DESCRIPTION
Spastic cerebral palsy is the most common form of cerebral palsy and is manifested as hyperactive tendon reflexes, muscle hypertonia, and increased resistance to increasing velocity of muscle stretch. Spastic cerebral palsy is further defined according to the affected limbs; spastic hemiplegia involves the arm and leg on one side; spastic diplegia is characterized by lower extremity involvement primarily or exclusively; and spastic quadriplegia affects both arms and legs equally. Spastic diplegia is the most common type. When involving the lower extremities, the hypertonia induced by spasticity prevents normal standing, walking, or crawling.
Selective dorsal (posterior) rhizotomy is a surgical procedure that is intended to reduce spasticity in the legs of individuals with cerebral palsy. A neurosurgeon performs a laminectomy to expose, locate and selectively sever over-activated nerves controlling the leg muscles. This reduces the amount of stimulation that reaches the leg muscles via the nerves and decreases spasticity.
Selective dorsal rhizotomy has been offered to individuals with spastic cerebral palsy in an attempt to increase ambulation, and to a smaller subset of individuals without ambulatory potential, whose severe spasticity limits adequate care and handling.
POLICY
Selective dorsal (posterior) rhizotomy for the treatment of spasticity in cerebral palsy that interferes with gross motor function or adequate care is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
MEDICAL APPROPRIATENESS
Selective dorsal (posterior) rhizotomy for the treatment of an individual with spasticity in cerebral palsy is considered medically appropriate if ALL the following criteria are met:
Has a diagnosis of spastic diplegia
Is three (3) to ten (10) years of age
Has a Modified Ashworth Scale score of 3 or 4
ANY ONE of the following:
Retains some ambulatory potential (e.g., documentation of results of three-month trial of physical therapy)
Has no ambulatory potential with severe spasticity that limits adequate care and handling
ABSENCE of ALL the following:
A history of:
Meningitis
Congenital brain infection
Congenital hydrocephalus unrelated to premature birth
Head trauma
A history of orthopedic surgery with subsequent recurrence of spasticity
Severe scoliosis
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
ADDITIONAL INFORMATION
The type of laminectomy (e.g., L1-L2, L1-S2) performed by individual neurosurgeons may vary. Well-designed and well-conducted investigations published in peer-reviewed journals to support the use of one surgical technique over another surgical technique are lacking.
Modified Ashworth Scale for Grading Spasticity
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Grade |
Description |
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0 |
No increase in muscle tone. |
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1 |
Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of the range of motion when the affected part(s) is moved in flexion or extension. |
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1+ |
Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of the ROM. |
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2 |
More marked increase in muscle tone through most of the ROM, but affected part(s) easily moved. |
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3 |
Considerable increase in muscle tone, passive movement difficult. |
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4 |
Affected part(s) rigid in flexion or extension. |
SOURCES
BlueCross BlueShield Association. Medical Policy Reference Manual. (2:2003) Selective posterior rhizotomy for the spasticity of cerebral palsy. (7.01.28). Archived October 2009. Retrieved April 18, 2011 from BlueWeb.
Bohannon, R. W., & Smith, M. B. (1987). Interrater reliability of a modified Ashworth scale of muscle spasticity. Physical Therapy, 67 (2), 206-207. (Level 4 Evidence - Independent)
Canale, S. T. (Eds.). (2003). Campbell's Operative Orthopaedics. (10th Ed., pp 1218-1223). Philadelphia: Mosby, Inc.
National Institute for Health and Clinical Excellence. (2010, December). Selective dorsal rhizotomy for spasticity in cerebral palsy. Retrieved April 19, 2011 from http://www.nice.org.uk/nicemedia/live/11220/52083/52083.pdf.
Nordmark, E., Josenby, A., Lagergren, J., Andersson, G., Stromblad, L., & Westbom, L. (2008) Long-term outcomes five years after selective dorsal rhizotomy. BMC Pediatrics, 8 (54). (Level 4 Evidence - Independent)
Park, T. S., Gaffney, P. E., Kaufman, B. A., Kaufman, B. A., & Molleston, M. C. (1993). Selective lumbosacral dorsal rhizotomy immediately caudal to the conus medullaris for cerebral palsy spasticity. Neurosurgery, 33 (5), 929-33.
Steinbok, P., Reiner, A. M., Beauchamp, R., Armstrong, R. W., Cochrane, D. D., & Kestle, J. (1997). A randomized clinical trial to compare selective posterior rhizotomy plus physiotherapy with physiotherapy alone in children with spastic diplegic cerebral palsy. Developmental Medicine and Child Neurology, 39 (3), 178-184. (Level 3 Evidence - Independent)
United Cerebral Palsy. (2003, May). Treatment of cerebral palsy: A research status report. Retrieved September 13, 2005 from http://www.ucp.org/ucp_generaldoc.cfm/1/4/11654/11654-11654/4790.
von Koch, C. S., Park, T. S., Steinbok, P., Smyth, M., & Peacock, W. J. (2001). Selective posterior rhizotomy and intrathecal baclofen for the treatment of spasticity. Pediatric Neurosurgery, 35, 57-65.
ORIGINAL EFFECTIVE DATE: 5/1987
MOST RECENT REVIEW DATE: 6/9/2011
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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