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,J ( 1.-DISLOCATION OF SHOULDER (831); RECURRENT (7J8~31)
I
RESTRICT-IONS/DEFER
RATIONALE
lGe~rlcInformation;
Ortt~pedlstevaluationIf recurrent.
I
N/A
,CLEARWITH
RE~TRICTIONS
-+ 1) Recurrent ( > 2) dislocations.
-+ 2) Period of < 6 mos. post-surgical repair.
~ N/A
,DEFER MNQ
UNTil:
1) Norecurrence,postsurgery6mos.or 2 yrs.withoutsurgery
2) Periodof 6 mos.posl op.;norecurrence.
MEDICALINFORMATIONNEEDED:
OrthopedicsORTHO-13
5/4/93
CRITERIA 1-+1) Singleepisode, no 1-+recurrence.
2) Norecurrentepisodes,las 2 yrs.,surgerynotrecbmmended.
3) No.recurrenlepisode,6 mos.pO:ltsurgicalrepair
,
ACTION i CLEAR
CRITERIA
ACTION
RESTRICT.IONS/DEFER
RATIONALE
ISIlOULJ)I~n: nOTATOn CUI"I"INJUnV (126.1)AND IU~I)Allt (83.63)
IMI'INGI~MENT SVNDnOMI~ j\NO REPAIR (726.2). .
I'~ 1) SingleJplsode,
asym,romalic1 yr.
~ 2) Surgilal repair 6 mos. posl,no dlmljllty.
3) Recur.nl symploms 01ImplnJhmenr, activity relatedand 2Ioldable.
~ N/A ~ 1) SymptomaticwithADLs.
-.. 2) Surgery advised, or < 6 mos.pas I surgery.
DEFERUNTIL:
1) Meets "Clear" criteria.
2) Post surgery 6 mos.
!~ N/A
,
4) Surgbal repair of either cuffor Irn/ngement with residualstabh Impairment.
MNQ
MEDICALINFORMATIONNEEDED:
OrthOP.dIC~~.
+CLEAR CLEARWITH
RESTRICTIONS
GenericInformation;
Or\hopedlstevaluationfor recurrentor chronic.
ORTHO-14
~.
5/4193
("
//
/
. ('---
BACK PAIN (847); MUSCLE STRAIN (847); SPRAIN (847); SCOLIOSIS (737.43);NECK PAIN (723.1) (excludes radiculopathy, osteoarthritis, or any more specific diagnosis)
I
CRITERIA
ACTION
RESTRICT-IONS/DEFER
RATIONALE
~ Single episode resolvedoccasional mild episodesrelieved with non-narcoticanalgesic; no Hx radicularinvolvement ( pain belowknee, numbness or tinglingsee ORTHO-16) (app. verbalHx OK).
~ N/A ~ Frequent and/or severe episodes H N/A
+ + + +CLEAR CLEAR WITH
RESTRICTIONSDEFER MNQ
A~ute 19Wback pain is usuallydue to muscle strain, tear, orsprain. These tend to resolve,but can become chronic.
UNTIL:Orthopedic Evaluation.
Until < 150% of ideal bodyweight and meets "Clearcriteria". Successfullymanaged (exercise, wI. loss,etc.). Physical abilities letter.
.. See weight guideline
MEDICALINFORMATIONNEEDED:
Orthopedics
Generic information;
RIO Hx radicular involvement if any symptoms within 4 years (see ORTHO-16 if any signs or symptoms of radicular involovement)
7/17/95
ORTHO-15
DEGENERATIVEDISCDISEASE ORTHO16
IncludesHemiated,Prolapsed,andRupturedInterVertebralDiscs.IncludesMicordiscectomy,Disectomy,Laminectomy,andDiscFusion.
IncludesSpinalStenosis.
AllApplicants:. ReportofMedicalExaminationto includethefollowing:DateofdiagnosisDescriptionofsymptomsattimeofdiagnosisCurrentstatusto includedescriptionofcurrentsymptomsTreatmenthistoryto includemedications,physicaltherapy,surgery,etcFormedications,includepastandcurrentuse.Historyofrecurrence(s)LimitationsorrestrictionsofADLs
Recommendationsforfollow-upoverthenext3years. SpecialistEvaluation(OrthopedistorNeurologist)if initialdiagnosis,symptoms,orsurgerywithinthepast3years;toincludetheinformationabove.
IfApplicable:. Ifdone,copyofMRIreportand/orotherradiographicordiagnosticstudiesDischargesummaryforallrelatedsurgeriesandhospitalizations.
~.
. .,
(continued on next page)
Effective 2/19/2004 Page 1 of 5
DEGENERATIVEDISCDISEASE ORTHO16
..:"."N .
... . .Associatedspir" " ". . . .
'Doesnotmeetclear.~ncfrcrit~ria'd~. .... .. .
... "..'Symptoms;ipast:orcurrent;:incl.
. .constitution~lsyrnptOinsi;e;g.;.j1
722.2 Herniated,RupturedorProlapsedInterVertebralDisc
CrossReferenceICD.9CM
:eviewerstoConsider:. NA
Goetz:Textbookof ClinicalNeurology,2nded.,Copyright@2003Elsevier
EpidemiologyandRiskFactors:Vertebraldiscdegenerativechangesareauniversalaccompanimentofaging.Teenagersrarelydevelopsymptomaticdischerniation.Thepeakincidenceofsymptomsoccursbetweentheagesof30and50.Patientsoftendescribetheonsetoflowbackpain,usuallyremittentandwithoutspecificfeaturesintheirtwenties,perhapsafteridentifiabletrauma,andtheonsetofmorespecificsymptomsthatleadstothediagnosisofdischerniationisoftennotprecededbyfurthertrauma.Probablytheaccumulationofdegenerativechangestotheannulusandthepreservationoftheexpansilegelatinousnucleus,overlappingwithaperiodoflifewhenjobandsports-relatedactivitiesincreasetheamountofmechanicalstressonthebody,accountforthispeakintheincidenceofdisease.Theincidencethenfallsoffintheolderpopulation,probablyduetothelackofmobilityofthedesiccateddiscandtherelativelackofphysicalactivity.Womenandmenareaffectedapproximatelyequally.
Thereis atendencytowarddischemiationinsomefamilies,suchasthosewithcongenitalspinalanomalies,includingfusedandmalformedvertebraeandlumbarspinalstenosisduetoshortpedicles.Patientswithincreasedweightandtallstatureareat increasedriskforthiscondition.Also,acquiredspinaldisorders,suchascommondegenerativearthritisandankylosingspondylitis,predisposetodiscdegeneration.Variousbehaviorsthatincreaseriskincludesedentaryoccupations,physicalinactivity,motorvehicleuse,vibration,andsmoking.Inyoungerwomen,pregnancyanddeliveryareassociatedwithlumbosacralherniation,andnewsymptomsof cervicaldischerniationmayoccurinpartbecauseofthebendingandliftinginvolvedinchildrearing.
Clinical Featuresand Associated Disorders: Themostcommonsite ofdischerniationin thecervicalregionis the C6-C7 level,~ollowedbyC5-C6,C7-T1,andC4-C5. PatientstypicallydevelopsomelocalpainintheneckthatradiatestotheshouldersortheIterscapularregion.In the mostcommonlateralherniations,radicularsymptomsensue.Thesesymptomsincludepainin the shoulder
, and arm,whichmayfollowa dermatomalpattembutmoretypicallyis deepandachingandonlyroughlycorrespondsto the involveddermatome.At the cervicallevels,therootsemergelaterallyto exit throughtheneuralforaminaabovethecorrespondinglynumberedvertebralbodies.Becausethe spinalcordandbonyvertebrallevelsare roughlyalignedin theneck,the levelof herniationcorrespondstothe levelof rootirrttation.Hence,C6-C7herniationaffectstheC7 root.Painmaybeexacerbatedbycoughingor straining.Numbnessismore likelytosupplyreliablelocalizinginformationthanpain.CompressionoftheC6roottypicallycausesnumbnessin the thumband
Effective2/19/2004 Page2 of5
DEGENERATIVEDISCDISEASE ORTHO16
indexfinger,andcompressionoftheC7roottypicallyinvolvestheindexandmiddlefingers.Whencompressionissevere,myotomalweakness,reflexloss,and,withtime,fasciculationsandatrophymayensue.WithC6compression,thebiceps,brachioradialis,pronatorteres,andradialwristextensorsmaybeweak,andthebrachioradialisandbicepsreflexesmaybediminishedorlost.WithC7weakness,thewristandfingerextensorsandthetricepsaretypicallyweak.Thetricepsreflexmayalsobediminishedorlost.WithC8compression,thereisofteninterscapularpainandpaininthemedialaspectofthearmandhandwithweaknessofthehandintrinsicmuscles.Thefingerflexorreflexmaybelost.LesionsaboveC6arelesscommonandareassociatedwithcorrespondinglymoreproximalsensorysymptomsandweakness.LesionsoftheC5rootmaycauseshoulderpainandpainandnumbnessinthelateralaspectoftheupperarm.ManymusclescanbeusedtotesttheC5root,includingtheinfraspinatus,supraspinatus,deltoid,biceps,andsupinator.Lesionsabovethislevelmaycauseneckpainandsensorylossintheneck,supraclaviculararea(C3),andacromioclaviculararea(C4)oftheshoulder.LesionsinvolvingthespinalcordorrootsaboveC4mayparalyzethediaphragmandcauserespiratorycompromise.
Inthelumbosacralregion,themostcommonsiteofherniationistheL5-S1level,followedbytheL4-L5levelandthenhigherlevels.Symptomsoflumbosacralherniationoftenfollowliftingortwistinginjuries,ortheymayresultfromaccumulatedlow-leveltrauma.Paintypicallyoccursintheparasacralareaandradiatestothebuttocks.BelowC8,therootsexitthroughtheneuralforaminabelowthecorrespondinglynumberedvertebralbodies.Inpatientswiththemostcommonposterolateralherniation,dermatomalradicularpaintypicallyoccursatthelevelbelowtheemergingroot,whichusuallyescapesentrapmentabovetheprotrudingdisc.Hence,L5-S1herniationaffectsthe81root.WithposterolateralL5-S1hemiationsand81rootentrapment,thepainradiatestotheposterioraspectofthethighand,especiallywhentherootisstretched,intotheposterolaterallowerleg,lateralheel,andsole.Thispatterncanbedemonstratedbystraight-legraising,inwhichthesmallertheangleofelevationrequiredtoelicitpain,thegreaterthesuggestionthatrootcompressionisresponsible.Characteristicpainonelevationoftheoppositelegmaybeevenstrongerevidenceofrootcompression.Somepatientswithsymptomsthatareexacerbatedbyroottractionavoidfullweightbearingontheheeloftheinvolvedside,standingwiththekneeflexedandtheheeloffthefloor.Whenpainislesssevere,symptomsmaybeelicitedbyhavingthepatientwalkontheheels.Numbnessisfeltintheposterolateralleg,lateralaspectoftheheel,andthesoleofthefoot.Thegastrocnemiusandhamstringsmaybeweak,andtheanklejerkmaybediminishedorlost.MorelateralherniationoftheL5-S1discorherniationoftheL4-L5discmayentraptheL5root.Herethepainmaybesimilar,withadjustmentofthefindingstofit theL5dermatomeandmyotome.Numbnessismostmarkedonthedorsumofthefoot.Weakmusclesincludethefootelevators(tibialisanteriorgroup),everters(peronei),andinvertors(tibialisposterior),andthetoeextensors(extensorhallucislongus).Herniationsathigherlevelsinthelumbosacralregioncausepainanddeficitsthatcorrespondtotherootsinvolved.
Inadditiontotheseradicularsyndromes,patientswithcentralherniationsinthecervicalorthoracicregionmaydeveloppainandacutemyelopathicsymptomswithspasticityandquadriparesisorparaparesis,sensorylossatorbelowthesegmentaldermatomeofthelesion,hyperactivereflexes,andBabinski'ssigns.Soonafteranacutelesiondevelops,thereflexesmaydiminishbecauseofspinalshock.Patientswithlumbosacralcentralherniationmaydevelopacutecompressionofthecaudaequina.Thiscausesradicularpain,paresthesias,andsensorylossreferabletomultiplebilateralroots,bilaterallegweakness,andlossofthelowerextremityreflexes.Bowelandbladderdysfunctionmayoccurearly.Whensubtle,thisdysfunctionmaybelimitedtoasymptomaticbladderretentionnotedonlyonpostvoidcatheterization.Whendysfunctionismoresevere,theremaybeperianalandperinealsensory10ss,lossofanaltoneandreflexes(thereflexanalsphincterconstrictionduetoperianalskinstimulationoranalwinkandthebulbocavernosusreflex),andfecalandurinaryretentionandincontinence.Degenerativeherniationsinthethoracicregionareuncommon,andsymptomsandfindingsattheselevelsshouldraiseasuspicionofotherunderlyinglesions,suchastumororabscess.Discherniationsatthislevelmaycauseradiatingdermatomalpainresultingfromrootcompression;morefrequently,theyprogresstospinalcordcompression.
SpinalStenosis:Thesymptommostsuggestiveoflumbarspinalstenosisisneurogenicclaudication.Lowbackpainradiatestothebuttocksandthighsandmayextendmoredistallyalongthelumbosacraldermatomes.Thispainisbroughtonbywalking.Unlikevascularclaudication,restintheuprightpositiondoesnotrelievethepain,butrestwhileseatedorforwardbending,suchasleaningonashoppingcart,mayproviderelief.Painisexacerbatedbyspinalextension,suchasdownhillwalking.Whenspinalstenosisissevere,patientsbendforwardwhilewalking.Symptomsandsignsmaybeeithermechanical,duetobone,ligament,andjointinvolvement,orradicular,duetocompromiseofthelateralrecessesorneuralforamina.Proximalcompressionresultingfromrootentrapmentmayincreasethevulnerabilityofnervestodysfunctionduetodistalentrapment.Thisdoublecrushphenomenonispresumedtobearesultofdisturbedaxoplasmicflowanddisruptedarchitectureoftheneurofilaments.Therefore,whensurgicalrepairofadistalentrapmentfailstoprovidetheexpectedrelief,acontributingradiculapathyresultingfromdegenerativediscdiseaseshouldbeconsidered.
DifferentialDiagnosis:Discherniationsmustbedifferentiatedfromothercausesof acuteandchronicneck,back,andextremitypain;radiculopathy;andmyelopathy.Malignantandbenigntumorsaffectingthespine;infection;epiduralhematoma;variousarthritides,includingrheumatoidarthritis,ankylosingspondylitis,andReiter'ssyndrome;andotherspondyloarthropathiesmaypresentwithsimilarearlysymptomsandsigns.Variousanomalies,suchasconjoinedspinalrootsand multiplerootsemergingthroughasingleforamen,mayalsobeconfusedwithdiscdisease.Degenerativearthritisof thespinecancausesymptomsbymanymechanisms,includingdischerniation,andthevariouslesionsthat arecausingsymptomsina particularpersonshouldbedifferentiatedasclearlyaspossibletoallowdirectedtherapy.
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DEGENERATIVEDISCDISEASE ORTHO16
'valuation:A carefulhistoryandphysicalexaminationarecriticalintheevaluationofdischerniation.Ithasbeenwellestablishedwith.11imagingmodalitiesthatasymptomaticpatientshaveahighincidenceofanatomicallesions.Todetectclinicallyrelevantillnessproperly,it isthereforeessentialtoestablishtheclosestpossibleclinicalcorrelationofthesymptomsandsignswiththeanatomicalfindingsofthevariousimagingstudies.Theinitialhistoryshouldscreenforproblemsthatraiseasuspicionofsevereunderlyingdisease.Allpatientsshouldbequestionedabouttrauma,cancer,infections,recentfever,andtheuseofanticoagulantmedications.Theunderlyingfamilyhistoryandriskfactorsfortumor,infection,hematoma,andvariousdisordersthatpredisposetodiscdiseaseshouldbesought.Thephysicalexamination,likewise,isundertakentoseekevidenceofothersevereunderlyingdiseaseandtolocalizeandclassifythepainandanydeficitsasmechanical,radicular,ormyelopathic.It ismostimportanttoimmediatelyestablishthepresenceofmajordeficitsthatdemandrapiddiagnosisandtreatment.Theseincludethecaudaequinaorconussyndrome,acuteorprogressivemyelopathy,andsevereradicularmotordeficits.If,ontheotherhand,thefindingsareconsistentwitharuptureddiscandeithernodeficitoramildtomoderateone,it isreasonabletotemporizebeforepursuingaworkuptoevaluatethecausethoroughly.Ifplainradiographsoftheaffectedarearevealnoevidenceofunexpectedlesions,conservativetherapyfordischerniationmaybetriedbeforefurtherimagingisperformed.Thisapproachisjustifiedbythegoodprognosisforspontaneousrecoveryofpatientswithacuteradiculopathywithmildtomoderatedeficits.Whentheclinicalexaminationleavesdoubtaboutthelocalizationofthelesion,electromyography(EMG)cansupplementthediagnosisofradiculopathiesandsuggestotherlocalizations,suchasplexopathiesandneuropathies.EMGismoresensitiveif it isdelayeduntilat least10to14daysaftertheonsetofa newdeficit.
Thetestsavailableforimagingincludeplainradiographs,computedtomography(CT),myelographywithorwithoutCT,andmagneticresonanceimaging(MRI).X-raystudiescanbeusedtoscreenforunexpectedinfection,tumor,ordeformityofthebonyspine.Radiographscannotshowtheneuraltissuesorthediscitself,butlossofdiscspaceheightandotherdegenerativechangesmayprovidesomeindirectdiagnosticinformation.Interpretationofplainradiographsmustbetemperedbyanawarenessofthehighfrequencyofdegenerativefindingsinasymptomaticpopulations.Plainradiographstakenunderconditionsofflexionandextensioncanalsobeusedtoassessspinalstability.Myelographyisinvasive,indirect,andnonspecific;however,itretainscertainadvantagesintheeraofMRI.Itcanvisualizetheentirelengthofthespineandbestdefinestherootsleeves.Althoughmyelographyalonecannotdistinguishbetweenosteophytesandaherniateddisccompromisingaforamen,whencombinedwithCT,itprovidesthebestvisualizationof lateralpathologyandsmallosteophytes.It isnowmostcommonlyusedtoanswerspecificquestionsthatremainaftertheMRIexamination.CTissuperior.')MRIindistinguishingsofttissuefrombone.MRIhasemergedasthepreferredimagingchoiceinmostcases.Itdemonstratesboneridsofttissuesdirectly,easilyallowsmultiplanarvisualization,andissuitedto thevisualizationofmultiplelevels.Thehighcontrastof
epiduralfatandthecerebrospinalfluid(CSF}-filledthecalsacallowsaccurateassessmentofsubtlecompressioninmostcases.LumbarspinalstenosisisevaluatedbyCTorMRI.MRIbestdemonstratestherelationshipofthebonyandneuralstructures.CTbestdemonstrateslateralrecessstenosis.Althoughthedimensionsofthebonycanalcanbeusedasguidelines,diagnosjsmustultimatelybebasedonthecorrelationofstenosiswiththeclinicalfindings.Thetransverseinterfacetdimensionshouldbegreaterthan16mm.Adimensionof lessthan10mmindicatesseverestenosis.Ananteroposteriordimensionoflessthan12mmsuggestsstenosis;however,thisfindingis lesssensitiveinpatientswithsymptomaticdisease.Alateralrecessof3mmorlesssuggestsstenosis.
Management:Thecrucialinitialstepinmanagementofpatientswithdischerniationsyndromeistoidentifythoselesionsthatmeritfurtherevaluationandimmediatetherapy.Intheremainingcases,thegoodprognosisforearlyrecoveryjustifiesatrialofconservativetherapybeforedefinitiveimagingisdone.Conservativetherapyincludesrestinapositionofcomfortfollowedbyearlyremobilization,gentleexercises,andanalgesicsforpainasneeded.Nonsteroidalanti-inflammatoryagentsprobablyprovidelittlereliefinmostcases.Forseverepain,judicioustime-limiteduseofnarcoticsshouldbeconsidered.Oralandepiduralcorticosteroidscanbehelpful.Manyothermodalitiesareavailable,buttherearefewreliabledataabouttheireffectivenessinpopulations:medicalandphysicalmeasures(e.g.,ice,heat,massage,andultrasound)thataddresssecondarymusclespasm,transcutaneouselectricalnervestimulation,acupuncture,exercise,andtraction.If improvementwithintheinitial4 to6weeksisnotsatisfactory,it ishelpfultoconfirmthediagnosisbyimaging.Thismayprovidea diagnosisofanunsuspectedcondition,localizationforepiduralsteroidinjection,or informationaboutsuitabilityforeventualsurgery.
Clearindicationsforsurgeryincludethepresenceofacutemyelopathy,caudaequinasyndrome,severeorprogressivemotordeficits,andintractablepain.Whenconservativemeasuresfailtoprovideasatisfactoryresponsewithin6to12weeks,surgeryshouldalsobeconsidered.Studiescomparingtheoutcomeofsurgicaltherapywithconservativecaresuggestthatearlyrecoveryoccursmoreoftenwithsurgery.Althoughthebenefitsofswgeryarelostwithprolongedfollow-upperiods,it is importanttopointoutthatinanoftencitedstudy,patientsintheconservativetherapygroupwhohadnotrespondedtothistherapyreceivedsurgery.Newermicrosurgicaltechniquesallowshorterhospitalizationandrehabilitationperiodsbuthavenotbeenshowntoimprovelong-termoutcome.Thesuccessrateof~hymopapainchemonucleolysishasnotreachedthatofsurgeryinmosthands,andthistreatmentcarriessignificantrisks.Percutaneousucleotomyhasalsobeendisappointingandshouldnotbepursuedgiventhecurrentlevelofexperience.Forpatientswithlumbarspinal
. stenosis,initialtherapyissymptomatic,withanalgesics,pain-modulatingmedications,andphysicalandoccupationaltherapy.Whensignificantdisabilityandpainremaindespiteconservativemeasures,referralfors.urgicaldecompressionshouldbeconsidered.
I
PrognosisandFuturePerspectives:Theprognosisforthereliefofpainandafullfunctionalrecoveryisgood.Withbedrestalone,Weberfoundthat70percentofpatientsexperienceddecreasedpainandimprovedfunctionwithin4weeks,and60percenthadreturned
Effective 2/19/2004 Page 4 of5
DEGENERATIVEDISCDISEASE ORTHO16
towork.Seventypercentwerefunctionallyunrestrictedat 1year.Withselectivesurgery,90 percentofpatientsshouldhaveagoodfunctionalrecoverywithina year.Patientswith psychosocialproblemstendtodoworsewith eithertherapy,butthosewithappropriateindicationsrespondbetterto surgery.Sensorydysfunctiondoesnotrecoverasfullyas motorfunction,anda largeproportionofpatientsretainsomesensorydeficits.Patientsinwhomrelapseoccursshouldbere-evaluatedfQrnew lesionsthatarepotentiallyaddressablebysurgery;however,thesuccessrateofsurgerydeclineswithfollow-upprocedures,anda significantproportionof patientswithdischerniationexperiencerelapsewithchroniclowbackpain.
Reviewers: PeterMoskovitz,M.D.(Orthopedics)3WashingtonCircle,#404,Washington,D.C.20037Phone:202-333-2820Fax:202-833-14110Email:pamosk@aol.com
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