: Partial Discectomy and Root Decompression

e. Post-Operative Therapy. A formal physical therapy program should be implemented post-operatively. Active treatment, which patients should have had prior to surgery, will frequently require a repeat of the sessions previously ordered.

2. Percutaneous Discectomy

a. Description. Percutaneous discectomy is an invasive operative procedure to accomplish partial removal of the disc through a needle which allows aspiration of a portion of the disc trocar under imaging control.

b. Complications. Appropriate medical disclosures should be provided to the patient as deemed necessary by the treating physician.

c. Surgical Indications. Percutaneous discectomy is indicated only in cases of suspected septic discitis in order to obtain diagnostic tissue. The procedure is not recommended for contained disc herniations or bulges with associated radiculopathy due to lack of evidence to support long-term improvement.

d. Operative Treatment: Partial Discectomy

3. Laminotomy/Laminectomy/Foramenotomy/ Facetectomy

a. Description. These procedures provide access to produce neural decompression by partial or total removal of various parts of vertebral bone.

b. Complications. Appropriate medical disclosures should be provided to the patient as deemed necessary by the treating physician.

c. Surgical Indications include all of the following: Primary radicular symptoms, radiculopathy and radiculitis on exam, correlating imaging study, and failure of non-surgical care.

d. Operative Treatment. Laminotomy, and/or partial discectomy and root decompression.

e. Post-Operative Therapy. A formal physical therapy program should be implemented post-operatively. Active treatment, which patients should have had prior to surgery, will frequently require a repeat of the sessions previously ordered. The implementation of a gentle aerobic reconditioning program (e.g., walking) and back education within the first post-operative week is appropriate in uncomplicated post-surgical cases. Some patients may benefit from several occupational therapy visits to improve performance of ADLs. Participation in an active therapy program which includes restoration of ROM, core stabilization, strengthening, and endurance is recommended to be initiated 3-6 weeks post-operatively. The goals of the therapy program should include instruction in a long-term home based exercise program. (Refer to Active Therapy.)

4. Lamino tomy/Laminectomy/Foramenotomy / Facetectomy for Central or Lateral Spinal Stenosis

a. Description - these procedures provide access to produce neural decompression by partial or total removal of various parts of spinous elements.

b. Complications-appropriate medical disclosures should be provided to the patient as deemed necessary by the treating physician.

c. Surgical indications include all of the following: radicular symptoms or symptoms of neurogenic claudication on exam, and failure of non-surgical care.

i. The non-operative improvement appears to be less likely for stenosis than for herniated discs.

d. Operative Treatment-laminotomy, laminectomy root decompression, and excision of synovial cyst.

e. Post-Operative Therapy-a formal physical therapy program should be implemented post-operatively. Active treatment, which patients should have had prior to surgery, will frequently require a repeat of the sessions previously ordered. The implementation of a gentle aerobic reconditioning program (e.g., walking) and back education within the first post-operative week is appropriate in uncomplicated post-surgical cases. Some patients may benefit from several occupational therapy visits to improve performance of ADLs. Participation in an active therapy program which includes restoration of ROM, core stabilization, strengthening, and endurance is recommended to be initiated three to six weeks post-operatively. The goals of the therapy program should include instruction in a long-term home based exercise program. (Refer to Therapy-Active).

5. Spinal Fusion

a. Description. Use of bone grafts, sometimes combined with metal devices, to produce a rigid connection between two or more adjacent vertebrae.

b. Complications. Appropriate medical disclosures should be provided to the patient as deemed necessary by the treating physician.

c. Surgical Indications. A timely decision-making process is recommended when considering patients for possible fusion. For chronic low back problems, fusion should not be considered within the first five months of symptoms, except for fracture or dislocation.

i. Although there is a statistical correlation between successful radiographic fusion and a good functional outcome, the relationship is not strong in the first two years. However, a recent observational study appears to indicate clinical deterioration in patients with unsuccessful radiographic fusion at an average of seven years post-operatively. There is good evidence that instrumented fusion, compared to non-instrumented fusion, produces a slightly better radiographically-confirmed bony union, with small to moderate functional advantages. Studies of surgical procedures report higher rates of complications with instrumented fusion.

ii. There is good evidence that intensive exercise for approximately 25 hours per week for four weeks combined with cognitive interventions emphasizing the benefits of maintaining usual activity, produces functional results similar to those of posterolateral fusion after one year. There is some evidence that lumbar fusion produces better symptomatic and functional results in patients with chronic non-radicular pain when several months of conservative treatment have not produced a satisfactory outcome. Fusions associated with decompression are more likely to reduce leg pain.

iii. Recombinant human bone morphogenetic protein (rhBMP-2) is a member of a family of cytokines capable of inducing bone formation. It is produced from genetically modified cell lines using molecular cloning techniques. At the time of this guideline writing, rhBMP-2 is FDA approved for use in anterior lumbar interbody fusion (ALIF) and is used with a carrier such as a collagen sponge or other matrix, and a cage. There is some evidence that anterior interbody cage fusion using rhBMP-2 results in shorter operative time compared with the use of iliac crest bone autograft. Minor pain at the iliac crest donor site may persist for 24 months or longer in approximately 30 percent of patients who undergo an autograft procedure. RhBMP-2 avoids the need for harvesting iliac crest donor bone and can therefore, avoid this complication of persistent pain. There is a potential for patients to develop sensitizing or blocking antibodies to rhBMP-2 or to the absorbable collagen sponge. The long-term effects are unknown. The rhBMP-2 used with the interbody fusion device is contraindicated for patients with a known hypersensitivity to Recombinant Human Bone Morphogenetic Protein -2, bovine type 1 collagen, or to other components of the formulation. Use of rhBMP-2 outside the anterior cage may carry a risk of swelling and ectopic bone formation which can encroach on neurovascular structures. At the time of this guideline writing, it is still investigational. Information concerning safe and effective dosing and application are being submitted to the FDA. All other applications are considered off-label and not FDA approved. There is insufficient information to form a recommendation with instrumentation other than the cage specifically designed for anterior procedures. If the FDA approves its use for other operative approaches, prior authorization is required. The patient must meet all indications on the device manufacturer's list and have no contraindications. The formation of exuberant or ectopic bone growth at the upper levels (L2-L4) may have a deleterious impact on certain neurovascular structures, such as the aorta and sympathetic nerve chain. There are also reports of osteoclastic activity with the use of rhBMP-2.

d. Indications for spinal fusion may include:

i. neural arch defect - spondylolytic spondylolisthesis, congenital unilateral neural arch hypoplasia;

ii. segmental instability - excessive motion, as in degenerative spondylolisthesis, surgically induced segmental instability;

iii. primary mechanical back pain/functional spinal unit failure - multiple pain generators objectively involving two or more of the following:

(a). internal disc disruption (poor success rate if more than one disc involved);

(b). painful motion segment, as in annular tears;

(c). disc resorption;

(d) facet syndrome; and/or

(e). ligamentous tear;

iv. revision surgery for failed previous operation(s) if significant functional gains are anticipated;

v. infection, tumor, or deformity of the lumbosacral spine that cause intractable pain, neurological deficit, and/or functional disability.

e. Pre-operative Surgical Indications: Required pre-operative clinical surgical indications for spinal fusion include all of the following:

i. all pain generators are adequately defined and treated; and

ii. all physical medicine and manual therapy interventions are completed; and

iii. x-ray, MRI, or CT/Discography demonstrate disc pathology or spinal instability; and

iv. spine pathology is limited to two levels; and

v. psychosocial evaluation with confounding issues addressed;

vi. for any potential fusion surgery, it is recommended that the injured worker refrain from smoking for at least six weeks prior to surgery and during the period of fusion healing. Because smokers have a higher risk of non-union and higher post-operative costs, it is recommended that insurers cover a smoking cessation program peri-operatively.

f. Operative Therapy. Operative procedures may include:

(a). intertransverse fusion;

(b). anterior fusion (with or without rhBMP-2) - generally used for component of discogenic pain where there is no significant radicular component requiring decompression;

(c). posterior interbody fusion - generally used for component of discogenic pain where posterior decompression for radicular symptoms also performed; or

(d). anterior/posterior (360 °) Fusion - most commonly seen in unstable or potentially unstable situations or non-union of a previous fusion.

g. Post-Operative Therapy. A formal physical therapy program should be implemented post-operatively. Active treatment, which patients should have had prior to surgery, will frequently require a repeat of the sessions previously ordered. The implementation of a gentle aerobic reconditioning program (e.g., walking), and back education within the first post-operative week is appropriate in uncomplicated post-surgical cases. Some patients may benefit from several occupational therapy visits to improve performance of ADLs. Participation in an active therapy program which includes core stabilization, strengthening, and endurance is recommended to be initiated once the fusion is solid and without complication. The goals of the therapy program should include instruction in a long-term home based exercise program. (Refer to Active Therapy).

h. Return-to-Work. Barring complications, patients responding favorably to spinal fusion may be able to return to sedentary-to-light work within 6 to 12 weeks post-operatively, light-to-medium work within six to nine months post-operatively and medium-to-medium/heavy work within 6 to 12 months post-operatively. Patients requiring fusion whose previous occupation involved heavy-to-very-heavy labor should be considered for vocational assessment as soon as reasonable restrictions can be predicted. The practitioner should release the patient with specific physical restrictions and should obtain a clear job description from the employer, if necessary. Once an injured worker is off work greater than six months, the functional prognosis with or without fusion becomes guarded for that individual.

6. Sacroiliac Joint Fusion

a. Description. Use of bone grafts, sometimes combined with metal devices, to produce a rigid connection between two or more adjacent vertebrae providing symptomatic instability as a part of major pelvic ring disruption.

i. Identifying the SI joint as the pain generator is challenging due to the multifactorial nature of low back pain. Once confirmed, management may include physical or manual therapy with a focus on core and pelvic stability, external orthodtics, periodic intra-articular injections, antiinflammatory medications, and life style changes including smoking cessation and weight loss.

b. Complications. Instrumentation failure, bone graft donor site pain, in-hospital mortality, deep infection, superficial infection, and graft extrusion.

c. General Requirements.

i. Conservative management should include all of the following:

(a). activity modification;

(b). active therapeutic exercise program, physical therapy, or manual therapy;

(c). anti-inflammatory medications and analgesics; and

(d). cortcosteroid injection.

ii. Tobacco cessation. a tobacco-cessation program resulting in abstinence from tobacco for at least six weeks prior to surgery is recommended.

iii. Body Mass Index (BMI). Patient with a BMI equal to or greater than 40 should attempt weight loss prior to surgery.

d. Indications and Criteria.

i. Percutaneous/Minimally Invasive SI Joint Fusion may be considered medically necessary when all of the following criteria are met:

(a). persistent pain with a VAS of 5 or greater for more than six months' duration that interferes with functional activities;

(b). failure of conservative management for at least six months;

(c). confirmation of the SI joint as a pain generator as demonstrated by all of the following:

(i). pain pattern consistent with SI joint pain;

(ii). positive finger Fortin test (tenderness over the sacral sulcus);

(iii). lack of tenderness elsewhere in the pelvic region;

(iv). positive result from at least three provocative tests:

[a]. long ligament test;

[b]. Faber's test/Patrick's sign;

[c]. active straight leg raise;

[d]. compression test;

[e]. distraction test;

[f]. thigh thrust test; or

[g]. Gaenslen's test;

(v). and other sources of pain have been excluded as a cause;

(d). diagnostic studies that include all of the following:

(i). imaging (plain radiographs and a CT) orMRIoftheSIjoint;

(ii). AP plain radiograph of the pelvis to exclude hip pathology;

(iii). CT or MRI of the lumbar spine to rule out neural compression or other degenerative condition;

(iv). imaging of SI joint that indicates evidence of injury and/or degeneration;

(e). and confirmation of the SI joint as the pain generator. This can be demonstrated by at least 50 percent reduction of pain for the expected duration of the anesthestic utilized following an intra-articular SI joint injection. This must be done on two separate occasions.

e. Exclusions

i. Indications other than those addresses in this section are considered not medically necessary, including but not limited to the following:

(a). presence of infection, tumor, or fracture;

(b). acute, traumatic instability of the SI joint;

(c). presence of compression that correlates with symptoms or other more likely source of pain;

(d). generalized pain behavior such as somotoform disorder or generalized pain disorders like fibromyalgia; or

(e). ankylosing spondylitis or rheumatoid arthritis.

7. Implantable spinal cord stimulators are reserved for those low back pain patients with pain of greater than six months duration who have not responded to the standard non-operative or operative interventions previously discussed within this document. Refer to OWCA's Chronic Pain Disorder Medical Treatment Guidelines.

8. Laser discectomy involves the delivery of laser energy into the center of the nucleus pulposus using a fluoroscopically guided laser fiber under local anesthesia. The energy denatures protein in the nucleus, causing a structural change which is intended to reduce intradiscal pressure. Its effectiveness has not been shown. Laser discectomy is not recommended.

9. Artificial Lumbar Disc Replacement

a. Description. This involves the insertion of a prosthetic device into an intervertebral space from which a degenerated disc has been removed, sparing only the peripheral annulus. The endplates are positioned under intraoperative fluoroscopic guidance for optimal placement in the sagittal and frontal planes. The prosthetic device is designed to distribute the mechanical load of the vertebrae in a physiologic manner and maintain range of motion.

i. General selection criteria for lumbar disc replacement includes symptomatic one-level degenerative disc disease. The patient must also meet fusion surgery criteria, and if the patient is not a candidate for fusion, a disc replacement procedure should not be considered. Additionally, the patient should be able to comply with pre-and post-surgery protocol.

ii. The theoretical advantage of total disc arthroplasty is that it preserves range of motion and physiologic loading of the disc. This could be an advantage for adults who are physically active. Studies do not demonstrate a long-term advantage of measured function or pain over comparison groups undergoing fusion. The longevity of this prosthetic device has not yet been determined. Significant technical training and experience is required to perform this procedure successfully. Surgeons must be well-versed in anterior spinal techniques and should have attended appropriate training courses, or have undergone training during a fellowship. Mentoring and proctoring of procedures is highly recommended. Reasonable pre-operative evaluation may include an angiogram to identify great vessel location. The angiogram may be either with contrast or with magnetic resonance imaging. An assistant surgeon with anterior access experience is required.

b. Complications:

i. nerve and vascular injury;

ii. dural tears;

iii. sexual dysfunction (retrograde ejaculation);

iv. mal-positioning of the prosthesis;

v. suboptimal positioning of the prosthetic may compromise the long-term clinical result;

vi. Complex Regional Pain Syndrome (CRPS);

vii. complications from Abdominal Surgery, (e.g., hernia or adhesions);

viii. re-operation due to complications;

ix. appropriate medical disclosures should be provided to the patient as deemed necessary by the treating physician.

c. Surgical Indications:

i. symptomatic one-level degenerative disc disease established by objective testing (CT or MRI scan followed by positive provocation discogram);

ii. symptoms unrelieved after six months of active non-surgical treatment;

iii. all pain generators are adequately defined and treated;

iv. all physical medicine and manual therapy interventions are completed;

v. spine pathology limited to one level;

vi. psychosocial evaluation with confounding issues addressed.

d. Contraindications:

i. significant spinal deformity/scoliosis;

ii. facet joint arthrosis;

iii. spinal instability;

iv. deficient posterior elements;

v. infection;

vi. any contraindications to an anterior abdominal approach (including multiple prior abdominal procedures);

vii. evidence of nerve root compression, depending on the device used;

viii. previous compression or burst fracture ;

ix. multiple-level degenerative disc disease (DDD);

x. spondylolysis;

xi. spondylolisthesis greater than 3 mm;

xii. osteoporosis or any metabolic bone disease;

xiii. chronic steroid use or use of other medication known to interfere with bone or soft tissue healing;

xiv. autoimmune disorder;

xv. allergy to device components/materials;

xvi. depending on the device selected, pregnancy or desire to become pregnant;

xvii. morbid obesity (e.g., body/mass index [BMI] of greater than 40, over 100 pounds overweight);

xviii. active malignancy.

e. Post-Operative Therapy. Bracing may be appropriate. A formal physical therapy program should be implemented post-operatively. Active treatment, which patients should have had prior to surgery, will frequently require a repeat of the sessions previously ordered. The implementation of a gentle aerobic reconditioning program (e.g., walking) and back education within the first post-operative week is appropriate in uncomplicated post-surgical cases. Some patients may benefit from several occupational therapy visits to improve performance of ADLs. Participation in an active therapy program which includes restoration of ROM, core stabilization, strengthening, and endurance is recommended to be initiated at the discretion of the surgeon. Lifting and bending are usually limited for several months at least. Sedentary duty may be able to begin within six weeks in uncomplicated cases. The goals of the therapy program should include instruction in a long-term home based exercise program. (Refer to Active Therapy.)

10. Kyphoplasty

a. Description. A surgical procedure for the treatment of symptomatic thoracic or lumbar vertebral compression fractures, most commonly due to osteoporosis or other metabolic bone disease, and occasionally with post-traumatic compression fractures and minor burst fractures that do not significantly compromise the posterior cortex of the vertebral body. Pain relief can be expected in approximately 90 percent of patients. Vertebral height correction is inconsistent, with approximately 35 percent to 40 percent of procedures failing to restore height or kyphotic angle.

b. Complications. Cement leakage occurs in approximately nine percent of kyphoplasties and may cause complications. New vertebral compression fracture may occur following kyphoplasty, but their occurrence does not appear to exceed that of osteoporotic patients who did not receive treatment.

c. Operative Treatment. Kyphoplasty involves the percutaneous insertion of a trocar and inflatable balloon or expanding polymer into the vertebral body, which re-expands the body, elevating the endplates and reducing the compression deformity. Polymethylmethacrylate (PMMA) bone cement is injected under low pressure into the cavity created by the balloon inflation. In contrast to vertebroplasty, which introduces PMMA cement under high pressure, the space created by balloon inflation allows a higher viscosity PMMA to be injected under lower pressure, which may reduce the risks associated with extravertebral extravasation of the material. There may be an advantage to performing the procedure within one month of the fracture, since the elevation of the endplates may be more readily achieved than when the procedure is delayed.

d. Surgical Indications. Kyphoplasty is an accepted treatment for the following indications:

i. compression fracture;

ii. vertebral height loss between 20 percent and 85 percent;

iii. vertebral height restoration. Kyphoplasty is more likely to increase vertebral height if performed within 30 days of fracture occurrence.

e. Contraindications:

i. the presence of neurologic compromise related to fracture;

ii. high-velocity fractures with a significant burst component;

iii. significant posterior vertebral body wall fracture;

iv. severe vertebral collapse (vertebra plana);

v. infection, and

vi. coagulopathy.

11. Vertebroplasty

a. Description vertebroplasty is a procedure for the treatment of painful thoracic and lumbar vertebral compression fractures caused by osteoporosis or other metabolic bone disease. Polymethylmethacrylate (PMMA) bone cement is injected with high pressure into the vertebral body via an 11- to 13-gauge needle, with the goal of stabilizing the spine and relieving pain. The procedure does not correct spinal deformity. Pain relief can be expected in approximately 90 percent of patients. Vertebral height correction is inconsistent, with approximately 35 percent to 40 percent of procedures failing to restore height or kyphotic angle.

b. Complications

i. Because the bone cement is of low viscosity, its injection under pressure frequently results in extravertebral extravasation of the material, with rare serious complications such as pulmonary embolism. Cement leakage alone occurs in approximately 40 percent of vertebroplasties.

ii. New vertebral compression fractures may occur following vertebroplasty, but their occurrence does not appear to exceed that of osteoporotic patients who did not receive treatment.

c. Indications:

i. compression fracture of preferably less than 30 days;

ii. vertebral height loss between 20 percent and 85 percent;

iii. intact posterior wall.

d. Contraindications:

i. the presence of neurologic compromise related to the fracture;

ii. high velocity fractures with a significant burst component;

iii. posterior vertebral body wall fracture;

iv. severe vertebral collapse (vertebra plana); and

v. infection; and

vi. coagulopathy.

12. Percutaneous radiofrequency disc decompression is an investigational procedure which introduces a 17 gauge cannula under local anesthesia and fluoroscopic guidance into the nucleus pulposus of the contained herniated disc, using radiofrequency energy to dissolve and remove disc material. Pressure inside the disc is lowered as a result. There have been no randomized clinical trials of this procedure at this time. Percutaneous radiofrequency disc decompression is not recommended.

13. Nucleus pulposus replacement involves the introduction of a prosthetic implant into the intervertebral disc, replacing the nucleus while preserving the annulus fibrosus. It is limited to investigational use in the United States at this time. It is not recommended.

14. Epiduroscopy and Epidural Lysis of Adhesions (Refer to Injections-Therapeutic).

15. Intraoperative neurophysiologic monitoring (IONM) is a battery of neurophysiologic tests used to assess the functional integrity of the spinal cord, nerve roots, and other peripheral nervous system structures (eg, brachial plexus) during spinal surgery. The underlying principle of IONM is to identify emerging insult to nervous system structures, pathways, and/or related vascular supply and to provide feedback regarding correlative changes in neural function before development of irreversible neural injury. IONM data provide an opportunity for intervention to prevent or minimize postoperative neurologic deficit. Current multimodality monitoring techniques permit intraoperative assessment of the functional integrity of afferent dorsal sensory spinal cord tracts, efferent ventral spinal cord tracts, and nerve roots. Combined use of these techniques is useful during complex spinal surgery because these monitoring modalities provide important complementary information to the surgery team. Intraoperative neurophysiologic monitoring should be used during spinal surgery when information regarding spinal cord and nerve root function is desired. The appropriate diagnostic modality for the proposed surgical intervention should be utilized at the discretion of the surgeon.

16. Non-invasive electrical bone growth stimulators may be considered:

a. as an adjunct to spinal fusion surgery for those at high risk for pseudoarthrosis, including one or more of the following fusion failure risk factors:

i. one or more previous failed spinal fusion(s);

ii. grade II or worse spondylolisthesis;

iii. fusion to be performed at more than one level;

iv. presence of other risk factors that may contribute to non-healing:

(a). current smoking;

(b). diabetes;

(c). renal disease;

(d). other metabolic diseases where bone healing is likely to be compromised (e.g.: significant osteoporosis);

(e). active alcoholism;

(f). morbid obesity BMI 40;

b. as treatment for individuals with failed spinal fusion. Failed spinal fusion is defined as a spinal fusion that has not healed at a minimum of six months after the original surgery, as evidenced by serial x-rays over a course of three months during the latter portion of the six month period;

c. no strict criteria for device removal are suggested in the literature. Implanted devices are generally removed only when the patient complains of discomfort, when there is device malfunction, or to allow for future ability to use MRI. Removal of batteries is not recommended unless there is a device malfunction or other complication.

La. Admin. Code tit. 40, § I-2023

Promulgated by the Louisiana Workforce Commission, Office of Workers Compensation Administration, LR 37:1676 (June 2011), amended by the Louisiana Workforce Commission, Office of Workers Compensation, LR 40:1151 (June 2014), Amended LR 461256 (9/1/2020).

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1203.1.