BlueCross BlueShield of Tennessee Medical Policy Manual

Intervertebral Disc Decompression using Radiofrequency Coblation (Nucleoplasty) or Laser Energy (Laser Discectomy)

DESCRIPTION

Laser energy (laser discectomy) and radiofrequency (RF) coblation (nucleoplasty) are being evaluated for decompression of the intervertebral disc.  For laser discectomy under fluoroscopic guidance, a needle or catheter is inserted into the disc nucleus, and a laser beam is directed through it to vaporize tissue.  A variety of different lasers have been investigated for laser disc decompression, including YAG, KTP, holmium, argon, and carbon dioxide lasers. Due to differences in absorption, the energy requirements and the rate of application differ among the lasers. In addition, it is unknown how much disc material must be removed to achieve decompression. Therefore, protocols vary according to the length of treatment, but typically the laser is activated for brief periods only.

RF ablation uses bipolar low-frequency energy in an electrical conductive fluid (e.g., saline) to generate a high-density plasma field around the energy source.  This creates a low-temperature field of ionizing particles that break organic bonds within the target tissue.  The disc nucleoplasty procedure is accomplished with a probe mounted with a RF coblation source.  The proposed advantage of coblation is that the procedure provides for controlled and highly localized ablation, resulting in minimal damage to surrounding tissue

POLICY

IMPORTANT REMINDERS

ADDITIONAL INFORMATION 

The available evidence is insufficient to draw conclusions regarding the efficacy of disc decompression using laser energy or radiofrequency coblation (nucleoplasty).  Additional randomized controlled trials are needed to further evaluate this technology.

SOURCES 

Abrishamkar, S., Kouchakzadeh, M., Mirhosseini, A., Tabesh, H., Rezvani, M.. Moayednia, A., et al. (2015). Comparison of open surgical discectomy versus plasma-laser nucleoplasty in patients with single lumbar disc herniation. Journal of Research in Medical Sciences, 20 (12), 1133-1137. (Level 2 evidence)

BlueCross BlueShield Association. Evidence Positioning System. (4:2018). Decompression of the intervertebral disc using laser energy (laser discectomy) or radiofrequency coblation (nucleoplasty) (7.01.93). Retrieved February 13, 2019 from https://www.evidencepositioningsystem.com/. (20 articles and/or guidelines reviewed)

Brouwer, P., Brand, R., van den Akker-van Marle, M., Jacobs, W., Schenk, B., van den Berg-Huijsmans, A., et al. (2015). Percutaneous laser disc decompression versus conventional microdiscectomy in sciatica: a randomized controlled trial. The Spine Journal, 15 (5), 857-865. Abstract retrieved July 20, 2016 from PubMed database.

Centers for Medicare & Medicaid Services. CMS.gov. NCD for thermal intradiscal procedures (TIPs) (150.11). Retrieved September 17, 2015 from http://www.cms.gov.

Chitagran, R., Poopitaya, S., & Tassanawipas, W. (2012). Result of percutaneous disc decompression using nucleoplasty in Thailand: a randomized controlled trial. Journal of the Medical Association of Thailand, Suppl 10, S198-S205. Abstract retrieved July 20, 2016 from PubMed database.

Eichen, P., Achilles, N., König, V., Mösges, R., Hellmich, M., Himpe, B., et al. (2014). Nucleoplasty, a minimally invasive procedure for disc decompression: A systematic review and meta-analysis of published clinical studies. Pain Physician, 2014 (17), E149-E173. (Level 4 evidence)

Manchikanti, L., Abdi, S., Atluri, S., Benyamin, R., Boswell, M., Buenaventura, R., et al. (2013). An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain Physician, 16 (2 Suppl), S49-S283.

Manchikanti, l., Falco, F., Benyamin, R., Caraway, D., Deer, T., Singh, V., et al. (2013). An update of the systematic assessment of mechanical lumbar disc decompression with nucleoplasty. Pain Physician, 16, SE25-SE54. (Level 1 evidence)

National Institute for Health and Care Excellence (NICE). (2016, January). Clinical guidance: Percutaneous coblation of the intervertebral disc for low back pain and sciatica. Retrieved July 20, 2016 from www.nice.org.uk.

Nie., HY., Qi,YB.,  Li, N.,  Wang, SL., & Cao, Y.X. (2018). Comprehensive comparison of therapeutic efficacy of radiofrequency target disc decompression and nucleoplasty for lumbar disc herniation: a five year follow-up. International Orthopaedics, 42 (4), 843-849. Abstract retrieved February 13, 2019 from PubMed database.

Singh, V., Manchikanti, L., Calodney, A., Staats, P., Falco, F., Caraway, D., et al. (2013). Percutaneous lumbar laser disc decompression: an update of current evidence. Pain Physician, 2013, 16, SE229-SE260. (Level 1 evidence)

U. S. Food and Drug Administration. (2000, February). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K000044. Retrieved January 21, 2011 from http://www.accessdata.fda.gov.

U. S. Food and Drug Administration. (2007, April). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K070466. Retrieved January 21, 2011 from http://www.accessdata.fda.gov.

U. S. Food and Drug Administration. (2009, July). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K091909. Retrieved January 21, 2011 from http://www.accessdata.fda.gov.

Winifred S. Hayes, Inc. Medical Technology Directory. (2014, May; last update search April 2018). Percutaneous disc decompression for cervical disc herniation. Retrieved February 13, 2019 from www.hayesinc.com/subscribers. (108 articles and/or guidelines reviewed)

Winifred S. Hayes, Inc. Medical Technology Directory. (2018, March). Percutaneous laser disc decompression for lumbar disc herniation. Retrieved February 13, 2019 from www.hayesinc.com/subscribers. (36 articles and/or guidelines reviewed)

ORIGINAL EFFECTIVE DATE:  6/1/2004

MOST RECENT REVIEW DATE:  3/28/2019

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