Medical Policy



Subject: Epiduroscopy
Document #: SURG.00073 Current Effective Date:    06/28/2017
Status: Reviewed Last Review Date:    05/04/2017

Description/Scope

This document addresses epiduroscopy, also known as epidural spinal endoscopy or epidural myeloscopy, an endoscopic procedure where the epidural space is explored for the diagnosis and treatment of radicular spinal pain.

Note: Please see the following related document for additional information:

Position Statement

Investigational and Not Medically Necessary:

Epiduroscopy, also known as epidural spinal endoscopy or epidural myeloscopy, is considered investigational and not medically necessary.

Rationale

There is insufficient scientific evidence in the peer-reviewed medical literature to determine the safety and efficacy of epiduroscopy as a diagnostic procedure or as a technique to guide interventional therapy.

Dashfield and colleagues (2005) reported on a study randomizing 60 participants with sciatica undergoing steroid injection with or without epiduroscopy guidance. No significant differences in outcomes were identified between the two groups. Ruetten and colleagues (2003) used epiduroscopy to guide interventions in 93 participants with chronic back-leg pain syndrome. Intervention was performed based on clinical judgment; therefore, this study does not permit an analysis of epiduroscopy, as a contributing modality to the overall treatment. In a review article, Gill and colleagues (2005) reported on 12 cases of visual impairment as a complication of epiduroscopy, considered a rare but significant complication of the procedure, in which a bolus injection of fluid resulted in a sudden increase in cerebrospinal fluid pressure and compression of the optic nerve.   

Bosscher and colleague (2012) used spinal canal endoscopy to study the spinal segment(s) where pain was elicited via endoscopic evaluation vs. the vertebral level from where the pain was thought to originate, as determined by clinical evaluation and by MRI. A total of 143 individuals who underwent spinal canal endoscopy (epiduroscopy) were asked whether pain generated by pressure upon epidural structures with the tip of an endoscope was similar in character and distribution (concordant) to the pain for which the individuals sought treatment. The segmental level determined to be the locus of pathology was reviewed in the clinical evaluation and MRI reports and then tabulated; 125 (87%) participants reported maximal reproducible pain at a specific level during epiduroscopy. The most common level was at L4 to L5. The least common level was L5 to S1. In 40 participants, the level determined by clinical evaluation correlated with the level at which pain could be reproduced during epiduroscopy. In 28 participants, the MRI indicated a specific vertebral level that corresponded to the level at which pain could be reproduced with epiduroscopy. The authors concluded that epiduroscopy is more reliable than is either clinical evaluation or MRI for determining the vertebral level where clinically significant spinal pathology occurs. However, this study was small, not randomized or blinded and had the potential for bias.  

Background/Overview

Epiduroscopy, also known as epidural spinal endoscopy or epidural myeloscopy, is a procedure in which a steerable or controllable flexible endoscope is used to visually examine the epidural anatomic structures to find epidural adhesions, fibrosis and scars. Although the procedure is mainly used for the visualization of the epidural space, treatments such as mechanical or laser lysis of spinal adhesions or introduction of steroids to areas of inflamed tissues may also be performed. The purported benefits of epiduroscopy are that it may be used both as a diagnostic, as well as an intervention for low back pain. The Myelotec Myeloscope (Myelotec, Inc. Roswell, GA) device was cleared by the U.S. Food and Drug Administration (FDA) in September 1996.

Definitions

Endoscope: A highly flexible viewing instrument with capabilities of diagnostic and therapeutic functions through special channels. 

Endoscopy: The visual inspection of any cavity of the body by means of an endoscope.

Radiculopathy: Any disease of the spinal nerve roots and spinal nerves; radiculopathy is characterized by pain which seems to radiate from the spine to extend outward to cause symptoms away from the source of the spinal nerve root irritation; causes of radiculopathy include deformities of the discs between the building blocks of the spine (the vertebrae).

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services are Investigational and Not Medically Necessary:
When the code describes a procedure indicated in the Position Statement as investigational and not medically necessary.

CPT  
64999 Unlisted procedure, nervous system [when specified as epiduroscopy]
   
ICD-10 Procedure  
00JU4ZZ Inspection of spinal canal, percutaneous endoscopic approach
00JV4ZZ Inspection of spinal cord, percutaneous endoscopic approach
   
ICD-10 Diagnosis  
  All diagnoses
   
References

Peer Reviewed Publications:

  1. Bosscher HA, Heavner JE. Diagnosis of the vertebral level from which low back or leg pain originates. A comparison of clinical evaluation, MRI and epiduroscopy. Pain Pract. 2012; 12(7):506-512.
  2. Dashfield AK, Taylor MB, Cleaver JS, Farrow D. Comparison of caudal steroid epidural with targeted steroid placement during spinal endoscopy for chronic sciatica: a prospective, randomized, double-blind trial. Br J Anaesth. 2005; 94(4):514-519.
  3. Geurts JW, Kallewaard JW, Richardson J, et al. Targeted methylprednisolone acetate/hyaluronidase/clonidine injection after diagnostic epiduroscopy for chronic sciatica: a prospective, 1-year follow-up study. Reg Anesth Pain Med. 2002; 27(4):343-352.
  4. Gill JB, Heavner JE. Visual impairment following epidural fluid injections and epiduroscopy: a review. Pain Med. 2005; 6(5):367-374.
  5. Igarashi T, Hirabayashi Y, Seo N, et al. Lysis of adhesions and epidural injection of steroid/local anaesthetic during epiduroscopy potentially alleviate low back and leg pain in elderly patients with lumbar spinal stenosis. Br J Anaesth. 2004; 93(2):181-187.
  6. Ruetten S, Meyer O, Godolias G. Endoscopic surgery of the lumbar epidural space (epiduroscopy): results of therapeutic intervention in 93 patients. Minim Invasive Neurosurg. 2003; 46(1):1-4.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. U.S. Food and Drug Administration (FDA) 510(k) Premarket Notification Database. Summary of Safety and Effectiveness. Myelotec Myeloscope. No. K960194. Rockville, MD: FDA. September 4, 1996. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf/K960194.pdf. Accessed on March 8, 2017.
Index

Epidural Myeloscopy
Epidural Spinal Endoscopy
Epiduroscopy

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Document History
Status Date Action
Reviewed 05/04/2017 Medical Policy & Technology Assessment Committee (MPTAC) review. Updated References section.
Reviewed 05/05/2016 MPTAC review. Updated References section. Removed ICD-9 codes from Coding section.
Reviewed 05/07/2015 MPTAC review. Updated References section.
Reviewed 05/15/2014 MPTAC review.
Reviewed 05/09/2013 MPTAC review.
Reviewed 05/10/2012 MPTAC review. Rationale and References updated.
Reviewed 05/19/2011 MPTAC review. Rationale, Background and References updated.
Reviewed 05/13/2010 MPTAC review. Rationale, Background and References updated.
Reviewed 05/21/2009 MPTAC review. Rationale and References updated.
Reviewed 05/15/2008 MPTAC review. References updated.
  02/21/2008 The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." This change was approved at the November 29, 2007 MPTAC meeting.
Reviewed 05/17/2007 MPTAC review. References updated.
Reviewed 06/08/2006 MPTAC review. References updated.
Revised 07/14/2005 MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.  
Pre-Merger Organizations Last Review Date Document Number Title
Anthem, Inc. 07/27/2004 SURG.00052 Chronic Spine Pain Treatments/Procedures (Minimally Invasive)
WellPoint Health Networks, Inc. 09/23/2004 5.10.02 Epiduroscopy