Policy
INDICATIONS FOR THORACIC SPINE CT
+If there is a combination request* for an overlapping body part, either requested at the same time or sequentially (within the past 3 months) the results of the prior study should be:

• Inconclusive or show a need for additional or follow up imaging evaluation OR
• The office notes should clearly document an indication why overlapping imaging is needed and how it will change management for the patient (the entire spinal cord and/or autonomic postganglionic chain must be assessed)

(*Unless approvable in the combination section as noted in the guidelines)

For evaluation of neurologic deficits when Thoracic Spine MRI is contraindicated or inappropriate^1-3

• With any of the following new neurological deficits documented on physical exam
  • Extremity muscular weakness (and not likely caused by plexopathy, or peripheral neuropathy)^{4, 5}
  • Pathologic (e.g., Babinski, Chaddock Sign) or abnormal reflexes6
  • Absent/decreased sensory changes along a particular thoracic dermatome (nerve distribution): pin prick, touch, vibration, proprioception, or temperature
  • Upper or lower extremity increase muscle tone/spasticity and likely localized to the thoracic spinal cord
  • New onset bowel or bladder dysfunction (e.g., retention or incontinence) — not related to an inherent bowel or bladder process
  • Gait abnormalities (see Table 1 for more details)
• Suspected cord compression with any neurological deficits as listed above
• Toe walking in a child when associated with upper motor neuron signs including hyperreflexia, spasticity; or orthopedic deformity with concern for spinal cord pathology (e.g., pes cavus, clawed toes, leg or foot length deformity (excluding tight heel cords))

For evaluation of back pain with any of the following when Thoracic Spine MRI is contraindicated^7-10

* National Imaging Associates, Inc. (NIA) is a subsidiary of Magellan Healthcare, Inc.

• With new or worsening objective neurologic deficits on exam, as above
• Failure of conservative treatment* for at least six (6) weeks within the last six (6) months¹¹
• With progression or worsening of symptoms during the course of conservative treatment*
• With an abnormal electromyography (EMG) or nerve conduction study (if performed) indicating a thoracic radiculopathy. (EMG is not recommended to determine the cause of axial lumbar, thoracic, or cervical spine pain)¹²
• Isolated thoracic pain in pediatric population¹³ — conservative care not required if red flags present
  • Red flags that prompt imaging should include the presence of: age 5 or younger, constant pain, pain lasting > 4 weeks, abnormal neurologic examination, early morning stiffness and/or gelling; night pain that prevents or disrupts sleep; radicular pain; fever; weight loss; malaise; postural changes (e.g., kyphosis or scoliosis); and limp (or refusal to walk in a younger child < 5 years old) AND initial radiographs have been performed^{14, 15}

As part of initial pre-operative/post-operative/procedural evaluation (“CT best examination to assess for hardware complication, extent of fusion” 16, 17 and MRI for cord, nerve root compression, disc pathology, or post-op infection)

If ordered by Neurosurgeon or orthopedic surgeon for purposes of surgical planning, a contraindication to MRI is not required.

• For preoperative evaluation/planning
• CT discogram
• CSF leak highly suspected and supported by patient history and/or physical exam findings (leak (known or suspected spontaneous (idiopathic) intracranial hypotension (SIH), post lumbar puncture headache, post spinal surgery headache, orthostatic headache, rhinorrhea or otorrhea, or cerebrospinal-venous fistula -preferred exam CT myelogram)¹⁸
• Prior to spinal cord stimulator to exclude canal stenosis if no prior imaging of the thoracic spine has been done recently and MRI is contraindicated
• A follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention, or surgery in the last 6 months. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested (routine surveillance post-op not indicated without symptoms)
• Surgical infection as evidenced by signs/symptoms, laboratory, or prior imaging findings
• New or changing neurological deficits or symptoms post-operatively ^{16, 19} — see neurological deficit section above
• When combo requests are submitted (i.e., MRI and CT of the spine), the office notes should clearly document the need for both studies to be done simultaneously, i.e., the need for both soft tissue and bony anatomy is required²⁰
  • Combination requests where both thoracic spine CT and MRI thoracic spine are both approvable (not an all-inclusive list):
    • OPLL (Ossification of posterior longitudinal ligament)
    • Most common in cervical spine (rare but more severe in thoracic spine)²¹
  • Pathologic or complex fractures
  • Malignant process of spine with both bony and soft tissue involvement
  • Clearly documented indication for bony and soft tissue abnormality where assessment will change management for the patient

For evaluation of suspected myelopathy when Thoracic Spine MRI is contraindicated^22-26

• Does NOT require conservative care
• Progressive symptoms including unsteadiness; broad-based gait; increased muscle tone; pins and needles sensation; weakness and wasting of the lower limbs; diminished sensation to light touch, temperature, proprioception, and vibration; limb hyperreflexia and pathologic reflexes; bowel and bladder dysfunction in more severe cases
• Any of the neurological deficits as noted above

For evaluation of trauma or acute injury²⁷

• Presents with any of the following neurological deficits as above
• With progression or worsening of symptoms during the course of conservative treatment*
• History of underlying spinal abnormalities (i.e., ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis) (Both MRI and CT would be approvable)^28-30
• When the patient is clinically unevaluable or there are preliminary imaging findings (x-ray or CT) needing further evaluation

(“MRI and CT provide complementary information. When indicated It is appropriate to perform
both examinations”)²⁷

For evaluation of known fracture or known/new compression fractures with worsening back pain^{27, 31}

• To assess union of a fracture when physical examination, plain radiographs, or prior imaging suggest delayed or non-healing
• To determine the position of fracture fragments
• With history of malignancy (if MRI is contraindicated or cannot be performed)
• With an associated new focal neurologic deficit as above³²
• Prior to a planned surgery/intervention or if the results of the CT will change management

CT myelogram: When MRI cannot be performed/contraindicated/surgeon preference^33-37

• When signs and symptoms are inconsistent or not explained by the MRI findings
• Demonstration of the site of a CSF leak (known or suspected spontaneous (idiopathic) intracranial hypotension (SIH), post lumbar puncture headache, post spinal surgery headache, orthostatic headache, rhinorrhea or otorrhea, or cerebrospinal-venous fistula)
• Surgical planning, especially regarding to the nerve roots or evaluation of dural sac

For evaluation of tumor, cancer, or metastasis with any of the following:
(MRI is usually the preferred study — CT may be needed to further characterize solitary indeterminate lesions seen on MRI)³⁸

• Primary tumor
  • Initial staging or re-staging of a known primary spinal tumor³⁹
  • Known spinal tumor with new signs or symptoms (e.g., new or increasing nontraumatic pain, physical, laboratory, and/or imaging findings)
  • With an associated new focal neurologic deficit as above³²
• Metastatic tumor
  • With evidence of metastasis on bone scan needing further clarification OR inconclusive findings on a prior imaging exam
  • With an associated new focal neurologic deficit³²
  • Known malignancy with new signs or symptoms (e.g., new or increasing nontraumatic pain, radiculopathy or neck pain that occurs at night and wakes the patient from sleep with known active cancer, physical, laboratory, and/or imaging findings) in a tumor that tends to metastasize to the spine^{40, 41}
• For evaluation of inconclusive/indeterminate finding on prior imaging that requires further clarification
  • One follow-up exam to ensure no suspicious change has occurred in prior imaging finding. No further surveillance unless specified as highly suspicious or change was found on last follow-up exam. When MRI cannot be performed or is contraindicated or CT is preferred to characterize the finding41

Indication for combination studies for the initial pre-therapy staging of cancer, OR active monitoring for recurrence as clinically indicated, OR evaluation of suspected metastases

• < 5 concurrent studies to include CT or MRI of any of the following areas as appropriate depending on the cancer: Neck, Abdomen, Pelvis, Chest, Brain, Cervical Spine, Thoracic Spine, or Lumbar Spine

For evaluation of known or suspected infection/abscess when Thoracic MRI is contraindicated^{42, 43}

• As evidenced by signs and/or symptoms, laboratory (i.e., abnormal white blood cell count, ESR and/or CRP) or prior imaging findings⁴⁴
• Follow-up imaging of infection
  • With worsening symptoms/laboratory values (i.e., white blood cell count, ESR/CRP) or radiographic findings⁴⁵

For evaluation of known or suspected inflammatory disease when MRI is contraindicated or cannot be performed²⁸

•  Ankylosing Spondylitis/Spondyloarthropathies with non-diagnostic or indeterminate x-ray and appropriate rheumatology workup

For evaluation of spine abnormalities related to immune system suppression, e.g., HIV, chemotherapy, leukemia, or lymphoma when Thoracic MRI is contraindicated⁴²

• As evidenced by signs/symptoms, laboratory, or prior imaging findings

Other Indications for a Thoracic Spine CT when MRI is contraindicated or cannot be performed
(Note — See combination requests, below, for initial advanced imaging assessment and pre-operatively)

• Tethered cord, or spinal dysraphism (known or suspected) based on preliminary imaging, neurological exam, and/or high-risk cutaneous stigmata^46-48
• Known Arnold-Chiari syndrome (For initial imaging see combination below)
  • Known Chiari I malformation without syrinx or hydrocephalus, follow-up imaging after initial diagnosis with new or changing signs/symptoms or exam findings consistent with spinal cord pathology⁴⁹
  • Known Chiari II (Arnold-Chiari syndrome), III, or IV malformation
• Syrinx or syringomyelia (known or suspected)
  • With neurologic findings and/or predisposing conditions (e.g., Chiari malformation, prior trauma, neoplasm, arachnoiditis, severe spondylosis)⁵⁰
  • To further characterize a suspicious abnormality seen on prior imaging
  • Known syrinx with new/worsening symptoms
• Toe walking in a child with signs/symptoms of myelopathy localized to the Thoracic Spine
• Suspected neuroinflammatory Conditions/Diseases (e.g., sarcoidosis, Behcet’s)
  • After detailed neurological exam and basic testing completed

COMBINATION STUDIES WITH THORACIC SPINE CT WHEN MRI IS CONTRAINDICATED OR CANNOT BE PERFORMED OR SURGEON PREFERENCE

Cervical and Thoracic CT

• Initial evaluation of known syrinx or syringomyelia
  • With neurologic findings and/or predisposing conditions (e.g., Chiari malformation, prior trauma, neoplasm, arachnoiditis, severe spondylosis⁵⁰)
  • To further characterize a suspicious abnormality seen on prior imaging
  • Known syrinx with new/worsening symptom

Any combination of Cervical and/or Thoracic and/or Lumbar CTs
Note: These body regions might be evaluated separately or in combination as documented in the clinical notes by physical examination findings (e.g., localization to a particular segment of the spinal cord), patient history, and other available information, including prior imaging.
 
Exception — Indications for combination studies^{51, 52}: Are approved indications as noted below and being performed in children who will need anesthesia for the procedure

• Any combination of these studies for:
  • Survey/complete initial assessment of infant/child with congenital scoliosis or juvenile idiopathic scoliosis under the age of 10^53-55 (e.g., congenital scoliosis, idiopathic scoliosis, scoliosis with vertebral anomalies)
  • In the presence of neurological deficit, progressive spinal deformity, or for preoperative planning⁵⁶
  • Back pain with known vertebral anomalies (hemivertebrae, hypoplasia, agenesis, butterfly, segmentation defect, bars, or congenital wedging) in a child on preliminary imaging
  • Scoliosis with any of the following⁵⁷:
    • Progressive spinal deformity;
    • Neurologic deficit (new or unexplained);
    • Early onset;
    • Atypical curve (e.g., short segment, > 30’ kyphosis, left thoracic curve,
    • associated organ anomalies);
    • Pre-operative planning; OR
    • When office notes clearly document how imaging will change management
• Arnold-Chiari malformations^{58, 59}
  • Arnold-Chiari I
    • For evaluation of spinal abnormalities associated with initial diagnosis of Arnold-Chiari Malformation. (C/T/L spine due to association with tethered cord and syringomyelia), and initial imaging has not been completed^{47, 53}
  • Arnold-Chiari II-IV — For initial evaluation and follow-up as appropriate
    • Usually associated with open and closed spinal dysraphism, particularly meningomyelocele)
• Tethered cord, or spinal dysraphism (known or suspected) based on preliminary imaging, neurological exam, and/or high-risk cutaneous stigmata,^46-48 when anesthesia required for imaging⁶⁰ (e.g., meningomyelocele, lipomeningomyelocele, diastematomyelia, fatty/thickened filum terminale, and other spinal cord malformations)
• Oncological Applications (e.g., primary nervous system, metastatic)
  • Drop metastasis from brain or spine (imaging also includes brain; CT spine imaging in this scenario is usually CT myelogram) — See Overview
  • Suspected leptomeningeal carcinomatosis (LC)⁶¹ — See Overview
  • Any combination of these for spinal survey in patient with metastases
  • Tumor evaluation and monitoring in neurocutaneous syndromes
• CSF leak highly suspected and supported by patient history and/or physical exam findings (leak (known or suspected spontaneous (idiopathic) intracranial hypotension (SIH), post lumbar puncture headache, post spinal surgery headache, orthostatic headache, rhinorrhea or otorrhea, or cerebrospinal-venous fistula -preferred exam CT myelogram))¹⁸
• CT myelogram when meets above guidelines and MRI is contraindicated or for surgical planning
• Post-procedure (discogram) CT
   

Background 
Computed tomography is used for the evaluation, assessment of severity, and follow-up of diseases of the spine. Its use in the thoracic spine is limited, however, due to the lack of epidural fat in this part of the body. CT myelography improves the contrast severity of CT, but it is also invasive. CT may be used for conditions, e.g., degenerative changes, infection, and immune suppression, when magnetic resonance imaging (MRI) is contraindicated. It may also be used in the evaluation of tumors, cancer, or metastasis in the thoracic spine, and it may be used for preoperative and post-surgical evaluations. CT obtains images from different angles and uses computer processing to show a cross-section of body tissues and organs. CT is fast and is often performed in acute settings. It provides good visualization of cortical bone.

OVERVIEW
Ankylosing Spondylitis/Spondyloarthropathies can cause back or sacroiliac pain of insidious onset (usually > 3 month), associated with morning stiffness not relieved with rest (usually age at onset < 40). They are associated with any of the following (Akgul, 2011; Bennett, 2010; Ostergaard, 2012; Sieper, 2014):

• Sedimentation rate and/or C-reactive protein (not an essential criteria)
• HLA B27 (not an essential criteria)
• Non-diagnostic or indeterminate x-ray
• Personal or family history of sacroilitis, peripheral inflammatory arthritis, and/or inflammatory bowel disease.

*Conservative Therapy: (Spine) should include a multimodality approach consisting of a combination of active and inactive components. Inactive components, such as rest, ice, heat, modified activities, medical devices, acupuncture and/or stimulators, medications, injections (epidural, facet, bursal, and/or joint, not including trigger point), and diathermy can be utilized. Active modalities may consist of physical therapy, a physician-supervised home exercise program**, regular osteopathic manipulative medicine treatments (OMT), and/or chiropractic care when considered safe and appropriate.

**Home Exercise Program - (HEP)/Therapy — The following elements are required to meet guidelines for completion of conservative therapy (ACR, 2015; Last, 2009):

• Information provided on exercise prescription/plan. 
• Follow-up with member with documentation provided regarding lack of improvement (failed) after completion of HEP (after suitable 6-week period), or inability to complete HEP due to physical reason — i.e., increased pain, inability to physically perform exercises. (Patient inconvenience or noncompliance without explanation does not constitute "inability to complete" HEP).
• Dates and duration of failed PT, physician-supervised HEP, or chiropractic treatment should be documented in the original office notes or an addendum to the notes.

Table 1: Gait and spine imaging^‡

(^‡References: Chhetri, 2014; Clinch, 2021; Gait, 2021; Haynes, 2018; Marshall, 2012; Pirker, 2017)

Myelopathy: Symptom severity varies, and a high index of suspicion is essential for making the proper diagnosis in early cases. Symptoms of pain and radiculopathy may not be present. The natural history of myelopathy is characterized by neurological deterioration. The most frequently encountered symptom is gait abnormality (86%), followed by increased muscular reflexes (79.1%), pathological reflexes (65.1%), paresthesia of upper limb (69.8%), and pain (67.4%) (Vitzthum, 2007).

CT and Infection of the spine — Infection of the spine is not easy to differentiate from other spinal disorders, e.g., degenerative disease, spinal neoplasms, and non-infective inflammatory lesions. Infections may affect different parts of the spine, e.g., vertebrae, intervertebral discs, and paraspinal tissues. Imaging is important to obtain early diagnosis and treatment to avoid permanent neurology deficits. When MRI is contraindicated, CT may be used to evaluate infections of the spine.

CT and Degenerative Disc Disease — Degenerative disc disease is very common and CT may be indicated when MRI is contraindicated, when chronic degenerative changes are accompanied by conditions, e.g., new neurological deficits; onset of joint tenderness of a localized area of the spine; new abnormal nerve conductions studies; exacerbation of chronic back pain unresponsive to conservative treatment; and unsuccessful physical therapy/home exercise program.

Infection, Abscess, or Inflammatory disease

• Most common site is the lumbar spine (58%), followed by the thoracic spine (30%) and the cervical spine (11%) (Graeber, 2019)
• High risk populations (indwelling hardware, history of endocarditis, IVDA, recent procedures) with appropriate signs/symptoms

CT Myelogram
Myelography is the instillation of intrathecal contrast media under fluoroscopy. Patients are then imaged with CT to evaluate for spinal canal pathology. Although this technique has diminished greatly due to the advent of MRI and its non-invasiveness and superior soft-tissue contrast, myelography is still a useful technique for conventional indications, such as spinal stenosis, when MRI is contraindicated or nondiagnostic, brachial plexus injury in neonates, radiation therapy treatment planning, and cerebrospinal fluid (CSF) leak (Pomerantz, 2016).

Cauda Equina Syndrome

• Symptoms include severe back pain or sciatica along with one or more of the following:
  • Saddle anesthesia — loss of sensation restricted to the area of the buttocks, perineum and inner surfaces of the thighs (areas that would sit on a saddle)
  • Recent bladder/bowel dysfunction
  • Achilles reflex absent on both sides
  • Sexual dysfunction that can come on suddenly
  • Absent anal reflex and bulbocavernosus reflex

Back Pain with Cancer History — Radiographic (x-ray) examination should be performed in cases of back pain when a patient has a cancer history, but without known active cancer or a tumor that tends to metastasize to the spine. This can make a diagnosis in many cases. This may occasionally allow for selection of bone scan in lieu of MRI in some cases. When radiographs do not answer the clinical question, then MRI may be appropriate after a consideration of conservative care.

Neoplasms causing VCF (vertebral compression fractures) include primary bone neoplasms, such as hemangioma or giant cell tumors, and tumor-like conditions causing bony and cellular remodeling, such as aneurysmal bone cysts, or Paget’s disease (osteitis deformans); infiltrative neoplasms, including and not limited to, multiple myeloma and lymphoma, and metastatic neoplasms (ACR, 2018).

Most common spine metastasis involving primary metastasis originate from the following tumors in descending order: breast (21%), lung (19%), prostate (7.5%), renal (5%), gastrointestinal (4.5%), and thyroid (2.5%). While all tumors can seed to the spine, the cancers mentioned above metastasize to the spinal column early in the disease process (Ziu, 2019).

Table 2: MRI and Cutaneous Stigmata (Dias, 2015)

References 

1. Acharya AB, Fowler JB. Chaddock Reflex. [Updated 2019 Dec 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan. https://www.ncbi.nlm.nih.gov/books/NBK519555/.
2. Akgul O, Ozgocmen S. Classification criteria for spondyloarthropathies. World J Orthop. Dec 18, 2011; 2(12):107-115. doi: 10.5312/wjo.v2.i12.07. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3302034/. Retrieved March 29, 2018.
3. Alexandru D. Evaluation and management of vertebral compression fractures. Perm J. Published online October 30, 2012:46-51. doi:10.7812/TPP/12-037.
4. Allegri M, Montella S, Salici F, et al. Mechanisms of low back pain: A guide for diagnosis and therapy. F1000Res. 2016 Oct; 2.
5. American Association of Neurological Surgeons (AANS). Tethered spinal cord syndrome. 2019.
6. American Association of Neurological Surgeons and Congress of Neurological Surgeons (AANSCNS). Choosing Wisely^®. http://www.choosingwisely.org/clinician-lists/american-association-neurological-surgeons-imaging-for-nonspecific-acute-low-back-pain/. Released June 24, 2014.
7. American College of Radiology (ACR). ACR Appropriateness Criteria^®. Published 2015.
8. American College of Radiology (ACR). ACR Appropriateness Criteria^®. Inflammatory Back Pain: Known or Suspected Axial Spondyloarthritis. https://acsearch.acr.org/docs/3094107/Narrative/. Revised 2021.
9. Ando K, Imagama S, Kobayashi K, et al. Clinical features of thoracic myelopathy: A single-center study. J Am Acad Orthop Surg Glob Res Rev. 2019 Nov; 3(11):e10.5435.
10. Behrbalk E, Salame K, Regev GJ, et al. Delayed diagnosis of cervical spondylotic myelopathy by primary care physicians. Neurosurg Focus. July 2013; 35(1):1-6.
11. Bennett AN, Marzo-Ortega H, Rehman A, et al. The evidence for whole-spine MRI in the assessment of axial spondyloarthropathy. Rheumatology. March 2010; 49(3):426-432. https://doi.org/10.1093/rheumatology/kep427. https://academic.oup.com/rheumatology/article/49/3/426/1787410. Retrieved May 12, 2018.
12. Berbari EF, Kanj SS, Kowalski TJ, et al. 2015 Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adults. Clin Infect Dis. 2015 Sep 15; 61(6):e26–e46.  
13. Bernstein RM, Cozen H. Evaluation of back pain in children and adolescents. Am Fam Physician. 2007;76(11):1669-1676.
14. Bond A, Manian FA. Spinal epidural abscess: A review with special emphasis on earlier diagnosis. Biomed Res Int. 2016; 2016:1614328.
15. Budoff MJ, Khairallah W, Li D, et al. Trabecular bone mineral density measurement using thoracic and lumbar quantitative computed tomography. Aca Radiology. 2012; 19(2):179-183. doi: 10.1016/j.acra.2011.10.006.
16. Chhetri SK, Gow D, Shaunak S, Varma A. Clinical assessment of the sensory ataxias; diagnostic algorithm with illustrative cases. Pract Neurol. 2014;14(4):242-251. doi:10.1136/practneurol-2013-000764.
17. Choi BW, Song KJ, Chang H. Ossification of the posterior longitudinal ligament: A review of literature. Asian Spine J. 2011; 5(4):267–276. doi:10.4184/asj.2011.5.4.267
18. Choosing Wisely^®. Lists. http://www.choosingwisely.org/clinician-lists/#keyword=spine&topic-area=Radiology&service=Imaging. Retrieved March 27, 2018.
19. Clinch J, Wood M, Driscoll S. Evaluation of gait disorders in children. BMJ Best Practice. Published February 23, 2021. Accessed July 14, 2021. https://bestpractice.bmj.com/topics/en-us/709.
20. D’ Alessandro. Does This Sacral Dimple Need to be Evaluated? PediatricEducation.org™. https://pediatriceducation.org/2009/07/20/does-this-sacral-dimple-need-to-be-evaluated/. Posted July 20, 2009. Retrieved March 29, 2018.
21. Davies BM, Mowforth OD, Smith EK, et al. Degenerative cervical myelopathy. BMJ. 2018; 360. doi: https://doi.org/10.1136/bmj.k186.
22. Dias M, Partington M. Congenital brain and spinal cord malformations and their associated cutaneous markers. Pediatrics. 2015; 136(4):e1105-19.
23. Duz B, Gocmen S, Secer HI, et al. Tethered cord syndrome in adulthood. J Spinal Cord Med. 2008; 31(3):272-278. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2565560/. Retrieved March 29, 2018.
24. Eubanks JD. Cervical radiculopathy: Nonoperative management of neck pain and radicular symptoms. Am Fam Physician. 2010 Jan 1; 81(1):33-40. https://www.aafp.org/afp/2010/0101/p33.pdf.  
25. Feldman DS, Straight JJ, Badra MI, Mohaideen A, Madan SS. Evaluation of an algorithmic approach to pediatric back pain. J Pediatr Orthop. 2006;26(3):353-357. doi:10.1097/01.bpo.0000214928.25809.f9.
26. Fisher BM, Cowles S, Matulich JR, Evanson BG, Vega D, Dissanaike S. Is magnetic resonance imaging in addition to a computed tomographic scan necessary to identify clinically significant cervical spine injuries in obtunded blunt trauma patients? Am J Surg. 2013;206(6):987-993; discussion 993-994. doi:10.1016/j.amjsurg.2013.08.021.
27. Gait abnormalities. Stanford Medicine 25. Published 2021. Accessed July 14, 2021. https://stanfordmedicine25.stanford.edu/the25/gait.html.
28. Graeber A, Cecava ND. Vertebral Osteomyelitis. [Updated 2019 Jun 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan.
29. Haynes KB, Wimberly RL, VanPelt JM, Jo C-H, Riccio AI, Delgado MR. Toe walking: A neurological perspective after referral from pediatric orthopaedic surgeons. Journal of Pediatric Orthopaedics. 2018;38(3):152-156. doi:10.1097/BPO.0000000000001115.
30. Hertzler DA, DePowell JJ, Stevenson CB, Mangano FT. Tethered cord syndrome: A review of the literature from embryology to adult presentation. Neurosurg Focus. 2010;29(1):E1. doi:10.3171/2010.3.FOCUS1079.
31. Hitson WJ, Lane JR, Bauer DF, et al. A prospective natural history study of nonoperatively managed Chiari I malformation: Does follow-up MRI surveillance alter surgical decision making? J Neurosurg Pediatr. 2015 Aug; 16(2):159-66.
32. Hou X, Sun C, Liu X, et al. Clinical features of thoracic spinal stenosis-associated myelopathy: A retrospective analysis of 427 cases. Clin Spine Surg. 2016 Mar; 29(2):86-9. doi: 10.1097/BSD.0000000000000081.
33. Jarvik JG, Gold LS, Comstock BA, et al. Association of early imaging for back pain with clinical outcomes in older adults. JAMA. 2015; 313(11):1143-1153. doi: 10.1001/jama.2015.1871.
34. Kim YS, Han IH, Lee IS, et al. Imaging findings of solitary spinal bony lesions and the differential diagnosis of benign and malignant lesions. J Korean Neurosurg Soc. August 2012; 52(2):126-132. doi: 10.3340/jkns.2012.52.2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3467370/. Retrieved March 29, 2018.
35. Koivikko MP, Koskinen SK. MRI of cervical spine injuries complicating ankylosing spondylitis. Skeletal Radiol. 2008 Sep; 37(9):813-9. doi:10.1007/s00256-008-0484-x. Epub 2008 Apr 18.
36. Last AR, Hulbert K. Chronic low back pain: Evaluation and management. Am Fam Physician. 2009; 79(12):1067-74.  
37. Lerner S, Hartmann S, Barbagallo GMV, et al. Management of spinal infection: A review of the literature. Acta Neurochir (Wien). 2018; 160(3):487–496. doi: 10.1007/s00701-018-3467-2.
38. Marshall FJ. Approach to the elderly patient with gait disturbance. Neurol Clin Pract. 2012;2(2):103-111. doi:10.1212/CPJ.0b013e31825a7823.
39. Milhorat TH, Bolognese PA, Nishikawa M, et al. Association of Chiari malformation type I and tethered cord syndrome: Preliminary results of sectioning filum terminale. Surg Neurol. July 1, 2009; 72(1):20-35. http://europepmc.org/abstract/med/19559924. Retrieved March 29, 2018.
40. Muller D, Bauer JS, Zeile M, et al. Significance of sagittal reformations in routine thoracic and abdominal multislice CT studies for detecting osteoporotic fractures and other spine abnormalities. Eur Radiol. 2008; 18(8):1696-1702. doi: 10.10007/s00330-008-0920-2.
41. North American Spine Society (NASS). Clinician Lists. Choosing Wisely^®. http://www.choosingwisely.org/clinician-lists/nass-emg-nerve-conduction-studies-to-determine-cause-of-spine-pain/. Released October 9, 2013.
42. North American Spine Society (NASS). Evidence-based Clinical Guidlines for Multidisciplinary Spine Care. Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders. 2010 North American Spine Society. https://www.spine.org/Portals/0/Assets/Downloads/ResearchClinicalCare/Guidelines/CervicalRadiculo pathy.pdf
43. North American Spine Society (NASS). Five Things Physicians and Patients Should Question. Choosing Wisely^®. http://www.choosingwisely.org/doctor-patient-lists/north-american-spine-society/. 2014.
44. Ostergaard M, Lambert RG. Imaging in ankylosing spondylitis. Ther Adv Musculoskelet Dis. August 2012; 4(4):301-311. doi: 10.1177/1759720X11436240. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3403247/. Retrieved March 29, 2018.
45. Ozturk C, Karadereler S, Ornek I, Enercan M, Ganiyusufoglu K, Hamzaoglu A. The role of routine magnetic resonance imaging in the preoperative evaluation of adolescent idiopathic scoliosis. Int Orthop. 2010;34(4):543-546. doi:10.1007/s00264-009-0817-y.
46. Pirker W, Katzenschlager R. Gait disorders in adults and the elderly: A clinical guide. Wien Klin Wochenschr. 2017;129(3-4):81-95. doi:10.1007/s00508-016-1096-4.
47. Pomerantz SR. Myelography: Modern technique and indications. Handb Clin Neurol. 2016; 135:193-208.
48. Radic JAE, Cochrane DD. Choosing wisely canada: pediatric neurosurgery recommendations. Paediatr Child Health. 2018;23(6):383-387. doi:10.1093/pch/pxy012.
49. Rao D, Scuderi G, Scuderi C, Grewal R, et al. The use of imaging in management of patients with low back pain . J Clin Imaging Sci. 2018 Aug 24; 8:30.
50. Scoliosis Research Society (SRS). Conditions and treatments: Juvenile scoliosis. 2019.
51. Shah LM, Salzman KL. Imaging of spinal metastatic disease. Int J Surg Oncol. 2011; 2011:769753.
52. Sieper J, Rudwaleit M, Baraliakos X, et al. The assessment of SpondyloArthritis international Society (ASAS) handbook: A guide to assess spondyloarthritis. Ann Rheum Dis. June 2009; 68 Suppl 2:ii1-44.
53. Starling A, Hernandez F, Hoxworth JM, et al. Sensitivity of MRI of the spine compared with CT myelography in orthostatic headache with CSF leak. Neurology. 2013;81(20):1789-1792. doi:10.1212/01.wnl.0000435555.13695.22.
54. Stolper K, Haug JC, Christensen CT, et al. Prevalence of thoracic spine lesions masquerading as cauda equina syndrome: yield of a novel magnetic resonance imaging protocol. Intern Emerg Med. 2017 Dec; 12(8):1259-1264. doi: 10.1007/s11739-016-1565-9.
55. Strahle J, Muraszko KM, Kapurch J, Bapuraj JR, Garton HJL, Maher CO. Chiari malformation Type I and syrinx in children undergoing magnetic resonance imaging. J Neurosurg Pediatr. 2011;8(2):205-213. doi:10.3171/2011.5.PEDS1121.
56. Strahle J, Smith BW, Martinez M, et al. The association between Chiari malformation Type I, spinal syrinx, and scoliosis. J Neurosurg Pediatr. 2015; 15:607-611. http://thejns.org/doi/pdf/10.3171/2014.11.PEDS14135. Retrieved March 29, 2018.
57. Taljanovic MS, Hunter TB, Wisneski RJ, et al. Imaging characteristics of diffuse idiopathic skeletal hyperostosis with an emphasis on acute spinal fractures: Review. AJR Am J Roentgenol. 2009;193(3 Suppl):S10-19, Quiz S20-24. doi:10.2214/AJR.07.7102.
58. Teoli D, Rocha Cabrero F, Ghassemzadeh S. Lhermitte Sign. In: StatPearls. StatPearls Publishing; 2021. Accessed July 15, 2021. http://www.ncbi.nlm.nih.gov/books/NBK493237/
59. Timpone V, Patel SH. MRI of a syrinx: Is contrast material always necessary? Am J Roentgenol. 2015; 204:1082-1085. 10.2214/AJR.14.13310.
60. Trenga AP, Singla A, Feger MA, et al. Patterns of congenital bony spinal deformity and associated neural anomalies on X-ray and magnetic resonance imaging. J Child Orthop. August 2016; 10(4):343-352. doi: 10.1007/s11832-016-0752-6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4940247/. Retrieved March 29, 2018.
61. Vilaca C, Orsini M, Leite MAA, et al. Cervical spondylotic myelopathy: What the neurologist should know. Neurol Int. 2016 Nov 2; 8(4):6330. doi: 10.4081/ni.2016.6330.
62. Vitzthum H, Dalitz K. Analysis of five specific scores of cervical spondylogenic myelopathy. Eur Spine J. December 2007; 16(12):2096-2103. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2140133/.
63. Waly FJ, Abduljabbar FH, Fortin M, et al. Preoperative computed tomography myelography parameters as predictors of outcome in patients with degenerative cervical myelopathy: Results of a systematic review. Global Spine J. 2017; 7(6):521–528. doi:10.1177/2192568217701101.
64. Ziu E, Viswanathan VK, Mesfin FB. Cancer, Spinal Metastasis. [Updated 2020 Mar 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441950/. 

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, Blue Cross Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

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