Description
General Information

• It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted.
• The guideline criteria in the following sections were developed utilizing evidence-based and peer-reviewed resources from medical publications and societal organization guidelines as well as from widely accepted standard of care, best practice recommendations.

Purpose
This guideline outlines the key surgical treatments and indications for common thoracic spinal disorders and is a consensus document based upon the best available evidence. Spine surgery is a complex area of medicine, and this document breaks out the clinical indications by surgical type.

This guideline does not address spinal deformity surgeries or the clinical indications for spinal deformity surgery.

Scope
Spinal surgeries should be performed only by those with extensive and specialized surgical training (neurosurgery, orthopedic surgery). Choice of surgical approach is based on anatomy, pathology, and the surgeon's experience and preference.

Instrumentation, bone formation or grafting materials, including biologics, should be used at the surgeon’s discretion; however, use should be limited to FDA approved indications regarding the specific devices or biologics.

Special Note
In order for surgeries to be considered medically necessary there must be clear medical records that demonstrate a clear surgical plan that matches the request for surgery.
 

BACKGROUND
Thoracic Decompression with or without fusion
Thoracic disc herniation with or without nerve root compression is usually treated conservatively (non-surgically). A back brace may be worn to provide support and limit back motion. Injection of local anesthetic and steroids around the spinal nerve (spinal nerve blocks) may be effective in relieving radicular pain. As symptoms subside, activity is gradually increased. This may include physical therapy and/or a home exercise program. Preventive and maintenance measures (e.g., exercise, proper body mechanics) should be continued indefinitely. Job modification may be necessary to avoid aggravating activities.

Simple laminectomy is rarely used in the treatment of thoracic disc herniation because of the high risk of neurologic deterioration and paralysis. Excision of the disc (discectomy) may be performed via several different surgical approaches –anteriorly, laterally, or transpedicular. Fusion should be performed only if surgery causes instability in the spinal column. Many newer techniques do not usually destabilize the thoracic spine.

Policy
INDICATIONS
All requests for thoracic spine surgery will be reviewed on a case-by-case basis. The following criteria must be met for consideration.

Decompression Surgery Only

• Positive clinical findings of myelopathy with evidence of progressive neurologic deficits consistent with worsening spinal cord compression – immediate surgical evaluation is indicated. Symptoms may include ANY of the following ^(1,2) :
  • Lower extremity weakness
  • Unsteady gait related to myelopathy/balance or generalized lower extremity weakness
  • Disturbance with coordination
  • Hyperreflexia
  • Positive Babinski sign
  • Clonus; OR
• Progressive neurological deficit (motor deficit, bowel or bladder dysfunction) or lower extremity weakness or paralysis with corresponding evidence of spinal cord compression on a magnetic resonance imaging (MRI) or computed tomography (CT) scan images – immediate surgical evaluation is indicated; OR
• When ALL of the following criteria are met:
  • Persistent or recurrent symptoms/pain with functional limitations that are unresponsive to at least 6 consecutive weeks in the last 6 months of documented, physician-directed appropriate conservative treatment to include at least 2 of the following:
    • Analgesics, steroids, and/or NSAIDs
    • Structured program of physical therapy
    • Structured home exercise program prescribed by a physical therapist, chiropractic provider or physician
    • Epidural steroid injections and/or selective nerve root block
  • Imaging studies confirm the presence of spinal cord or spinal nerve root compression at the level corresponding with the clinical findings (MRI or CT)

• For deformity cases – refer to Evolent Clinical Guideline 1760 for Deformity Surgery
• For myelopathy or radiculopathy secondary to cord or root compression (see criteria described above) satisfying the indications for decompressive surgery requiring extensive decompression that results in destabilization of the thoracic spine

NOTE: There is no current evidence base to support fusion in the thoracic spine for degenerative disease without significant neurological compression or significant deformity as outlined above.

NOTE: Cases may not be approved if the below contraindications exist:

• Medical contraindications to surgery: Such as osteoporosis; infection of soft tissue adjacent to the spine, whether or not it has spread to the spine; severe cardiopulmonary disease; anemia; malnutrition, systemic infection, and elevated blood sugar ⁽⁵⁾
• Psychosocial risk factors: It is imperative to rule out non-physiologic modifiers of pain presentation or non-operative conditions mimicking radiculopathy or instability (such as peripheral neuropathy, piriformis syndrome, myofascial pain, sympathetically mediated pain syndromes, sacroiliac dysfunction, psychological conditions, etc.) prior to consideration of elective surgical intervention. ^(5,6) Individuals with clinically significant depression or other psychiatric disorders being considered for elective spine surgery will be reviewed on a case-by-case basis and the surgery may be denied for risk of failure.
• Active Tobacco or Nicotine use prior to fusion surgery. Individuals must be free from smoking and/or nicotine use for at least six weeks prior to surgery and during the entire period of fusion healing. Cessation must be confirmed by a negative cotinine test prior to surgery approval. ^(7,8)
• Morbid obesity: Contraindication to surgery in cases where there is significant risk and concern for improper post-operative healing, post-operative complications related to morbid obesity, and/or an inability to participate in post-operative rehabilitation. ^(9,10) These cases will be reviewed on a case-by-case basis and may be denied given the risk of failure.

NOTE: Cases of severe myelopathy and progressive neurological dysfunction may require surgery despite these general contraindications.

Summary of Evidence

Preoperative Maximization to Reduce Complications in Spinal Surgery ⁽³⁾

• Study Design: This is an invited narrative review.
• Target Population: The study focuses on patients undergoing elective spine surgery.
• Key Factors: The review summarizes current literature on modifiable risk factors that can be optimized preoperatively to reduce complications and improve patient-reported outcomes in spinal surgery. These factors include obesity, malnutrition, diabetes, preoperative anemia, vitamin D deficiency, nicotine use, and opioid use.

Clinical characteristics and surgical outcome of thoracic myelopathy caused by ossification of the ligamentum flavum: a retrospective analysis of 85 cases ⁽¹⁾

• Study Design: This is a retrospective comparative study.
• Target Population: The study includes 85 patients with thoracic myelopathy caused by ossification of the ligamentum flavum (OLF) in China.
• Key Factors: The study assesses the safety and effectiveness of posterior decompressive laminectomy and resection of OLF. It identifies important predictors of surgical outcomes, such as the level of OLF, preoperative duration of symptoms, intramedullary signal change on T2-weighted imaging, and preoperative severity of myelopathy.

The incidence and risk factors of postoperative neurological deterioration after posterior decompression with or without instrumented fusion for thoracic myelopathy ⁽²⁾

• Study Design: This is a retrospective study.
• Target Population: The study involves 168 patients with thoracic myelopathy who underwent posterior decompression with or without instrumented fusion.
• Key Factors: The study explores the incidence and risk factors of postoperative neurological deterioration. It identifies several risk factors, including the presence of ossification of the posterior longitudinal ligament combined with OLF, spinal canal occupancy ratio more than 70%, intraoperative bleeding more than 800 mL, and mean arterial pressure less than 81 mm Hg.

Shared Findings:

• Both Li et al 2016 ⁽¹⁾ and Wang et al 2016 ⁽²⁾ highlight the importance of preoperative factors in predicting surgical outcomes. Specifically, they both identify the severity of myelopathy and intramedullary signal changes on T2-weighted imaging as significant predictors.
• All three studies emphasize the importance of optimizing patient conditions preoperatively to improve surgical outcomes and reduce complications. ^(1–3)

Differing Findings:

• Maitra 2020 ⁽³⁾ focuses on a broader range of modifiable risk factors and their optimization to improve patient-reported outcomes in spinal surgery.
• Li et al 2016 ⁽¹⁾ provides a detailed analysis of the clinical features, radiological findings, and surgical outcomes of thoracic myelopathy caused by OLF, emphasizing the effectiveness of posterior decompressive laminectomy and resection of OLF.
• Wang et al 2016 ⁽²⁾ specifically investigates the incidence and risk factors of postoperative neurological deterioration, identifying several intraoperative and preoperative factors that contribute to this complication.

Conclusion:

In summary, while all three studies emphasize the importance of preoperative optimization and identify significant predictors of surgical outcomes, they differ in their specific focus areas and the range of factors they consider. Maitra 2020 provides a broad overview of modifiable risk factors, Li et al 2016 focuses on the clinical and surgical aspects of thoracic myelopathy caused by OLF, and Wang et al 2016 investigates the risk factors for postoperative neurological deterioration.

References

1.       Li Z, Ren D, Zhao Y, et al. Clinical characteristics and surgical outcome of thoracic myelopathy caused by ossification of the ligamentum flavum: a retrospective analysis of 85 cases. Spinal Cord. 2016;54(3):188-196. doi:10.1038/sc.2015.139

2.       Wang H, Ma L, Xue R, et al. The incidence and risk factors of postoperative neurological deterioration after posterior decompression with or without instrumented fusion for thoracic myelopathy. Medicine. 2016;95(49):e5519. doi:10.1097/MD.0000000000005519

3.       Maitra S, Mikhail C, Cho SK, Daubs MD. Preoperative Maximization to Reduce Complications in Spinal Surgery. Global Spine J. 2020;10(1_suppl):45S-52S. doi:10.1177/2192568219882349

4.       Daniels AH, Singh M, Knebel A, et al. Preoperative Optimization Strategies in Elective Spine Surgery. JBJS Rev. 2025;13(2). doi:10.2106/JBJS.RVW.24.00210

5.       Rajaee SS, Kanim LEA, Bae HW. National trends in revision spinal fusion in the USA. Bone Joint J. 2014;96-B(6):807-816. doi:10.1302/0301-620X.96B6.31149

6.       North American Spine Society. Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis. NASS. Published online 2011. doi:https://www.spine.org/Portals/0/Assets/Downloads/ResearchClinicalCare/Guidelines/LumbarStenosis.pdf

7.       Rajesh N, Moudgil-Joshi J, Kaliaperumal C. Smoking and degenerative spinal disease: A systematic review. Brain and Spine. 2022;2. doi:10.1016/j.bas.2022.100916

8.       Nunna RS, Ostrov PB, Ansari D, et al. The Risk of Nonunion in Smokers Revisited: A Systematic Review and Meta-Analysis. Global Spine J. 2022;12(3):526-539. doi:10.1177/21925682211046899

9.       Feeley A, McDonnell J, Feeley I, Butler J. Obesity: An Independent Risk Factor for Complications in Anterior Lumbar Interbody Fusion? A Systematic Review. Global Spine J. 2022;12(8):1894-1903. doi:10.1177/21925682211072849

10.     Cofano F, Perna G Di, Bongiovanni D, et al. Obesity and Spine Surgery: A Qualitative Review About Outcomes and Complications. Is It Time for New Perspectives on Future Researches? Global Spine J. 2022;12(6):1214-1230. doi:10.1177/21925682211022313

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2025 Forward