New York State Medical Treatment Guidelines for Therapeutic Procedures: Operative in workers compensation patients

The guidelines provided by the New York State Workers Compensation Board aim to assist healthcare professionals in the implementation of therapeutic operative procedures. These directives support physicians and healthcare practitioners in determining the appropriateness of operative interventions as part of a comprehensive treatment plan.

Healthcare professionals specializing in operative therapeutic procedures can rely on the guidance provided by the Workers Compensation Board to make well-informed decisions about the most suitable surgical interventions for their patients.

It is important to stress that these guidelines are not meant to replace clinical judgment or professional expertise. The ultimate decision regarding therapeutic operative procedures should involve collaboration between the patient and their healthcare provider.

Discectomy, Microdiscectomy, Sequestrectomy, Endoscopic Decompression

Lumbar Discectomy

Suggested – for specific patients as advised by the clinical situation. Reasons: Opting for lumbar discectomy is advised as an effective surgical solution to expedite recovery in individuals grappling with radiculopathy stemming from persistent nerve root compression. This recommendation applies to those who endure considerable pain and functional restrictions six to 12 weeks post conservative therapy, without any progressive neurological deficits.

To proceed, the following conditions must be met: 1) manifestation of radicular pain syndrome with existing dermatomal pain and/or numbness, or myotomal muscle weakness, aligning with a herniated disc at the corresponding level; 2) confirmation through MRI or CT, with or without myelography, indicating ongoing nerve root compression at the anticipated level and side based on history and clinical examination; 3) persistent and significant pain and functional limitations persisting after six to 12 weeks of conservative therapy without progressive neurological deficits.

For individuals eligible for discectomy, it’s crucial to know that, except for cases like cauda equina syndrome and exceptionally rare progressive major neurologic deficits, there’s evidence suggesting no urgency in making surgical decisions. Whether surgery is done early or delayed, there seems to be no disparity in long-term functional recovery. The methods of open discectomy, microdiscectomy, and endoscopic discectomy are all potential approaches. The choice between them should be a collaborative decision between the surgeon and the patient, awaiting quality evidence to offer guidance.

it’s advised against as a treatment for acute or non-acute back pain lacking radiculopathy.


Percutaneous Discectomy

As for Percutaneous Discectomy, steer clear. Neither percutaneous discectomy (nucleoplasty), laser discectomy, nor disc coblation therapy is recommended for addressing any back or radicular pain syndrome.



Avoid adhesiolysis for both acute and non-acute back pain, spinal stenosis, or radicular pain syndromes.


Decompressive surgery

Consider decompressive surgery, specifically laminotomy/facetectomy laminectomy, for certain patients as advised by the clinical situation. Here’s why: It’s a recommended and effective treatment for individuals dealing with symptomatic spinal stenosis (neurogenic claudication) that doesn’t respond well to conservative management. Additionally, decompressive surgery might be necessary for patients with cauda equina syndrome resulting from disc herniation.


Spinal Fusion

Lumbar Fusion isn’t automatically approved for pre-authorization; providers intending to carry out this procedure need to seek approval from the carrier beforehand.

Consider lumbar fusion in specific patients as suggested by the clinical situation. It’s also advisable for treating spinal stenosis when concomitant spondylolisthesis is confirmed. The decision on instrumentation should be a collaborative one between the surgeon and the patient, considering factors such as the degree of instability, associated deformities/body habitus, patient age, bone quality, and medical comorbidities. However, lumbar fusion isn’t recommended for cases lacking spondylolisthesis, instability, or surgical instability and facetectomy exceeding 50% of the facets.

Conditions for lumbar fusion consideration include: 1) presence of neurogenic claudication (leg pain and/or numbness with standing or walking); 2) imaging confirmation through MRI or CT/myelogram that the compressed nerve roots align with the neurological symptoms; 3) inadequate response or unsatisfactory outcomes to sufficient conservative treatment over at least a six to eight-week period, which may or may not involve an epidural steroid injection.

Lumbar fusion is suggested as an effective treatment for both isthmic and degenerative spondylolisthesis.


Spinal fusion with a third discectomy

Consider spinal fusion with a third discectomy for specific patients who need a third lumbar discectomy at the same level. It’s a viable option during the third discectomy. Conditions for consideration involve meeting the criteria for a third discectomy on the same disc.

Additionally, contemplate it as a treatment for Degenerative Disc Disease, “Discogenic Back Pain,” or “Black Disc Disease” without instability in certain patients where non-surgical approaches haven’t provided relief or improved function. Patients should be fully aware that this procedure might not entirely alleviate symptoms and could result in no improvement. If possible, explore an intensive Functional Rehabilitation Program as the initial approach.

However, it’s not recommended for treating patients with radiculopathy from herniated nucleus pulposus (disc herniation) or those experiencing non-acute back pain following lumbar discectomy.


Electrical Bone Growth Stimulators

Electrical Bone Growth Stimulators aren’t automatically greenlit for pre-authorization; providers keen on conducting these procedures must seek approval from the carrier beforehand.

Consider them as a complementary measure to spinal fusion surgery, especially for individuals at a heightened risk of pseudoarthrosis. The indicators for consideration encompass having one or more of the following fusion failure risk factors:
1. Previous unsuccessful spinal fusions
2. Spondylolisthesis graded II or worse
3. Fusion planned for more than one level
4. Presence of other risk factors that could contribute to non-healing, such as current smoking, diabetes, renal disease, other metabolic conditions affecting bone healing (like significant osteoporosis), active alcoholism, or morbid obesity with a BMI over 40.

Suggested – for addressing individuals with unsuccessful spinal fusion. The term “failed spinal fusion” is used when a spinal fusion doesn’t show signs of healing at least six months post the initial surgery, as confirmed by consecutive x-rays taken over a three-month period during the latter part of those six months.


Disc Replacement

Okay, so here’s the deal – if you’re thinking about getting an artificial disc replacement, it’s not automatically greenlit. The powers that be want you or your doctor to give them a heads-up first. Basically, if a healthcare provider wants to go ahead with this procedure, they need to get the nod from the higher-ups before they can go ahead and do it. It’s suggested for specific cases where it makes sense, like when someone’s dealing with lower back issues and the usual treatments haven’t been doing the trick. So, it’s not a one-size-fits-all kind of thing, more like a case-by-case basis.

Alright, so here’s the lowdown on the criteria you gotta meet for this thing:

  1. You’ve gotta be fully grown and not dealing with serious health issues like kidney problems, super intense diabetes, bone troubles, or infections – basically, no major health drama.
  2. Your CT or MRI should show that you’ve got a problem with a single disc between the third lumbar vertebra and the sacrum. And it should be one of these issues: a slipped disc, bony growths, or your disc losing height.
  3. Your symptoms need to match up with what they’re planning to fix. It’s gotta be either crazy nerve pain shooting down your leg or some messed-up stuff going on in your spinal cord.
  4. Before they even think about swapping out a disc, you’ve gotta give other treatments a shot for at least six weeks. That could be things like physio, meds, wearing a brace, seeing a chiropractor, chilling in bed, getting spinal shots, or hitting the gym. They’ll need to see that you’ve tried all that and it hasn’t worked before they consider the disc switcheroo. And, of course, you gotta have the paperwork to prove it.


If you’re thinking about getting a new disc, it has to get the thumbs-up from the FDA. Anything else in the artificial disc world is basically in the experimental zone. They’re still figuring things out.

Now, here’s the ‘not recommended’ list – it’s a no-go if you’ve had surgery before on that same spot, if there’s talk of fusing nearby vertebrae, if you need more than one disc replacement in your lower back, or if the bones in that area have seen better days due to injuries. Also, if there’s an infection in your system, or specifically at the operation spot, it’s a red flag. Allergies to certain materials like titanium, polyurethane, or ethylene oxide residues are a no-no. And if your bones are feeling a bit fragile, like really bad on the density scale, they might not give you the green light for this disc swap.


Vertebroplasty and Kyphoplasty

So, if you’re thinking about getting Vertebroplasty or Kyphoplasty, it’s not automatically given the green light. Your healthcare provider needs to do a bit of paperwork and get the thumbs-up from the powers that be before they can go ahead with the procedure.

These procedures are not for everyone, but they might be on the table if you’ve got a vertebral body compression fracture causing serious pain that just won’t budge with the usual treatments. They might consider it if your pain is sticking around despite trying other options. And, if you’ve had fractures even with bisphosphonate therapy, you might be a good fit for this kind of treatment



Sacroiliac Surgery

Here’s the scoop on Sacroiliac joint fusion – it’s not automatically approved, your healthcare provider needs the green light before going ahead with it.

This procedure is not for everyone, but it might be an option if you’re dealing with Sacroiliac (SI) joint pain. Picture this: pain kicking off in your lower back and butt, maybe spreading to your hip, groin, or upper thigh. It’s not always on just one side – it could hit both. And it’s not picky – sitting, standing, sleeping, walking, or tackling stairs might make it worse. Sometimes, it’s a real pain (literally) to sit or sleep on the side that’s bothering you. Some folks struggle with things like driving or standing for too long. The pain might crank up a notch when you’re making transitions, like going from sitting to standing, standing on one leg, or climbing stairs.

But here’s the thing – before jumping into SI joint fusion, they’ve got to rule out other culprits like issues in your lower back or hip causing the pain. Gotta make sure we’re pinpointing the right problem

Considering SI joint fusion? Here’s when it might come into play:

  1. You’re feeling the pain in the area below your lower back, specifically over the back part of your pelvis. It’s got to match up with what we’d expect from SI joint pain.
  2. The pain is no joke – at least a 5 on a 0 to 10 scale. It’s not just a minor annoyance; it’s impacting your day-to-day life or putting a damper on your regular activities.
  3. We’re ruling out any widespread pain issues or general pain disorders. This is about targeting the specific pain in your SI joint, not something more general like fibromyalgia.
  4. Before even thinking about fusion, you’ve given non-surgical options a real shot for a solid 6 months. That means tweaking medications, adjusting your activity level, maybe using a brace, and hitting the exercises hard, focusing on the lower back, pelvis, SI joint, and hip. It’s a real commitment, including a home exercise program.
  5. During a physical exam, the sore spot is right where we’d expect it – over the sacral sulcus. We’re not finding similar levels of tenderness anywhere else.
  6. You’ve got some positive vibes from at least 3 of these tests – they might press on your thigh, do a squeeze, or check a few other moves to see how your SI joint reacts.
  7. When it comes to checking things out, they’ve done a thorough job: X-rays and either CT or MRI to make sure there’s nothing nasty going on, especially ruling out tumors, infections, or inflammation in your SI joint. They’re also checking your hip to make sure it’s not causing any trouble and taking a peek at your lumbar spine to rule out any nerve issues or general wear and tear causing your back or butt pain.
  8. They’ve done some fancy injections on two separate occasions, guided by images and filled with contrast to really get a clear picture. If you felt at least 75% better for the expected duration of the anesthetic, that’s a good sign.
  9. Before jumping into any major procedures, they’ve also tried out a therapeutic injection (you know, one with corticosteroids) at least once.
  10. The person doing the procedure? They’ve got some serious skills – either trained in neurosurgery or orthopedic spine surgery.
  11. And just to make sure, the surgeon has either gone through specific training for this kind of procedure or got the hospital’s blessing to perform this particular type of SI joint surgery. So, it’s not just anyone – they know their stuff.


Intraoperative Monitoring / Image Guidance / Robotic Surgery

So, when it comes to setting up thoracic and lumbar instruments, we’ve got this standard procedure called Intraoperative Monitoring – it’s like our go-to move, especially when we’re dealing with stuff like pedicle screws. During this, we might use some cool techniques like somatosensory evoked potentials (SSEP) and motor evoked potentials (MEP). Basically, it helps us keep tabs on the spinal cord and nerve roots, making sure everything’s in check, especially when we’re placing those screws.

And here’s the modern twist – we often bring in image guidance or even some robotic assistance to get these instruments in just the right spot. It’s like having an extra set of eyes to make sure things go smoothly during the surgery.

Now, this isn’t a one-size-fits-all deal. It’s all about what the surgeon thinks is best for the situation. So, if they think it’s necessary, they might throw in some intraoperative monitoring, image guidance, or even bring in the robots. It’s all about making sure things are as safe and sound as possible during the spinal surgery.


Implantable Spinal cord Stimulators (SCS)


Hey, if you’re curious about Spinal Cord Stimulators, the New York Non-Acute Pain Medical Treatment Guidelines are the go-to source for info. Just a heads-up, these stimulators aren’t automatically given the green light – they’re not on the pre-authorized procedures list. So, if a provider’s thinking of going ahead with it, they’ve gotta shoot a pre-authorization request over to the carrier before diving into the procedure

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