MRI Lumbar Spine - CAM 709

Description
Magnetic resonance imaging (MRI) is used in the evaluation, diagnosis, and management of spine-related conditions, e.g., degenerative disc disease, cauda equine compression, radiculopathy, infections, or cancer in the lumbar spine. MRI provides high quality multiplanar images of organs and structures within the body without the use of x-rays or radiation. In the lumbar area where gonadal exposure may occur, MRI’s lack of radiation is an advantage.

OVERVIEW
Ankylosing Spondylitis/Spondyloarthropathies is a cause of back or sacroiliac pain of insidious onset (usually > 3 months), associated with morning stiffness not relieved with rest (usually age at onset < 40). It is 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

Table 1: Gait and spine imaging‡ 

Gait

Characteristic

Work up/Imaging

Hemiparetic

Spastic unilateral, circumduction

Brain and/or, Cervical spine imaging based on associated symptoms

Diplegic

Spastic bilateral, circumduction

Brain, Cervical and Thoracic Spine imaging

Myelopathic

Wide based, stiff, unsteady

Cervical and/or Thoracic spine MRI based on associated symptoms

Ataxic

Broad based, clumsy, staggering, lack of coordination, usually also with limb ataxia

Brain imaging

Apraxic

Magnetic, shuffling, difficulty initiating

Brain imaging

Parkinsonian

Stooped, small steps, rigid, turning en bloc, decreased arm swing

Brain Imaging

Choreiform

Irregular, jerky, involuntary movements

Medication review, consider brain imaging as per movement disorder Brain MR guidelines

Sensory ataxic

Cautious, stomping, worsening without visual input (ie + Romberg)

EMG, blood work, consider spinal (cervical or thoracic cord imaging) imaging based on EMG

Neurogenic

Steppage, dragging of toes

EMG→ foot drop Lumbar spine MRI

Pelvis MR appropriate evidence of plexopathy

Vestibular

Insecure, veer to one side, worse when eyes closed, vertigo

Consider Brain/IAC MRI as per GL

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

*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**, and/or osteopathic manipulative medicine (OMT) or chiropractic care.

**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; AND
  • 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 2: MRI and Cutaneous Stigmata (Dias, 2015) 

Risk Stratification for Various Cutaneous Markers

High Risk

Intermediate Risk

Low Risk

 

• Hypertrichosis

• Infantile hemangioma

• Artretic meningocele

• DST

• Subcutaneous lipoma

• Caudal appendage

• Segmental hemangiomas in association with LUMBAR‡ syndrome

 

 

• Capillary malformations (also referred to as NFS or salmon patch when pink and poorly defined or PWS when darker red and well-defined)

 

 

• Coccygeal dimple

• Light hair

• Isolated café au lait spots

• Mongolian spots

• Hypo- and hypermelanotic macules or papules

• Deviated or forked gluteal cleft

• Nonmidline lesions

 

‡LUMBAR, lower body hemangioma and other cutaneous defects, urogenital abnormalities, ulcerations, myelopathy, bony defects, anorectal malformations, arterial anomalies, and renal anomalies.

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

MRI and Back Pain MRI is the initial imaging modality of choice in the evaluation of complicated low back pain. Contrast administration may be used to evaluate suspected inflammatory disorders, e.g., discitis, and it is useful in evaluating suspected malignancy. Radiculopathy, disease of the nerve roots, is the most common indication for MRI of patients with low back pain. The nerve roots become irritated and inflamed, due to direct pressure from degenerative changes in the lumbar spine, creating pain and numbness. Symptoms of radiculopathy also include muscle weakness. MRI is indicated for this condition if the symptoms do not improve after conservative treatment over six weeks. MRI is also performed to evaluate Cauda equina syndrome, severe spinal compression.

Sacral Dimples - Simple midline dimples are the most commonly encountered dorsal cutaneous stigmata in neonates and indicate low risk for spinal dysraphism. Only atypical dimples are associated with a high risk for spinal dysraphism, particularly those that are large (>5 mm), high on the back (>2.5 cm from the anus) or appear in combination with other lesions (D’Alessandro, 2009). High-risk cutaneous stigmata in neonates include hemangiomas, upraised lesions (i.e., masses, tails, and hairy patches), and multiple cutaneous stigmata (Table 2).

Tethered spinal cord syndrome – This is a neurological disorder caused by tissue attachments that limit the movement of the spinal cord within the spinal column. Although this condition is rare, it can continue undiagnosed into adulthood. The primary cause is myelomeningocele and lipomyelomeningocele; the following are other associations that vary in severity of symptoms and treatment.

  • Dermal sinus tract (a rare congenital deformity)
  • Diastematomyelia (split spinal cord)
  • Lipoma
  • Tumor
  • Thickened/tight filum terminale
  • History of spine trauma/surgery
  • Arnold-Chiari Malformation

Magnetic resonance imaging (MRI) can display the low level of the spinal cord and a thickened filum terminale, the thread-like extension of the spinal cord in the lower back. Treatment depends upon the underlying cause of the tethering. If the only abnormality is a thickened, shortened filum then limited surgical treatment may suffice.

Spina Bifida Occulta (AANS, 2020)  

  • Called the hidden spina bifida, as the spinal cord and the nerves are usually normal and there is no opening on the skin on the back.
  • This subtype occurs in about 12% of the population and the majority of people are not aware that they have spina bifida occulta unless it is discovered on an x-ray performed for an unrelated reason.
  • Approximately 1 in 1,000 individuals can have an occult structural finding that leads to neurological deficits or disabilities as bowel or bladder dysfunction, back pain, leg weakness or scoliosis.

Back Pain with Cancer - History Radiographic (x-ray) examination should be performed in cases of back pain when a patient has a cancer history. This can make a diagnosis in many cases. This may occasionally allow for selection of bone scan in lieu of MRI. 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).

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 (as listed above)
    • Achilles reflex absent on both sides
    • Sexual dysfunction that can come on suddenly
    • Absent anal reflex and bulbocavernosus reflex

MRI and Neurocutaneous Syndromes 

  • In NF-1, clinical evaluation appears to be more useful to detect complications than is screening imaging in asymptomatic patients. Imaging is indicated in evaluation of suspected tumors based on clinical evaluation and for follow-up of known intracranial tumors (Borofsky, 2013).
  • Conversely in NF-2, routine MR imaging screening is always indicated, given the high prevalence of CNS tumors, especially vestibular schwannomas. In patients with NF-2, routine screening brain/IAC imaging is indicated annually starting from age 10, if asymptomatic, or earlier with clinical signs/symptoms. Most individuals with NF2 eventually develop a spinal tumor, mostly commonly schwannomas, but meningioma and ependymomas are also seen. Spinal imaging at baseline and every 2 to 3 years is also advised with more frequent imaging, if warranted, based on sites of tumor involvement (Evans, 2017).
  • In patients with Tuberous Sclerosis, Brain MRI should be obtained every 1-3 years up until age 25 for surveillance for CNS abnormalities (Krueger, 2013).
  • In Von Hippel Lindau Syndrome, imaging of the brain and spinal cord for hemangioblastomas is recommended every 2 years (Varshney, 2017).
  • In Sturge Weber Syndrome, Brain MRI can rule out intracranial involvement only after age 1 and is recommended in patients <1 year only if symptomatic (Comi, 2011).

Policy
LUMBAR SPINE MRI is considered MEDICALLY NECESSARY for the following indications:

(Combination requests at end of the document)

For evaluation of neurologic deficits (Acharya, 2019; ACR, 2013; NASS, 2010; Stolper, 2017)

  • With any of the following new neurological deficits documented on physical exam
    • Extremity muscular weakness
    • Pathologic or abnormal reflexes
    • Absent/decreased sensory changes along a particular lumbar dermatome (nerve distribution): pin prick, touch, vibration, proprioception or temperature
    • Lower extremity increased muscle tone/spasticity
    • New onset bowel or bladder dysfunction (e.g., retention or incontinence)
    • Gait abnormalities (see Table 1 for more details)
    • New onset foot drop
  • Cauda Equina Syndrome as evidence by severe back pain/sciatica along with one of the defined symptoms (see Background section)

For evaluation of back pain with any of the following (AAFP, 2012; ACEP, 2014; ACR, 2015; Allegri, 2016; Ammendolia, 2015; Jarvik, 2015; Last, 2009; NASS, 2013; Quaseem, 2017; Schneider, 2019)

  • 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) months
  • 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 lumbar radiculopathy. (EMG is not recommended to determine the cause of axial lumbar, thoracic, or cervical spine pain (NASS, 2013)).
  • Isolated back pain in pediatric population (ACR, 2016) – conservative care not required if red flags present (see combination request below  cervical and thoracic spine may also be indicated)
    • 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 <5yo) AND initial radiographs have been performed (Bernstein, 2007; Feldman, 2006)
    • Back pain associated with suspected inflammation, infection, or malignancy

As part of initial post-operative / procedural evaluation ("CT best examination to assess for hardware complication, extent of fusion" (ACR, 2015; Rao, 2018) and MRI for cord, nerve root compression, disc pathology or post-op infection) 

  • For preoperative evaluation/planning
  • 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))
  • 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)
  • Changing neurologic status post-operatively
  • Surgical infection as evidenced by signs/symptoms, laboratory, or prior imaging findings
  • Residual or new neurological deficits or symptoms (Rao, 2018)- 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 required (Fisher, 2013)
    • Combination requests where both lumbar spine CT and MRI lumbar spine are both approvable (not an all-inclusive list)
      • 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 trauma or acute injury (ACR, 2018) 

  • Presents with any of the 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 or diffuse idiopathic skeletal hyperostosis) both MRI and CT are approvable (Koivikko, 2008)
  • 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") (ACR, 2018).

Pars defect (spondylolysis) or spondylolisthesis 

  • Pars defect (spondylolysis) or spondylolisthesis in adults when Flexion/Extension x-rays show instability
  • Clinically suspected Pars defect (spondylolysis) which is not seen on plain films in pediatric population (<18 yr) (flexion extension instability not required) and imaging would change treatment (Cohen, 2005; Kobayashi, 2013; Rush, 2015)

NOTE: Initial imaging (x-ray, or planar bone scan without SPECT; Bone scan with SPECT is superior to MRI and CT in the detection of pars intrarticularis pathology including spondylolysis) (Matesan, 2016).

For evaluation of known or new compression fractures (ACR, 2018)

  • With history of malignancy
    • To aid in differentiation of benign osteoporotic fractures from metastatic disease 
      • A follow up MRI in 6-8 weeks after initial MRI when initial imaging cannot decipher benign osteoporotic fracture from metastatic disease
  • With an associated new focal neurologic deficit as above
  • Prior to a planned surgery/intervention or if the results of the MRI will change management.

For evaluation of tumor, cancer, or metastasis with any of the following (MRI is usually the preferred study, but CT may be needed to further characterize solitary indeterminate lesions seen on MRI) (Kim, 2012; McDonald, 2019; Roberts, 2010)

Primary tumor 

  • Initial staging or re-staging of a known primary spinal tumor
  • Known primary 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 above (Alexandru, 2012)

Metastatic tumor 

  • With evidence of metastasis on bone scan needing further clarification OR inconclusive findings on a prior imaging exam
  • Known malignancy with new signs or symptoms (e.g., new or increasing nontraumatic pain, physical, laboratory, and/or imaging findings) in a tumor that tends to metastasize to the spine
  • With an associated new focal neurologic deficit (Alexandru, 2012)
  • Initial imaging of new or increasing non-traumatic back pain or radiculopathy or back pain that occurs at night and wakes the patient from sleep with known active cancer and a tumor that tends to metastasize to the spine (ACR, 2018; Ziu, 2020)

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 (ACR, 2018)

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, or inflammatory disease (ACR, 2015; Lerner, 2018) 

  • Infection
    • As evidenced by signs and/or symptoms, laboratory (i.e., abnormal white blood cell count, ESR and/or CRP) or prior imaging findings (Bond, 2016)
    • Follow-up imaging of infection
      • With worsening symptoms/laboratory values (i.e., white blood cell count, ESR/CRP) or radiographic findings (Berbari, 2015)
  • Spondyloarthropathies
    • Ankylosing Spondylitis/Spondyloarthropathies with non-diagnostic or indeterminate x-ray and rheumatology workup

For evaluation of spine abnormalities related to immune system suppression, e.g., HIV, chemotherapy, leukemia, or lymphoma (ACR, 2018)

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

Other Indications for a Lumbar Spine MRI

(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 (AANS, 2019; Duz, 2008; Milhorat, 2009)
  • Known anorectal malformations (Kim, 2010a; Morimoto, 2003)
  • Suspicious sacral dimple (those that are deep, larger than 0.5 cm, located within the superior portion of the gluteal crease or above the gluteal crease, multiple dimples, or associated with other cutaneous markers) (D’Alessandro, 2009) or duplicated or deviated gluteal cleft (Zywicke, 2011)
    • in patients <3 months should have ultrasound
  • 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))
  • Known Chiari II ( Arnold-Chiari syndrome), III, or IV malformation.
  • For follow-up/repeat evaluation of Arnold-Chiari I with new signs or symptoms suggesting recurrent spinal cord tethering (For initial diagnosis see below)

COMBINATION OF STUDIES WITH LUMBAR SPINE MRI

Indications for combination studies: (ACR, 2017, 2019) - For approved indications as noted below and being performed in a child under 8 years of age who will need anesthesia for the procedure

Any combination of Cervical and/or Thoracic and/or Lumbar MRIs

  • Any combination of these studies for: 
    • Scoliosis survey in infant/child with congenital scoliosis or juvenile idiopathic scoliosis under the age of 10 (ACR, 2018; SRS, 2019; Strahle, 2015)
    • In the presence of neurological deficit, progressive spinal deformity, or for preoperative planning (Trenga, 2016)
    • Back pain and vertebral anomalies (hemivertebrae, hypoplasia, agenesis, butterfly, segmentation defect, bars, or congenital wedging) in a child on preliminary imaging
    • Scoliosis with any of the following (Ozturk, 2010):
      • Progressive spinal deformity;
      • Neurologic deficit;
      • 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 I (Radic, 2018; Strahle, 2011)
    • 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 (Milhorat, 2009; Strahle, 2015).
  • Arnold Chiari II-IV
    • For initial evaluation and follow-up as appropriate
  • Tethered cord, or spinal dysraphism (known or suspected) based on preliminary imaging, neurological exam, and/or high-risk cutaneous stigmata (AANS, 2019; Duz, 2008; Milhorat, 2009), when anesthesia is required for imaging (Hertzler, 2010)
  • 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))
  • Back pain in a child with any of the following red flags (conservative care not required when 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 <5yo) AND initial radiographs have been performed (Bernstein, 2007; Feldman, 2006)
  • Drop metastasis from brain or spine (imaging also includes brain)
  • Suspected leptomeningeal carcinomatosis (LC) (Shah, 2011)
  • Any combination of these for spinal survey in patient with metastases
  • Tumor evaluation and monitoring in neurocutaneous syndromes - See Background
  • 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))

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Coding Section

Codes

Number

Description

CPT

72148

Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; without contrast material

 

72149

with contrast material(s)

 

72158

lumbar

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 and 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.

"Current Procedural Terminology © American Medical Association.  All Rights Reserved" 

History From 2019 Forward 

12/07/2021  Annual review, updating policy criteria, description and references. 
12/01/2020 Annual review, adding criteria for new neurologic deficits, ankylosing spondylitis, metastatic disease. Also adding clarifying language to existing criteria. Updating references and description. 
12/02/2019               NEW POLICY
Complementary Content
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