MRI Thoracic Spine - CAM 710

Description
Magnetic resonance imaging (MRI) produces high quality multiplanar images of organs and structures within the body without using ionizing radiation. It is used for evaluation, assessment of severity, and follow-up of diseases of the spine and is the preferred modality for imaging intervertebral disc degeneration. High contrast resolution (soft tissue contrast) and multiplanar imaging (sagittal as well as axial planes) are helpful in the evaluation of possible disc herniation and detecting nerve root compression. MRI is one of the most useful techniques to evaluate spine infection and is also used to evaluate tumors, cancer, and immune system suppression. 

OVERVIEW
Ankylosing Spondylitis/Spondyloarthropathies is a cause of back or sacroiliac pain of insidious onset (usually > 3 month), 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

*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 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 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.

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

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 (i.e., + 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)

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.

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).

Ossification Posterior Longitudinal Ligament (OPLL) (Choi, 2011) - Most common in cervical spine (rare but more severe in thoracic spine)

Tethered spinal cord syndrome - 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.

MRI and Spinal Infections Infection of the spine is not easy to differentiate from other spinal disorders, e.g., degenerative disease, spinal neoplasms, and noninfectious inflammatory lesions. Infections may affect different parts of the spine, e.g., vertebrae, intervertebral discs and paraspinal tissues. Imaging is important in obtaining an early diagnosis and treatment to avoid permanent neurologic deficits. MRI is the preferred imaging technique to evaluate infections of the spine. With its high contrast resolution and direct multiplanar imaging, it has the ability to detect and delineate infective lesions irrespective of their spinal location.

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).

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 

Spinal MRI and Neuromyelitis optica spectrum disorders (NMOSD) - NMOSD are inflammatory disorders of the central nervous system characterized by severe, immune-mediated demyelination and axonal damage predominantly affecting the optic nerves and spinal cord, but NMOSD may also affect the brain and brainstem. NMOSD can be distinguished from multiple sclerosis and other inflammatory disorders by the presence of the aquaporin-4 (AQP4) antibody. Features of NMOSD include attacks of bilateral or sequential optic neuritis acute transverse myelitis and the area postrema syndrome (with intractable hiccups or nausea and vomiting). The evaluation of suspected NMOSD entails brain and spinal cord neuroimaging. In contrast to MS (in which spinal cord involvement tends to be incomplete and asymmetric), NMOSD have a longer extent of spinal cord demyelination generally involving three or more vertebral segments.

Policy
INDICATIONS FOR THORACIC SPINE MRI
(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 o Pathologic (e.g., Babinski, Lhermitte's sign, Chaddock Sign) or abnormal reflexes (Teoli, 2021)
    • 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
    • New onset bowel or bladder dysfunction (e.g., retention or incontinence)
    • Gait abnormalities (see Table 1 for more details)
  • Suspected cord compression with any neurological deficits as listed above.

For evaluation of back pain with any of the following
(Allegri, 2016; AANSCNS, 2014; Jarvik, 2015)

  • With new or worsening objective neurologic deficits (as listed above) on exam
  • 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 thoracic 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 lumbar 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
  • Prior to spinal cord stimulator to exclude canal stenosis if no prior MRI imaging of the thoracic spine has been done recently (Carayannopoulos, 2019)
  • 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 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) (Choi, 2011)
      • 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
(ACR, 2015; Behrbalk, 2013; Davies, 2018; Sarbu, 2019; Vilaca, 2016)

  • Does NOT require conservative care
  • Progressive symptoms including hand clumsiness, worsening handwriting, difficulty with grasping and holding objects, diffuse numbness in the hands, pins and needles sensation, increasing difficulty with balance and ambulation
  • Any of the neurological deficits as noted above 

For evaluation of known or suspected multiple sclerosis (MS)
(ACR, 2015; CMSC, 2018; Filippi, 2016; Kaunzner, 2017)

  • Suspected or known MS with new or changing symptoms suggesting underlying thoracic spinal cord disease (i.e., transverse myelitis, progressive myelopathy)
  • Suspected or known pediatric demyelinating diseases (MS/ADEM)
  • Combination studies for MS
    • Cervical and/or Thoracic MRI for evaluation of suspected multiple sclerosis (MS) when Brain MRI does not fulfill diagnostic criteria (Filippi, 2016)
    • Cervical and/or Thoracic MRI with suspected transverse myelitis-with appropriate clinical symptoms (e.g., bilateral weakness, sensory disturbance, and autonomic dysfunction which typically evolve over hours or days)
    • Brain MRI with Cervical and/or Thoracic MRI for evaluation of neuromyelitis optica spectrum disorders (recurrent or bilateral optic neuritis; recurrent transverse myelitis) (Wingerchuk, 2015)
    • Known MS, entire CNS axis (Brain, and/or Cervical and/or Thoracic spine) is approvable prior to the initiation or change of disease modification treatments and assess disease burden (to establish a new baseline)
    • Follow-up scans, including brain and spine imaging, if patients have known spine disease:
      • 6-12 months after starting/changing treatment
      • Every 1-2 years while on disease-modifying therapy to assess for subclinical disease activity, less frequently when stable for 2-3 years

For evaluation of trauma or acute injury (ACR, 2018)

  • 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 are approvable (ACR, 2021; Koivikko, 2008; Taljanovic, 2009)
  • 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).

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 (indeterminate) benign osteoporotic fracture from metastatic disease (Kumar, 2016)
  • 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 occurs at night and wakes the patient from sleep with known active cancer and a tumor that tends to metastasize to the spine (McDonald,2019; Ziu, 2019)

For evaluation of inconclusive 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 appropriate rheumatology workup

For evaluation of spine abnormalities related to immune system suppression, e.g., HIV, chemotherapy, leukemia, or lymphoma
(ACR, 2015)

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

Other Indications for a Thoracic 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 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 pathology (Hitson, 2015)
    • 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 (Timpone, 2015))
    • To further characterize a suspicious abnormality seen on prior imaging
    • Known syrinx with new/worsening symptoms
  • 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))

COMBINATION STUDIES WITH THORACIC 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 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

72146

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

 

72147

with contrast material(s)

 

72157

thoracic

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.

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

History From 2019 Forward 

12/01/2021  Annual reivew, updating policy criteria, description and references. 
11/05/2020  Annual review, updating policy to include expanded verbiage for trauma/injury, metastatic disease, transverse myelitis and new neurologic deficits. Also adding clarifying language for other criteria. Updating description and references 
12/3/2019               NEW POLICY
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