SUBJECT: NASS Draft Model Coverage Policy on Lumbar Discectomy
Dear Dr. Wang:
On behalf of the American Association of Neurological Surgeons (AANS), the Congress of Neurological
Surgeons (CNS) and the AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves
(DSPN), we appreciate the opportunity to comment on the North American Spine Society’s draft model
coverage policy recommendation for lumbar discectomies. Lumbar discectomy is one of the most
common procedures performed in spinal surgery, and coverage recommendations may have a
significant impact on the practice of spinal surgery in the United States.
The draft coverage policy states that the indications for performing a lumbar discectomy include infection
of the disc space, cauda equina syndrome or radiculopathy. The main indication for surgical intervention
is a herniated disc with worsening neurologic motor function, weakness, bowel or bladder dysfunction
(i.e., cauda equina). Radiculopathy causing severe pain should expedite surgical intervention, forgoing a
trial of non-operative management — including epidural steroid injection. The policy does leave the
option of monitoring some milder deficits that have been stable or slowly improving. While we are
generally in agreement with the proposal, we would recommend the following revisions to the draft
policy:
- Exceptions to Period of Conservative Care. On page 3, items 3c, i and ii, the draft policy includes factors that would mitigate the need for non-operative therapy prior to surgical intervention. Listed are severe pain forcing bedrest or preventing work and unresponsive to appropriate injections and herniation resulting in functionally limiting motor weakness. We would recommend that any neurological deficit, including sensory loss, be listed as mitigating the need for conservative treatment.
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