BlueCross BlueShield of Tennessee Medical Policy Manual

Dynamic Spinal Visualization

DESCRIPTION

Dynamic spinal visualization is a general term addressing different imaging technologies, including digital motion x-ray and videofluoroscopy (i.e., cineradiography/videoradiography).Unlike standard x-rays, which take a single picture at one point in time, videofluoroscopy provides motion pictures of the body. These technologies allow the simultaneous visualization of movement of internal body structures, such as the spine (vertebrae), with corresponding external body movement. These technologies have been proposed for the evaluation of spinal disorders including low back pain.

Digital motion x-ray (i.e., DMX) involves the use of either film x-ray or computer-based x-ray snapshots taken in sequence as the individual moves. Film x-rays are digitized into a computer for manipulation while computer-based x-rays are automatically created in a digital format. The digitized snapshots are then put in order using a computer program and played on a video monitor, creating a moving image of the inside of the body.

Dynamic magnetic resonance imaging (MRI) is also being evaluated for imaging of the cervical spine. This technique uses an MRI-compatible step-less motorized positioning device and a real-time true fast imaging with steady-state precession sequence to provide passive kinematic imaging of the cervical spine.

Note: This policy does not address radiographic digitization of an x-ray. Radiographic digitization is the computer enhancement of a “still” x-ray and does not involve movement or motion.

POLICY

IMPORTANT REMINDERS

ADDITIONAL INFORMATION

The current literature evaluating the clinical utility of dynamic spinal visualization techniques, including digital motion x-ray and cineradiography/videofluoroscopy, or dynamic magnetic resonance imaging for the evaluation and assessment of the neck and back is limited to a few studies involving small numbers of participants. Thus, the clinical utility of this technique has not been demonstrated and these technologies remain investigational. 

SOURCES

Ahmadi, A., Maroufi, N., Behtash, H., Zekavat, H., & Parnianpour, M. (2009). Kinematic analysis of dynamic lumbar motion in patients with lumbar segmental instability using digital videofluoroscopy. European Spine Journal, 18 (11), 1677-1685. (Level 4 evidence)

American College of Radiology. (2012) ACR Appropriateness Criteria® suspected spine trauma. Retrieved August 1, 2016 from the National Guideline Clearinghouse (NGC#009236).

BlueCross BlueShield Association. Medical Policy Reference Manual. (9:2015). Dynamic spinal visualization (6.01.46). Retrieved August 1, 2016 from BlueWeb. (10 articles and/or guidelines reviewed)

Gerigk. L., Bostel, T., Hegewald, A., Thome, C., Groden, C., Neumaier-Probst, E., et al. (2012, March) Dynamic magnetic resonance imaging of the cervical spine with high-resolution 3-dimensional T2-imaging. Clinical Neuroradiology; 22(1):93-99. Abstract retrieved August 1, 2016 from PubMed database.

Mellor F. E., Muggleton, J. M., Bagust, J., Mason, W., Thomas, P. W., & Breen, A. C. (2009). Midlumbar lateral flexion stability measured in healthy volunteers by in vivo fluoroscopy. Spine, 34 (22), E811-E817. (Level 4 evidence - Independent study)

U. S. Food and Drug Administration. (2008, August). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K080847. Retrieved July 24, 2002 from http://www.accessdata.fda.gov.

U. S. Food and Drug Administration. (2009, May). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K082781. Retrieved July 24, 2002 from http://www.accessdata.fda.gov.  

U. S. Food and Drug Administration. (2013, August). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K130743. Retrieved August 1, 2016 from http://www.accessdata.fda.gov.

ORIGINAL EFFECTIVE DATE:  8/11/2007

MOST RECENT REVIEW DATE:  9/8/2016

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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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