Keywords
percutaneous procedures - denervation - facetary - facet joints - terminology - legislation
Palavras-chave
procedimentos percutâneos - denervação - facetária - facetas - terminologia - legislação
Introduction
Lower back pain is one of the most frequent disorders affecting the population, with
∼ between 60 and 80% of people presenting at least one episode of pain.[1] The treatment is often complex, with an important economic and social impact. In
∼ between 15 and 45% of the cases, some authors believe that low back pain has a larger
component originating from lumbar facets (or zygapophyseal joints).[2]
[3] Among the main characteristics of the lumbar pain with facet origin, in addition
to the pain in the lumbar region itself, there is also an increase in pain intensity
with spine extension; irradiation of the pain to the posterior region of the thigh
but not below the knees, pain on palpation of posterior spine elements and response
to pain control with injection of perifaceted local anesthetics or in the medial dorsal
branch region.[2]
[3] Based on this physiopathological concept, surgical procedures for cutaneous blocking
(temporary or definitive) of the pain impulse from the facets have been used in the
diagnosis (such as therapeutic tests) or in the treatment of the so-called facet pain.[4]
[5]
The present article aims to discuss the Brazilian terminology and legislation regarding
the faceted percutaneous procedures for the treatment of lumbar pain, since the theme
is constantly the target of disputes between health practitioners.
Definitions and Terms
The term "rhizotomy" is often used in the description of the percutaneous treatment
of facet pain. "Rizo" refers to the roots, while "Tomy" means section or "Cut." The
term rhizotomy is often used as a synonym to "neurotomy," a term that refers to the
section or cut of a nerve or nervous root. The term denervation seems to be more appropriate,
since it means depriving an area of a specific nerve, but not necessarily cutting
it, being, thus, more appropriate.
Rhizotomies are used for the treatment of various neurosurgical diseases, such as
selective dorsal rhizotomy (SDR), used for the treatment of spasticity, especially
in patients with severe spastic diparesis or diplegia of limbs (usually related to
cerebral palsy).[6]
[7] There are also rhizotomies for treating trigeminal neuralgia, performed with alcohol
or phenol (chemical rhizomes), with a balloon (mechanical rhizotomy) or radiofrequency,
for the destruction of sensory fibers and symptoms relief.[6]
[7]
However, the present article focuses on the rhizotomies made in the spine for pain
treatment. Since the targets of the injury or anesthetic blockade are the nervous
branches and not the roots, the term rhizotomy seems incorrect, so the term used from
now on is denervation. In the lumbar spine, rhizotomies are used to damage the dorsal-medial
branches of the spinal nerves, with the aim of damaging the sensory fibers that cause
back pain related to the factional syndrome.[2]
[4] They can be chemically performed, usually with local anesthetic and corticosteroids,
or with radiofrequency injury, where an electrical current will result in selective
neural injury. In general, two or three levels should be injured so that the facets
are denervated, since innervation is generally multisegmental.[2]
[4]
Current Legislation
The Brazilian Hierarchized Classification of Medical Procedures (CBHPM, in the Portuguese
acronym) constitutes the parameter of medical payments that aims to ensure the adequate
and balanced remuneration of the medical services provided.[8] It was a result of a joint action between the Brazilian Physician Association (AMB,
in the Portuguese acronym), the Federal Council of Medicine (CFM, in the Portuguese
acronym) and medical specialty societies. The CBHPM is the responsibility of AMB,
which is also responsible for the inclusion of new items in the table.
There are four different forms of facetary percutaneous procedures described in the
CBHPM ([Table 1]).[8]
Table 1
Description of facet percutaneous procedures according to the Brazilian Medical Association
2016 Brazilian Hierarchical Classification of Medical Procedures
|
Procedure
|
Code
|
Operacional cost – size
|
Auxiliaries number
|
Anesthetic size
|
|
Percutaneuos rhizotomy per segment – any method
|
3.14.03.33–6
|
10C
|
01
|
5
|
|
Articular facet percutaneous denervation per segment
|
3.14.03.03–4
|
9C
|
01
|
4
|
|
Paraspinal facet block
|
3.16.02.12–6
|
4C
|
0
|
3
|
|
Spine: foraminal , facet or articular infiltration
|
4.08.13.35–5
|
5A
|
0
|
5
|
The unified terminology of supplementary health (TUSS, in the Portuguese acronym),
in which the codes and nomenclatures of the medical procedures are standardized in
harmony with the information of private health, determined by the information exchange
in supplementary health (TISS, in the Portuguese acronym), was created by the National
Supplementary Health Agency (ANS, in the Portuguese acronym), and its use has become
mandatory since 2010.[9] It is based on the CBHPM 5th edition. The TUSS is not a price table, but a terminological reference, and in it
five distinct lumbar faceted percutaneous procedures are described.
The Rol de Procedimentos Médicos e Eventos em Saúde (list of medical procedures and
health events) is the list of procedures, exams and treatments with mandatory coverage
by health plans.[10] It should be noted that this is the minimum coverage the health plans should offer,
it is valid for plans with contracts beginning after the 1st of January 1999, and it is revised every 2 years. The 1st list was published in 1998, and it was updated in 2001, 2004, 2008, 2010, 2011 and
2013. The current list, updated in January 2, 2016, includes 21 new procedures, such
as laboratory exams and oral medication for cancer treatment, as well as the expansion
of consultations with speech therapists, nutritionists, physical therapists and psychotherapists.[10] Currently, in the health plans contracted after January 2, 1999, the minimum coverage
of health plans is defined by the CBHPM and TUSS tables and the list of procedures
and events in health. There are also four forms of lumbar faceted percutaneous procedures
described in it.
The ANS elaborated a table with the correlation between the items in the list of procedures
and health events and the corresponding terms in the TUSS ([Table 2]).[9]
Table 2
Correlation table between the unified supplementary health terminology (see 1.0.2)
and the list of procedures and events in health of the National Agency for Supplementary
Health (RN n 262/2011 altered by RN N 281/2011)
|
TUSS code
|
Group – Subgroup – TUSS
|
Procedure TUSS
|
ANS list (RN n. 262/2011 altered by RN n. 281/2011)
|
|
40813363
|
Diagnostic and therapeutical procedures – interventional methods
|
Spine: foraminal , facet or articular infiltration
|
Extra-articular diagnnostic or therapeutical punction /artrocentesis (infiltration/dry
needling): imaging-oriented or not
|
|
31403034
|
Invasive surgical procedures – central and peripheric nervous system
|
Articular facet percutaneous denervation per segment
|
Articular facet percutaneous denervation
|
|
31403336
|
Invasive surgical procedures – central and peripheric nervous system
|
Percutaneuos rhizotomy per segment – any method
|
Percutaneuos rhizotomy
|
|
31602126
|
Invasive surgical procedures – other procedures
|
Paraspinal facet block
|
Paraspinal facet block
|
|
30715423
|
Invasive surgical procedures – musculoskeletal system
|
Radiculotomy
|
Percutaneuos rhizotomy
|
Abbreviations: ANS, National Agency for Supplementary Health; TUSS, unified supplementary
health terminology
Considering that the procedures are not detailed, there are no scientific criteria
for differentiating them. Terminologies can be used, in our opinion, to refer to the
procedure performed in a chemical or radiofrequency manner.
In the ANS 2016 list, there are four different procedures, one of which is percutaneous
rhizotomy with or without radiofrequency, with a guideline of use (DUT, in portuguese
acronym).[10]
[11] The following four procedures are described:
-
Percutaneous denervation of articular facet – Group: Central and peripheral nervous
system; Subgroup: Peripheral nerves.
-
Paraspinal facet block – Group: Other invasive procedures; Subgroup: Anesthetic nerve
blocks and neurovascular stimuli.
-
Vertebral column: Foraminal, facet or articular infiltration – Group: Diagnostic methods
per image; Subgroup: Interventional and therapeutical diagnostic methods by image.
-
Percutaneous rhizotomy with or without radiofrequency (with DUT) – Group: Central
and peripheral nervous system; Subgroup: Peripheral nerves. To use this procedure,
see DUT number 62.[11] In it, percutaneous rhizotomy with or without radiofrequency has the following criteria
for use:
Group I
-
Limitation of activities of daily living (ADLs) for at least 6 weeks;
-
Reduction > 50% of the reported pain measured by the visual analogue scale (VAS) after
facet infiltration using local anesthetic;
-
Failure in the appropriate conservative treatment.
Group II
-
4.2 Mandatory coverage for patients with focal and intense spasticity with disabling
symptoms, even after the completion of medical and treatment with a physical therapist.
-
4.3 Patients with trigeminal, glossopharyngeal, occipital or intermediate nerve neuralgia,
refractory or intolerant to continuous clinical treatment for at least 3 months.
As an important consideration, the DUT 62 published in the ANS list does not specify
the form of rhizotomy (with or without radiofrequency) for which it applies. Thus,
the technical opinion published in August 2015 by the Brazilian Column Society (SBC,
in the Portuguese acronym), disputes the ANS's DUT.[12] The requests from SBC for DUT change are summarized below:
Request n. 1: Define that this DUT applies only to cases in which the radiofrequency
method is used, and does not apply to percutaneous chemical rhizotomy. Reason: The
DUT was proposed to guide the percutaneous radiofrequency rhizotomy, not the chemical
procedure, which became systematically denied by the carriers, in many cases, based
on the DUT. Thus, the DUT should not be used for periradicular or facet infiltrations
(or percutaneous rhizotomies by chemical method)
Request n. 2: Removal of group II, which cites the exclusion criteria for the procedure.
Reasons
-
Previous surgery in another segment is not contraindication for the performance of
the radiofrequency rhizotomy;
-
Herniated discs are not contraindications to facet rhizotomies, because the degenerative
disc process can occur simultaneously in the articular facets.
-
Cases of lumbar stenosis can be beneficiated by rhizotomies when the lumbar pain component
is more exuberant.
Request n. 3: Inclusion of the considerations elaborated by the Brazilian Society
of Neurosurgery (SBN, in the Portuguese acronym) related to the use of radiofrequency
in treating spinal diseases, published in June 2014.
Reason: In document SBN-89/2014,13 The SBN elaborates a document directed to the health
plans carriers due to the constant denials they gave to patents for facet and periradicular
infiltrations, based on DUT 62. In the document, SBN clarifies that the DUT of the
ANS refers exclusively to radiofrequency rhizotomies, and cannot be extrapolated to
facet or periradicular infiltrations. Moreover, it proposes that radiofrequency rhizotomy
should have higher fees than those of infiltrations, since it requires a longer time
of radiological exposure, knowledge and management of technological resources and
locational tests that precede the ablation. Finally, they emphasize that the DUT does
not contemplate the exceptions, already exposed above in the SBC document. The document
concludes with the consideration that the tomography or radioscopy-guided infiltrations
correspond, in technical terms, to percutaneous rhizotomy by chemical agents and,
therefore, it should be charged the same as the CBHPM code 3.14.03.33.6 (Percutaneous
rhizotomy by any method per segment — 10C).
Discussion
Firstly, lack of definition for the terminology leads to different types of interpretations,
which can make health plan carriers classify interventions as small size procedures,
despite their technical characteristics, to decrease the compensation paid to health
professionals. In our interpretation, considering the previous exposure, where the
"rhizotomy" or "radiculotomy" corresponds to the section of nerves, we believe that
the term "denervation" should be used preferentially. The terms rhizotomy and radiculotomy
would not be used for percutaneous procedures in the spine, be they with local anesthetic,
any other chemical method or even radiofrequency.
Moreover, according to the SBN-89/2014 evaluation and the attached justification,
percutaneous radiofrequency denervation should be considered more complex than chemical
denervation.[13]
The facet blockade with local anesthetic, necessary for the diagnosis of facet syndrome
and a prerequisite for the use of radiofrequency, requires the same technical nuances
as the facet denervation by chemical method, therefore they can be under a single
code, since it represents the same procedure.
In this way, hierarchically, there would be the definition of two procedures:
-
Percutaneous denervation by chemical method (including diagnostic facet block with
local anesthetic) by segment
-
Radiofrequency percutaneous denervation - with revision of the DUT 62, according to
the suggestion of the SBN and the SBC, by segment.
Even more so, although the operational size is similar, it is essential to separate
the foraminal (epidural) infiltrations from the facet ones, since they have distinct
clinical indications as well as different complication profiles. Epidural infiltrations
could be described, as follows, in three groups:
-
foraminal steroids and/or local anesthetic infiltration per segment
-
interlaminar steroids and/or local anesthetics infiltration per segment
-
caudal steroids and/or local anesthetics infiltration
Conclusions
Terminology unification and the abolition of redundancies in the tables, referring
to the same procedures with different hierarchizations, are fundamental to reduce
litigations between physicians and health carriers. In addition, it allows better
future scientific studies, both evaluating the effectiveness of the methods and cost.
In the present article, we present a proposal of a single terminology and hierarchization
of the facet percutaneous procedures used for the treatment of lumbar pain.
