PMCCPMCCPMCC

Search tips
Search criteria 

Advanced

 
Logo of vapaAbout author manuscriptsSubmit a manuscriptPublic Access
 
Spine (Phila Pa 1976). Author manuscript; available in PMC 2017 September 13.
Published in final edited form as:
PMCID: PMC5596507
NIHMSID: NIHMS902790

Identifying Neck and Back Pain in Administrative Data: Defining the right cohort

Structured Abstract

Study design

We reviewed existing methods for identifying patients with neck and back pain in administrative data. We compared these methods using data from the Department of Veterans Affairs.

Objective

To answer the following questions: 1) what diagnosis codes should be used to identify patients with neck and back pain in administrative data; 2) because the majority of complaints are characterized as non-specific or mechanical, what diagnosis codes should be used to identify patients with non-specific or mechanical problems in administrative data; and 3) what procedure and surgical codes should be used to identify patients who have undergone a surgical procedure on the neck or back.

Summary of background data

Musculoskeletal neck and back pain are pervasive problems, associated with chronic pain, disability, and high rates of healthcare utilization. Administrative data have been widely used in formative research which has largely relied on the original work of Volinn, Cherkin, Deyo and Einstadter and the Back Pain Patient Outcomes Assessment Team first published in 1992. Significant variation in reports of incidence, prevalence, and morbidity associated with these problems may be due to non standard or conflicting methods to define study cohorts.

Methods

A literature review produced seven methods for identifying neck and back pain in administrative data. These code lists were used to search VA data for patients with back and neck problems, and to further categorize each case by spinal segment involved, as non- specific/mechanical and as surgical or not.

Results

There is considerable overlap in most algorithms. However, gaps remain.

Conclusions

Gaps are evident in existing methods and a new framework to identify patients with neck and back pain in administrative data is proposed.

Keywords: Back pain, Neck pain, Low back pain, Back Pain/epidemiology, Databases, Factual, Disease/classification, Health Services Research

Neck and back pain are highly prevalent problems and administrative data are commonly used to describe the incidence, prevalence, and geographic variation in practice for these conditions.111 This work has largely relied on the methods published in 1992 by Volinn, Cherkin, Deyo and Einstadter and the Back Pain Patient Outcomes Assessment Team (BOAT)12, 13, 14 that identified neck and back pain from ICD-915 codes and used hospitalization as a proxy for morbidity.1214, 16, 17 This original work has led to a broad range of research on neck and back problems using hospital, workers’ compensation and Medicare data. 1825 More recently, the International Society for Pharmacoeconomics and Outcomes Research26 has adopted guidelines for conducting and reviewing research using retrospective administrative databases, but this guideline, while successful in creating an international standard for doing this type research, does not address the idiosyncracies of spine data. With these new guidelines and two decades of changes in medical practice24 as well as a change in focus from analyzing events to evaluating episodes of care,27, 28 a revised methodology may be needed. The purpose of this study was to review methods used to identify patients with neck or back pain in administrative data and, if appropriate, establish a revised framework. Our objective for these analyses was to answer three questions: 1) what diagnosis codes should be used to identify patients with neck and back pain in administrative data; 2) because the majority of complaints are characterized as non-specific or mechanical, what diagnosis codes should be used to distinguish these particular patients in administrative data from patients with more complex problems; and 3) what diagnosis and procedure and surgical codes should be used to identify patients who have undergone surgical or invasive procedures on the neck or back.

Methods

We used a snowball sampling approach to identify algorithms used to identify patients with neck or back pain problems in administrative data. We started by searching the Web of Knowledge (Thomson Reuters Institute for Scientific Information) for articles that referenced Cherkin, Deyo’s 1992 publication.13 Next, we searched PubMed to identify studies that reported using diagnosis or procedure codes to identify these patients in administrative data, using key, words and MeSH terms; we focused on studies written in English. (Search logic is available in Appendix A) These searches plus additional recommendations identified 170 manuscripts for review. We excluded twelve papers based on review of the title (for example, conditions other than neck or back pain) and reviewed 158 abstracts and 48 manuscripts in depth. (APPENDIX B lists the manuscripts reviewed in depth.) Studies were excluded, for example, if they did not include a code algorithm or list 2931, if the study included only a limited number of diagnoses or reported on a limited number of surgical procedures 3239, or if the reports did not involve the use of previously collected administrative data. We additionally excluded studies that were not about neck or back pain, and those studies that used the original Cherkin and Deyo algorithm13, 1823 without modification. This review yielded six papers including Cherkin and Deyo13 that listed diagnosis and procedure-based algorithms for coding neck and back pain (see Table 1).1214, 16, 17, 40,

Table 1
Comparison of Coding Algorithms

Angevine et al.17 used the most limited list of diagnoses and procedures to identify care for cervical disc disease. Martin et al.40 had the broadest list of codes to estimate costs of neck and back care using the Medical Expenditure Panel Survey (MEPS). The six studies generally used the same criteria to define non-specific/mechanical neck or back pain, excluding cases with evidence of neoplasm, trauma, inflammatory spondyloarthropathies, and infection or pregnancy. Investigators additionally limited their analyses to adults (exclusion range <15 to < 20 years of age) and clinical conditions (e.g. spinal stenosis, congenital anomalies and pathologic fracture) depending on their data sources and their research questions.

To this list of six papers, we added the AHRQ Healthcare Cost and Utilization Project (HCUP) Clinical Classification Software42 algorithms for “Spondylosis; intervertebral disc disorders; other back problems” (category 205 ) and “Sprains and strains” (category 232). Category 232 - includes all body parts, but we included only those codes that refer specifically to the spine. Between the six papers and two HCUP categories, we had a total of eight coding algorithms. The inclusion and exclusion codes are listed in Appendix C. Because the Cherkin & Deyo paper 13 extended work by Volinn and Loeser,12, 43 we have not incorporated the Volinn list in this table.

These seven algorithms had varying and sometimes conflicting definitions of neck and back pain. Because of this and because current research and clinical practice guidelines differentiate between pain originating in the neck and pain originating in other areas of the spine,44, 45 we standardized our definitions for this project. We adopted the following definitions, consistent with international work9: “spine pain” includes conditions that originate anywhere in the spine; “neck pain” includes conditions that originate in the cervical spine; “back pain” includes conditions originating from the thoracic, lumbar, and sacral spine, including the coccyx; and “low back pain” includes conditions that arise from the lumbar and sacral spine, including the coccyx. 9 These conditions could be “associated with pain as well as causing radicular symptoms from compression or irritation of nerve roots”.13 Non-specific or mechanical spine pain was defined as “without primary neoplastic, infectious, or inflammatory cause” and excluding codes consistent with “pregnancy or major trauma”.13, 16

The algorithms shared many features and their differences were primarily definitional (See Appendix C). Most inclusion and exclusion criteria followed the Cherkin and Deyo13 algorithm, except Taylor, 16 which included thoracic diagnoses in the definition of back and neck problems, and the HCUP back category which included cervical and thoracic diagnoses and the diagnoses pertaining to the coccyx. The most significant differences were between the Cherkin and Deyo13 algorithm, HCUP category 205, and Martin et al.40 In these studies they differed in their definitions of neck vs. back and whether the report was about any neck and back problems, or limited to non-specific problems [e.g. whether to include or exclude ankylosing spondylitis and other inflammatory spondylopathies (720.0 – 720.9), curvatures of the spine, (737.0–737.9), acquired spondylolisthesis and other acquired deformity of the back or spine (738.4–738.5), nonallopathic lesions of the spine (739.1–739.4), anomalies of the spine (756.10–756.2), open or closed spinal fractures with and without mention of spinal cord injury (805 – 806), and other, multiple and ill-defined vertebral dislocations (839.0– 839.5)]. In addition, there are many codes for which the spinal segment is not defined (721.90; 721.91; 722.2; 722.6; 722.70; 722.90; 738.4; and 847.9; 996.4) and were included in both low back and neck pain algorithms. At the end of Appendix C, these non-specific codes and the exclusions due to conditions which were used by Cherkin and Deyo13 to define “non-specific or mechanical low back pain” are included.

To evaluate the differences in these seven algorithms, we used administrative data from the Veterans Health Administration (VA). We identified all patients who received health care services for back or neck problems in fiscal years (FY) 2002 through 2009, analyzing the VA Patient Treatment Files for inpatient utilization and the National Patient Care Database encounter files for outpatient data, using the inclusion diagnosis codes listed in Appendix C. These databases include diagnostic and procedure information for all health care services provided by VA. We searched all available diagnoses in each encounter to identify patients with any spine-related problem. NOTE, in VA up to 20 diagnoses can be included in outpatient data.

To characterize spine conditions as non-specific, we identified the first or incident spine pain event (inpatient admission or outpatient visit or encounter) for each patient in FY2002–2009 VA data, and identified those that would be excluded based on each of the diagnoses included in the “non-specific/mechanical” exclusion list (e.g. pregnancy related or due to infection or trauma). We also identified patients who had undergone a surgical or spinal procedure by procedure code.

Results

We identified 2.77 million unique patients who received care for neck and back problems in VA in fiscal years 2002 – 2009. Tables 2 and and3 demonstrate3 demonstrate the results when each selection method was added to the previous algorithm for back pain and neck pain. For example, using the Cherkin and Deyo list alone, 2,129,984 unique individuals with back problems were identified in these data (Table 2). When we add the codes included in the HCUP Back category (205), we identify an additional 33,495 individuals, and when we add the HCUP sprains and strains diagnoses, we identify an additional 3,537 individuals. Finally, when we add the codes from the expanded Martin list another 3,750 individuals are identified. For the most part these differences are definitional, e.g. the Cherkin and Deyo study was about low back pain, which they defined as including thoraco-lumbar, lumbar, lumbo-sacral and sacral symptoms, but not thoracic alone and not coccygeal, while the HCUP back category and the Martin study include all spinal segments. Table 4 demonstrates the number of individuals identified using ICD-9 codes that are not segment specific.

Table 2
Count of unique patients with back pain: sequential addition of patients by reference
Table 3
Count of unique patients with neck pain: sequential addition of patients by reference
Table 4
Count of patients identified by codes that are not specific to spinal segment

Because several of the codes that were not spinal segment specific were included in both neck pain and back pain algorithms, we continued the analyses to further define whether a patient had neck pain or back pain. We selected those cases in which a code referring to a non-specific spinal segment had served to identify the case for the cohort (e.g. in the incident event in these data) and searched for additional segment-specific codes in the first and subsequent encounters. (Table 5) We found that approximately 75 per cent of all cases included diagnoses referring to the back only, and 15 per cent referred to the neck only. The remaining 10 per cent included more than one area of the spine or combinations of codes for neck, back and non specific parts of the spine. Approximately 6.5 percent of cases included only non-specific codes.

Table 5
Count of patients by spinal segment diagnoses

Next, using the Cherkin and Deyo13 definitions, to identify patients with non-specific neck or low back pain, we excluded those cases “with a primary neoplastic, infectious, or inflammatory cause” and those “associated with pregnancy or major trauma”.13, 16 We identified the number of cases to be excluded if one of these conditions appeared in the data within one year prior to the first neck or back problem, and any years after. (Table 6) We included, “any years after” in order to control for potential prodromal conditions unidentified at first onset of the spine problem. Next, we examined the neoplasm exclusions. We hypothesized that, because diagnoses of primary skin and prostate cancers are common but rarely contribute to spine pain, and are either acutely treatable or slow-growing, asymptomatic, and non-metastatic, we removed the diagnoses for primary skin cancers (ICD-9 173.–173.9) and primary prostate cancer (ICD-9-185) from the exclusion list (NOTE exclusion of secondary malignant neoplasms - e.g. ICD codes 196–239.9- served to exclude those patients with cases of skin or prostate cancer that had advanced beyond the primary site). This served to reduce the number of cases excluded from the first step by 15 percent (from 1,000,709 cases excluded to 853,615 cases excluded). Also because administrative data that reflects health care encounters to “rule out” a diagnosis might include the diagnosis to be “ruled out”, we then demonstrated this potential effect by requiring each of the exclusionary conditions to appear in the data two or more times within 12 months46. (Table 6) This second method reduced the number of cases to exclude due to pregnancy more than 83 percent, the number due to intraspinal abcess (324.1) and osteomyelitis, etc. (730.07–730.99) by approximately 45 per cent, and the number due to neoplasm (not including primary skin and prostate cancer) by one-third.

Table 6
Defining non-specific/mechanical back or neck pain (any occurrence by ICD-9 code, not sequential exclusion)

We next reviewed the algorithms used by the authors above 13, 14, 16, 17 to characterize hospitalizations as surgical and non-surgical, and these were straightforward. In these studies, once the spinal segment and the inclusion diagnoses had been defined, surgical and non-surgical hospitalizations were defined by the presence or not, of a limited list of ICD-9 surgery codes for spinal canal decompression, laminectomy, discectomy, fusion and refusion (ICD-9 codes 03.0, 03.02, 03.09, 03.6, 80.5, 80.50–80.52, 80.59, 81.0, 81.00–81.08, 81.3–81.39), excision of bone for graft (77.70 and 77.79) and insertion or removal of an internal fixation device or bone growth stimulator (78.50, 78.59, 78.60,78.69, 78.90,78.99). Because of changes in medical practice, and because some of these procedures might more recently be performed in an outpatient setting, we added appropriate CPT codes to this surgery list (CPT Surgery/Musculoskeletal System/Spine (Vertebral Column) CPT 22100–22865 and 62263 – 63710). We found that using the ICD codes alone we identified 36,724 patients who had undergone one of the spinal surgeries identified above, and adding the CPT codes, we identified a total of 46,615 patients, a 27% increase in the number of patients identified as having undergone a surgery or procedure. (See Appendix D for detail).

Discussion

We identified five papers published since Cherkin and Deyo13 that defined algorithms to identify patients with neck or back pain in administrative data. These methods, for the most part, are based on the algorithms developed by the Back Pain Outcomes Assessment Team (BOAT) for the study of back and neck pain.13, 14, 17 modified to address the questions of individual researchers. We found that there was overlap in the definitions of neck and back conditions and that it was necessary to clarify which spinal segments were included in each classification. In addition, we found that more than 204,000 cases in our 2002 – 2009 population were assigned a diagnosis in the first encounter that was not spinal segment specific, thus requiring additional analyses to specify the appropriate spinal segment.

We found consistency in the definitions of mechanical or non-specific spine pain (exclusion of neoplasm, infectious or inflammatory causes, pregnancy, trauma, etc.) and that requiring confirmation of an exclusionary diagnosis with a second encounter with that diagnosis reduced the number of cases excluded by 32–38 percent. We also determined that removing primary skin and prostate cancers from the neoplasm exclusions reduced the number of cases excluded by 147,094 individuals (14.7%). Finally, we determined that the addition of procedure codes to surgery algorithms had the potential to identify many more cases (in this case 275 more cases) to consider when analyzing surgery in more recent data.

Our findings suggest that, rather than code lists, the research community should adopt important technical guidelines for use in studies of neck and back pain using retrospective databases. 26 First, in order to enhance utility and comparability of results9, researchers should specify the focus of their research using anatomical references to describe neck and back pain. Second, if the researchers plan to include diagnosis codes that are not spine segment specific (e.g. ICD codes 721.90; 721.91; 722.2; 722.6; 722.70; 722.90; 738.4; and 847.9) they should confirm that these non-specific codes are associated with their segments of interest with additional exploration of the data.(For example, if the code used to select a patient is 721.9, spondylosis of unspecified site without mention of myelopathy, then the researcher should search forward in the data to determine if the preponderance of data reflected a neck or back condition.) Third, researchers should consider whether exclusionary diagnoses should be confirmed with at least two encounters and whether common conditions that rarely have impact on spine pain (for example, primary skin and prostate cancer) should be removed from exclusion lists. Fourth, researchers should use relevant diagnosis and procedure and surgery codes and both inpatient and outpatient data to identify the population of patients who receive spine related surgery and procedures. Additionally, to enhance comparability, researchers should report if they exclude any of the following conditions from their cohort: ankylosing spondylitis, etc (720.0–720.9); curvatures of the spine (737.0 – 737.9, excludes congenital); acquired spondylolisthesis and other acquired deformity of the back or spine (738.4–738.5); nonallopathic lesions of the spine (739.1–739.4); anomalies of the spine (756.10–756.2); open/closed spinal fractures (805.0–806.9); and other vertebral dislocations (839.0–839.5). Finally, the research community should determine whether the above diagnostic groups should be included or excluded in analyses and reports of non-specific neck or back problems.

This study has several strengths that suggest that these recommendations will improve the validity and generalizability of studies which use this revised framework. First, the literature review identified 48 studies that reported using diagnosis and procedure codes to identify patients with neck and back conditions in administrative data. While the majority of these studies relied on the original algorithms developed by Cherkin and Deyo and the BOAT research group,13 consolidating the code list into a single table served to highlight the patterns of inclusion, exclusion and omission specific to each algorithm. This has provided an introduction to the scope of variation to be considered in defining a new framework. Second, we have tested these algorithms and assumptions in an extremely large administrative database. VA has been using an electronic health record for over ten years, and national compilations of longitudinal data have been used in this study. VA administrative data is comprehensive and includes inpatient, outpatient, ancillary and pharmaceutical care for a large population of Veterans (each year +/− 5 million Veterans receive health care services through the Veterans Health Administration). In addition, VA administrative data is routinely used to assess the quality and timeliness of care provided in VHA, and has been a primary resource for VA quality, safety and outcomes research.26, 4749 As a result, testing the algorithms on such a large data set is unlikely to miss any important trends that might be present in smaller patient populations. Third, diagnosis and procedural coding activities are highly automated and professionalized in VA. This expertise is demonstrated in the frequency reports (Tables 2, ,33 and and4)4) in which, as per correct coding conventions defined by the American Hospital Association, American Medical Association, the Centers for Medicare and Medicaid Services, and the National Center for Health Statistics, no patients are identified with three digit major codes, and no patients were identified with four digit subcodes if there was a five digit code available for more specificity (see Table 2, ICD-9 722.5, 722.51, 722.52). In VA, coding rules are integrated into the electronic data capture and all inpatient coding is done by credentialed experts. In practical terms, this means that diagnosis and procedure codes entered into the administrative data represent, in the most accurate way possible, the diagnoses, services and procedures received by an individual patient. In some cases, however, the professionalism in coding practice may also be a limitation, as it may not accurately reflect the errors produced in other environments where data entry is not automated or done by expert coders (for example see Stano and Smith).50 Only further research can confirm what errors occur and what methods should be used for correction.

Our review of the algorithms used to identify patients with neck and back problems in administrative data suggest that an update to the most commonly used algorithm is warranted. This new methodology would have the researcher use international standards9 to define the spinal segment(s) of interest, confirm anatomical references when including diagnosis codes that are not segment specific, confirm the presence of excluding diagnoses in more than a single encounter of care, and would define surgical patients using both surgical and procedure codes from both inpatient and outpatient events of interest. This new framework also includes the recommendation for specificity in reporting on the spinal segment of interest and the conditions to be included and excluded from the analyses. This methodology is not limited to the use of CPT and ICD9 codes but is appropriate for use in any epidemiological or health services research which uses administrative data for the study of neck and back pain conditions. With such a standardized methodology and reporting format, methodological variation in reports of the incidence, prevalence and outcomes of care can be minimized.

Key Points

  • Methods for identifying patients with neck and back problems in administrative data have not kept pace with changes in practice and coding.
  • A review of current methods suggests a new framework for identifying patients with neck and back pain in administrative data.
  • An updated framework to identify patients with neck and back pain in administrative data will help capture more cases for analyses.

Acknowledgments

Funding for this study was provided by the VA Health Services Research and Development Service (HSR&D IIR 09-062) and was approved by the Stanford IRB and the VA Palo Alto Health Care Research and Development program.

Appendix A: Pubmed Search Logic

Back and International Classification of Disease (ICD) and epidemiology; Neck and ICD and epidemiology; Back and ICD and surgery; Neck and ICD and surgery; Back and Common Procedure Terminology (CPT) and epidemiology; Neck and CPT and epidemiology; Back and CPT and surgery; and Neck and CPT and surgery. In addition we performed a search using a consolidation of the previous logic: ((“back pain”[MeSH Terms] OR (“back”[All Fields] AND “pain”[All Fields]) OR “back pain”[All Fields]) OR (“low back pain”[MeSH Terms] OR (“low”[All Fields] AND “back”[All Fields] AND “pain”[All Fields]) OR “low back pain”[All Fields]) OR (“neck pain”[MeSH Terms] OR (“neck”[All Fields] AND “pain”[All Fields]) OR “neck pain”[All Fields])) AND (cpt[All Fields] OR (common[All Fields] AND procedural[All Fields] AND terminology[All Fields]) OR icd[All Fields] OR icd9[All Fields] OR (international classification of diseases[All Fields] OR international classification of diseases/classification[All Fields] OR international classification of diseases/economics[All Fields] OR international classification of diseases/history[All Fields] OR international classification of diseases/instrumentation[All Fields] OR international classification of diseases/standards[All Fields] OR international classification of diseases/trends[All Fields] OR international classification of diseases/utilization[All Fields])) AND ((“surgery”[Subheading] OR “surgery”[All Fields] OR “surgical procedures, operative”[MeSH Terms] OR (“surgical”[All Fields] AND “procedures”[All Fields] AND “operative”[All Fields]) OR “operative surgical procedures”[All Fields] OR “surgery”[All Fields] OR “general surgery”[MeSH Terms] OR (“general”[All Fields] AND “surgery”[All Fields]) OR “general surgery”[All Fields]) OR (“epidemiology”[Subheading] OR “epidemiology”[All Fields] OR “prevalence”[All Fields] OR “prevalence”[MeSH Terms])

APPENDIX B

Manuscripts reviewed in depth:

  1. Cherkin DC, Deyo RA, Volinn E, Loeser JD. Use of the International Classification of Diseases (ICD-9-CM) to identify hospitalizations for mechanical low back problems in administrative databases. Spine. 1992;17(7):817–825.
  2. Dasinger LK, Krause N, Deegan LJ, Brand RJ, Rudolph L. Duration of work disability after low back injury: a comparison of administrative and self-reported outcomes. Am J Ind Med. 1999;35(6):619–631.
  3. Dasinger LK, Krause N, Deegan LJ, Brand RJ, Rudolph L. Physical workplace factors and return to work after compensated low back injury: a disability phase-specific analysis. J Occup Environ Med. 2000;42(3):323–333.
  4. Dasinger LK, Krause N, Thompson PJ, Brand RJ, Rudolph L. Doctor proactive communication, return-to-work recommendation, and duration of disability after a workers’ compensation low back injury. J Occup Environ Med. Jun 2001;43(6):515–525.
  5. Deyo RA, Mirza SK, Martin BI, Kreuter W, Goodman DC, Jarvik JG. Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA. Apr 7 2010;303(13):1259–1265.
  6. Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol. Jun 1992;45(6):613–619.
  7. Einstadter D, Kent DL, Fihn SD, Deyo RA. Variation in the rate of cervical spine surgery in Washington State. Med Care. Aug 1993;31(8):711–718.
  8. Elam K, Taylor V, Ciol MA, Franklin GM, Deyo RA. Impact of a worker’s compensation practice guideline on lumbar spine fusion in Washington State. Med Care. May 1997;35(5):417–424.
  9. Faciszewski T, Jensen R, Berg RL. Procedural coding of spinal surgeries (CPT-4 versus ICD-9-CM) and decisions regarding standards: a multicenter study. Spine (Phila Pa 1976). Mar 1 2003;28(5):502–507.
  10. Fishman P, Von Korff M, Lozano P, Hecht J. Chronic care costs in managed care. Health Aff (Millwood). May-Jun 1997;16(3):239–247.
  11. Krause N, Dasinger LK, Deegan LJ, Brand RJ, Rudolph L. Alternative approaches for measuring duration of work disability after low back injury based on administrative workers’ compensation data. Am J Ind Med. 1999;35(6):604–618.
  12. Lavis JN, Malter A, Anderson GM, et al. Trends in hospital use for mechanical neck and back problems in Ontario and the United States: discretionary care in different health care systems. CMAJ. Jan 13 1998;158(1):29–36.
  13. Lipscomb HJ, Cameron W, Silverstein B. Back injuries among union carpenters in Washington State, 1989–2003. Am J Ind Med. Jun 2008;51(6):463–474.
  14. Martin BI, Deyo RA, Mirza SK, et al. Expenditures and health status among adults with back and neck problems. JAMA. Feb 13 2008;299(6):656–664.
  15. Martin BI, Turner JA, Mirza SK, Lee MJ, Comstock BA, Deyo RA. Trends in health care expenditures, utilization, and health status among US adults with spine problems, 1997–2006. Spine (Phila Pa 1976). Sep 1 2009;34(19):2077–2084.
  16. Nilasena DS, Vaughn RJ, Mori M, Lyon JL. Surgical trends in the treatment of diseases of the lumbar spine in Utah’s Medicare population, 1984 to 1990. Med Care. Jun 1995;33(6):585–597.
  17. Nimgade A, McNeely E, Milton D, Celona J. Increased expenditures for other health conditions after an incident of low back pain. Spine (Phila Pa 1976). Apr 1 2010;35(7):769–777.
  18. Phibbs CS, Bhandari A, Yu W, Barnett PG. Estimating the costs of VA ambulatory care. Med Care Res Rev. Sep 2003;60(3 Suppl):54S–73S.
  19. Ray GT, Collin F, Lieu T, et al. The cost of health conditions in a health maintenance organization. Med Care Res Rev. Mar 2000;57(1):92–109.
  20. Romano PS, Campa DR, Rainwater JA. Elective cervical discectomy in California: postoperative in-hospital complications and their risk factors. Spine (Phila Pa 1976). Nov 15 1997;22(22):2677–2692.
  21. Stano M, Smith M. Chiropractic and medical costs of low back care. Med Care. Mar 1996;34(3):191–204.
  22. Steenstra IA, Verbeek JH, Prinsze FJ, Knol DL. Changes in the incidence of occupational disability as a result of back and neck pain in the Netherlands. BMC Public Health. 2006;6:190.
  23. Taylor VM, Anderson GM, McNeney B, et al. Hospitalizations for back and neck problems: a comparison between the Province of Ontario and Washington State. Health Serv Res. Oct 1998;33(4 Pt 1):929–945.
  24. Van Eerd D, Cote P, Beaton D, Hogg-Johnson S, Vidmar M, Kristman V. Capturing cases in workers’ compensation databases: the example of neck pain. Am J Ind Med. Jul 2006;49(7):557–568.
  25. Vogt MT, Kwoh CK, Cope DK, Osial TA, Culyba M, Starz TW. Analgesic usage for low back pain: impact on health care costs and service use. Spine (Phila Pa 1976). May 1 2005;30(9):1075–1081.
  26. Volinn E, Mayer J, Diehr P, Van Koevering D, Connell FA, Loeser JD. Small area analysis of surgery for low-back pain. Spine (Phila Pa 1976). May 1992;17(5):575–581.
  27. Wang MC, Chan L, Maiman DJ, Kreuter W, Deyo RA. Complications and mortality associated with cervical spine surgery for degenerative disease in the United States. Spine (Phila Pa 1976). Feb 1 2007;32(3):342–347.
  28. Wang MC, Laud PW, Macias M, Nattinger AB. Utility of a Combined CPT and ICD9-CM Code Algorithm in Classifying Cervical Spine Surgery for Degenerative Changes. Spine (Phila Pa 1976). Jan 17 2011.
  29. Wang MC, Kreuter W, Wolfla CE, Maiman DJ, Deyo RA. Trends and variations in cervical spine surgery in the United States: Medicare beneficiaries, 1992 to 2005. Spine (Phila Pa 1976). Apr 20 2009;34(9):955–961; discussion 962–953.
  30. Wang MC, Laud PW, Macias M, Nattinger AB. Strengths and limitations of International Classification of Disease Ninth Revision Clinical Modification codes in defining cervical spine surgery. Spine (Phila Pa 1976). Jan 1 2011;36(1):E38–44.
  31. Weinstein JN, Lurie JD, Olson PR, Bronner KK, Fisher ES. United States’ trends and regional variations in lumbar spine surgery: 1992–2003. Spine. Nov 1 2006;31(23):2707–2714.
  32. Baaj AA, Uribe JS, Nichols TA, et al. Health care burden of cervical spine fractures in the United States: analysis of a nationwide database over a 10-year period. J Neurosurg Spine. Jul 2010;13(1):61–66.
  33. Bener A, Rahman YS, Mitra B. Incidence and severity of head and neck injuries in victims of road traffic crashes: In an economically developed country. Int Emerg Nurs. Jan 2009;17(1):52–59.
  34. Besman A, Kaban J, Jacobs L, Jacobs LM. False-negative plain cervical spine x-rays in blunt trauma. Am Surg. Nov 2003;69(11):1010–1014.
  35. Bourbeau R, Desjardins D, Maag U, Laberge-Nadeau C. Neck injuries among belted and unbelted occupants of the front seat of cars. J Trauma. Nov 1993;35(5):794–799.
  36. Brolin K, von Holst H. Cervical injuries in Sweden, a national survey of patient data from 1987 to 1999. Inj Control Saf Promot. Mar 2002;9(1):40–52.
  37. Brown CV, Antevil JL, Sise MJ, Sack DI. Spiral computed tomography for the diagnosis of cervical, thoracic, and lumbar spine fractures: its time has come. J Trauma. May 2005;58(5):890–895; discussion 895–896.
  38. Campbell PG, Malone J, Yadla S, et al. Comparison of ICD-9-based, retrospective, and prospective assessments of perioperative complications: assessment of accuracy in reporting. J Neurosurg Spine. Jan 2010;14(1):16–22.
  39. Cimmino MA, Ugolini D, Cauli A, et al. Frequency of musculoskeletal conditions among patients referred to Italian tertiary rheumatological centers. Clin Exp Rheumatol. Nov–Dec 2006;24(6):670–676.
  40. Daniels AH, Arthur M, Hart RA. Variability in rates of arthrodesis for patients with thoracolumbar spine fractures with and without associated neurologic injury. Spine (Phila Pa 1976). Oct 1 2007;32(21):2334–2338.
  41. Dunning KK, Davis KG, Cook C, et al. Costs by industry and diagnosis among musculoskeletal claims in a state workers compensation system: 1999–2004. Am J Ind Med. Mar 2009;53(3):276–284.
  42. Hu RW, Jaglal S, Axcell T, Anderson G. A population-based study of reoperations after back surgery. Spine (Phila Pa 1976). Oct 1 1997;22(19):2265–2270; discussion 2271.
  43. Mulligan RP, Friedman JA, Mahabir RC. A nationwide review of the associations among cervical spine injuries, head injuries, and facial fractures. J Trauma. Mar 2009;68(3):587–592.
  44. Mulligan RP, Mahabir RC. The prevalence of cervical spine injury, head injury, or both with isolated and multiple craniomaxillofacial fractures. Plast Reconstr Surg. Nov 2010;126(5):1647–1651.
  45. Patel AA, Spiker WR, Daubs M, Brodke D, Cannon-Albright LA. Evidence for an inherited predisposition to lumbar disc disease. J Bone Joint Surg Am. Feb 2 2011;93(3):225–229.
  46. Patil PG, Turner DA, Pietrobon R. National trends in surgical procedures for degenerative cervical spine disease: 1990–2000. Neurosurgery. Oct 2005;57(4):753–758; discussion 753–758.
  47. Peterson L, Junge A, Chomiak J, Graf-Baumann T, Dvorak J. Incidence of football injuries and complaints in different age groups and skill-level groups. Am J Sports Med. 2000;28(5 Suppl):S51–57.
  48. Sebert SL, Brick JE, Anderson K. Acute low back pain findings and management in an academic medical center. W V Med J. Jul–Aug 1998;94(4):202–204.

APPENDIX C Inclusion and Exclusion lists consolidated

Body
part
ICD-9 # or
E-code
2009 ICD-9 Code DescriptionsCherkin &
Deyo ‘92
Inpt Hosp
for LBP
NHDS
HCUP
Back
HCUP
Sprains
&
Strains
Martin ‘08
Back and
neck
MEPS
data
Taylor ‘98
Inpt for
Back and
neck
Washingto
n and
Ontario
Einstadter
‘93 Inpt
Neck
Surgery
Washington
Angevine
‘03 Inpt
Neck
Surgery
NHDS
C721.0Cervical spondylosis without myelopathyEXCLINCLINCLINCLINCLINCL
C721.1Cervical spondylosis with myelopathyEXCLINCLINCLINCLINCLINCL
C722.0Displacement of cervical intervertebral disc without myelopathyINCLINCLINCLINCLINCL
C722.4Degeneration of cervical intervertebral discINCLINCLINCLINCLINCL
C722.71Intervertebral disc disorder with myelopathy-cervical regionINCLINCLINCLINCLINCL
C722.81Postlaminectomy syndrome-cervical regionINCLINCLINCLINCL
C722.91Other and unspecified disc disorder-cervical regionINCLINCLINCLINCLINCL
C723.0Spinal stenosis of cervical regionINCLINCLINCLINCLINCL
C723Other disorders of the cervical regionINCL
C723.1CervicalgiaINCLINCLINCLINCL
C723.2Cervico-cranial syndromeINCLINCLINCLINCL
C723.3Cervicobrachial syndrome (diffuse)INCLINCLINCLINCLINCL
C723.4Brachial neuritis or radiculitisINCLINCLINCLINCL
C723.5Torticollis, unspecifiedINCLINCLINCLINCL
C723.6Panniculitis specified as affecting neckINCLINCLINCL
C723.7Ossification of posterior longitudinal ligament in cervical regionINCLINCLINCLINCL
C723.8Other syndromes affecting cervical regionINCLINCLINCLINCL
C723.9Unspecified musculoskeletal disorders and symptoms referable to neckINCLINCLINCLINCL
C738.2Acquired deformity of the neckINCLINCL
C739.1Non allopathic lesions cervicalINCLINCL
C756.2Congenital Anomalies of the Spine - cervical ribEXCL
C784.0Headache
C805.0Closed cervical vertebral fractures without mention of spinal cord injuryINCLEXCL
C805.1Cervical fracture, open, without mention of spinal cord injuryEXCLINCLEXCL
C806.0Cervical fracture, closed with spinal cord injuryEXCLINCLEXCL
C806.1Cervical fracture, open with spinal cord injuryEXCLINCLEXCL
C839.0Other, multiple, and ill-defined vertebral dislocations cervical vertebra, closedEXCLINCLEXCL
C839.1Other, multiple, and ill-defined vertebral dislocations cervical vertebra, openEXCLINCLEXCL
C847.0Sprains and strains of other and unspecified parts of back-neckINCLINCLINCLINCL
T721.2Thoracic spondylosis without myelopathyEXCLINCLINCLINCL
T721.41Thoracic spondylosis with myelopathyINCLINCLINCL
T722.11Displacement thoracic intervertebral disc without myelopathyINCLINCLINCL
T722.31Schmorl’s nodes-thoracic regionINCLINCLINCL
T722.72Intervertebral disc disorder with myelopathy-thoracic regionINCLINCLINCL
T722.82Postlaminectomy syndrome-thoracic regionINCLINCLINCL
T722.92Other and unspecified disc disorder-thoracic regionINCLINCLINCL
T724.01Spinal stenosis, other than cervical-thoracic regionINCLINCLINCL
T724.1Pain in thoracic spineINCLINCLINCL
T737.0Adolescent postural kyphosisINCL
T737.10Kyphosis (acquired)(postural)INCLINCLINCL
T737.1Kyphosis acquiredINCL
T737.11Kyphosis due to radiationINCL
T737.34Thoracogenic scoliosisINCL
T737.41Curvature of the spine associated with other conditions, kyphosisINCL
T739.2Non allopathic lesions, thoracic
T805.2Thoracic fracture, closed, without mention of spinal cord injuryINCLEXCL
T805.3Thoracic fracture, open, without mention of spinal cord injuryEXCLINCLEXCL
T806.2Thoracic fracture, closed with spinal cord injuryEXCLINCLEXCL
T806.3Thoracic fracture, open with spinal cord injuryEXCLINCLEXCL
T847.1Sprains and strains of other and unspecified parts of back-thoracicINCLINCL
TL721.4Thoracic or lumbar spondylosis with myelopathyINCLINCL
TL722.1Displacement of thoracic or lumbar inter-vertebral disc w/o myelopathyINCLINCLINCL
TL722.5Degeneration of thoracic or lumbar intervertebral discINCL
TL722.51Degeneration of thoracic or thoracolumbar intervertebral discINCLINCLINCL
TL724.00Spinal stenosis - unspecified regionINCLINCLINCLINCL
TL724.0Spinal stenosis, other than cervicalINCL
TL724.09Spinal stenosis, other than cervical-otherINCLINCLINCLINCL
TL724.4Thoracic or lumosacral neuritis or radiculitis, unspecifiedINCLINCLINCLINCL
TL724.5Backache, unspecifiedINCLINCLINCLINCL
TL839.2Other, multiple, and ill-defined vertebral dislocations thoracic and lumbar vertebra, closedEXCLINCLEXCL
TL839.3Other, multiple, and ill-defined vertebral dislocations thoracic and lumbar vertebra, openEXCLINCLEXCL
L721.42Lumbar spondylosis w/o myelopathyINCLINCLINCLINCL
L722.10Displacement of lumbar inter-vertebral disc w/o myelopathyINCLINCLINCLINCL
L722.32Schmorl’s nodes lumbar regionINCLINCLINCLINCL
L722.73Intervertebral disc disorder with myelopathy, lumbar regionINCLINCLINCLINCL
L722.83Postlaminectomy syndrome lumbar regionINCLINCLINCLINCL
L722.93Other and unspecified disc disorder, lumbar regionINCLINCLINCLINCL
L724.02Spinal stenosis, other than cervical-lumbar regionINCLINCLINCLINCL
L724.2Lumbago, low back pain, low back syndromeINCLINCLINCLINCL
L724.3SciaticaINCLINCLINCLINCL
L737.2Lordosis (acquired)INCL
L737.2Lordosis (acquired)(postural)INCL
L737.21Lordosis, postlaminectomyINCL
L737.22Other post surgical lordosisINCL
L737.29Lordosis acquired otherINCL
L737.42Curvature of the spine associated with other conditions, LordosisINCL
L738.4Acquired spondylolisthesisINCLINCLINCL
L739.3Nonallopathic lesions, lumbar regionINCLINCL
L805.4Lumbar fracture, closed, without mention of spinal cord injuryINCLINCLEXCL
L805.5Lumbar fracture, open, without mention of spinal cord injuryEXCLINCLEXCL
L806.4Lumbar fracture, closed with spinal cord injuryEXCLINCLEXCL
L806.5Lumbar fracture, open with spinal cord injuryEXCLINCLEXCL
L847.2Sprains and strains of other and unspecified parts of back-lumbarINCLINCLINCLINCL
LS721.3Lumbosacral spondylosis w/o myelopathyINCLINCLINCLINCL
LS722.52Degeneration of lumbar or lumbosacral intervertebral discINCLINCLINCLINCL
LS724.8Other symptoms referable to backINCLINCLINCLINCL
LS724.9Other unspecified back disordersINCLINCLINCLINCL
LS756.11Spondylolysis, lumbosacral regionINCLINCL
LS846.0Sprains and strains - lumbosacral (joint) (ligament)INCLINCLINCLINCL
S720.1Spinal enthesopathyEXCLINCLINCLEXCLEXCL
S720.2Sacroilitis, not elsewhere classifiedEXCLINCLINCLEXCLEXCL
S724.6Disorders of sacrumINCLINCLINCLINCL
S739.4Nonallopathic lesions, sacral regionINCLINCL
S846Sprains and strains of sacroiliac regionINCL
S846.1Sprains and strains - Sacroiliac ligamentINCLINCLINCLINCL
S846.2Sprains and strains - acrospinatus (ligament)INCLINCLINCLINCL
S846.3Sprains and strains - sacrotuberous (ligament)INCLINCLINCLINCL
S846.8Sprains and strains - other specified sites of sascroiliac regionINCLINCLINCLINCL
S846.9Sprains and strains - unspecified site of sacroiliac regionINCLINCLINCLINCL
S847.3Sprains and strains of other and unspecified parts of back-sacrumINCLINCLINCLINCL
SCX805.6Sacrum and coccyx fracture, closed, without mention of spinal cord injuryINCLEXCL
SCX805.7Sacrum and coccyx fracture, open, without mention of spinal cord injuryEXCLINCLEXCL
SCX806.6Sacrum and coccyx fracture, closed with spinal cord injuryEXCLINCLEXCL
SCX806.7Sacrum and coccyx fracture, open with spinal cord injuryEXCLINCLEXCL
CX724.70Unspecified disorder of coccyxINCLINCL
CX724.7Disorders of the coccyxINCL
CX724.71Hypermobility of coccyxINCLINCL
CX724.79Disorders of coccyx-otherINCLINCL
CX847.4Sprains and strains of other and unspecified parts of back-coccyxINCLINCL
307.89Psychogenic back painINCLINCL
720Ankylosing spondylitis and other inflammatory spondylopathiesEXCLINCLEXCLEXCL
720.0Ankylosing spondylitisEXCLINCLEXCLEXCL
720.8Other inflammatory spondylopathiesEXCLINCLEXCLEXCL
720.81Other inflammatory spondylopathies in diseases classified elsewhereEXCLINCLINCLEXCLEXCL
720.89Other inflammatory spondylopathies - otherEXCLINCLINCLEXCLEXCL
720.9Unspecified inflammatory spondylopathyEXCLINCLINCLEXCLEXCL
721Spondylosis and allied disordersINCL
721.5Spondylosis and allied disorders - Kissing SpineINCLINCLINCLINCL
721.6Spondylosis and allied disorders - Ankylosing vertebral hyperostosisINCLINCLINCLINCL
721.7Traumatic spondylopathyINCLINCLINCLINCL
721.8Other allied disorders of the spineINCLINCLINCLINCL
721.90Spondylosis of unspecified site without mention of myelopathyINCLINCLINCLINCLINCL
721.9Spondylosis of unspecified siteINCL
721.91Spondylosis of unspecified site with myelopathyINCLINCLINCLINCLINCL
722Intervertebral disc disordersINCL
722.2Displacement of intervertebral disc, site unspecified, w/o myelopathyINCLINCLINCLINCLINCL
722.30Schmorl’s nodes-unspecified regionINCLINCLINCLINCL
722.3Schmorl’s nodesINCL
722.39Schmorl’s nodes-otherINCLINCLINCL
722.6Degeneration of intervertebral disc site unspecifiedINCLINCLINCLINCLINCL
722.70Intervertebral disc disorder with myelopathy-unspecified regionINCLINCLINCLINCLINCL
722.7Intervertebral disc disorder with myelopathyINCL
722.80Postlaminectomy syndrome-unspecified regionINCLINCLINCLINCL
722.8Postlaminectomy syndromeINCLINCLINCL
722.90Other and unspecified disc disorder-unspecified regionINCLINCLINCLINCLINCL
722.9Other and unspecified disc disorder site unspecifiedINCL
724Other and unspecified disorder of backINCL
737Curvature of the spine - excludes congenitalINCL
737.12Kyphosis, postlaminectomyINCL
737.19Kyphosis acquired-otherINCL
737.30Scoliosis [and kyphoscoliosis], idiopathicINCLINCLINCL
737.3Kyphoscoliosis and scoliosisINCL
737.31Resolving infantile idiopathic scoliosisINCL
737.32Progressive infantile idiopathic scoliosisINCL
737.33Scoliosis due to radiationINCL
737.39Other kyphoscoliosis and scoliosisINCL
737.4Curvature of the spine with other conditionsINCL
737.40Curvature of the spine associated with other conditions, unspecifiedINCL
737.43Curvature of the spine associated with other conditions, ScoliosisINCL
737.8Other curvatures of the spineINCL
737.9Unspecified curvature of the spineINCL
738.5Other acquired deformity of the back or spineINCLINCL
756.10Anomaly of spine, unspecifiedINCLINCL
756.12SpondylolisthesisINCLINCL
756.13Congenital anomalies of the spine - absence of a vertebraINCLINCL
756.14Congenital anomalies of the spine - hemivertebraINCLINCL
756.15Congenital anomalies of the spine - congenital fusion of the vertebraeINCLINCL
756.16Congenital anomalies of the spine - Klippel-feilINCLINCL
756.17Congenital anomalies of the spine - spina bifida occultaINCLINCL
756.18Congenital anomalies of the spineINCLINCL
756.19Congenital anomalies of the spine - otherINCLINCL
805Fracture of vertebral column without mention of spinal cord injuryINCLEXCL
805.8Vertebral fractures, unspecified closed, without mention of spinal cord injuryINCLINCLEXCL
805.9Vertebral fractures, unspecified copen, without mention of spinal cord injuryEXCLINCLEXCL
806Fracture of vertebral column with spinal cord injuryEXCLINCLEXCL
806.8Vertebral fractures, unspecified closed with spinal cord injuryEXCLINCLEXCL
806.9Vertebral fractures, unspecified open with spinal cord injuryEXCLINCLEXCL
839.4Other, multiple, and ill-defined vertebral dislocations, closed - otherEXCLINCLEXCL
839.5Other, multiple, and ill-defined vertebral dislocations, open - otherEXCLINCLEXCL
847Sprains and strains of other and unspecified parts of backINCL
847.9Sprains and strains of other and unspecified parts of back-unspecifiedINCLINCLINCLINCLINCL
996.4Mechanical complication of internal orthopedic device, implant and graftINCLINCL
03.2 – 03.29Chordotomy (procedure)EXCL
140–239.99NeoplasmsEXCLEXCLEXCL
630–676.9PregnancyEXCLEXCLEXCL
730.730.99Osteomyelitis, periostitis, and other infections involving boneEXCLEXCLEXCL
E800–E849.9Transportation AccidentsEXCLEXCL

APPENDIX D Spine surgeries and procedures by year and code

ICD-9 CodeDescription20022003200420052006200720082009
0302Reopening of laminectomy site676010478114122138110
0309Other exploration and decompression of spinal canal17482118219424822772292430393089
036Lysis of adhesions of cord or nerve root1319312926231719
7770Excision of bone for graft810201051059107
7779Excision of bone for graft361364341303266352858946
7869Removal of internal fixation device (non-specific - vertebral, pelvic or phalangeal)89117154136156178227256
8050Excision or destruction of intervertebral disc, unspecified6595461121
8051Excision of intervertebral disc23752583266428082771299034073381
8052Intervertebral chemonucleolysis221141
8059Other destruction of intervertebral disc27545458
8100Spinal fusion, not otherwise specified2125331524212420
8101Atlas-axis spinal fusion2140533328454046
8102Other cervical fusion, anterior technique9571098120712541391144916341691
8103Other cervical fusion, posterior technique190243272306358407485478
8104Dorsal and dorsolumbar fusion, anterior technique2931272738263629
8105Dorsal and dorsolumbar fusion, posterior technique56587987134116143134
8106Lumbar and lumbosacral fusion, anterior technique88739588121106150175
8107Lumbar and lumbosacral fusion, lateral transverse process technique56806160608696135
8108Lumbar and lumbosacral fusion, posterior technique41146152263865879411451180
8109Other spinal fusion1
8130Refusion of spine, not otherwise specified1112
8131Refusion of atlas-axis spine31143
8132Refusion of other cervical spine, anterior technique1926203428324240
8133Refusion of other cervical spine, posterior technique67181419333238
8134Refusion of dorsal and dorsolumbar spine, anterior technique45237
8135Refusion of dorsal and dorsolumbar spine, posterior technique463781417
8136Refusion of lumbar and lumbosacral spine, anterior technique31512271112
8137Refusion of lumbar and lumbosacral spine, lateral transverse process technique5132585
8138Refusion of lumbar and lumbosacral spine, posterior technique2217293541535795
8139Refusion of spine, not elsewhere classified2112
ICD-9 Uniques = 4292644304986523655595857622069717210

APPENDIX D Surgeries and Procedures by year and code

CPT CodeDescription20022003200420052006200720082009
22100Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; cervical21123122
22101Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; thoracic121
22102Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; lumbar63444
22103Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; each additional segment113541
22110Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; cervical334133
22112Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; thoracic241
22114Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; lumbar2122
22116Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; each additional vertebral segment11552
22206Osteotomy of spine, posterior or posterolateral approach, three columns, one vertebral segment (eg, pedicle/vertebral body subtraction); thoracic22
22207Osteotomy of spine, posterior or posterolateral approach, three columns, one vertebral segment (eg, pedicle/vertebral body subtraction); lumbar14
22208Osteotomy of spine, posterior or posterolateral approach, three columns, one vertebral segment (eg, pedicle/vertebral body subtraction); each additional vertebral segment23
22210Osteotomy of spine, posterior or posterolateral approach, one vertebral segment; cervical443123
22212Osteotomy of spine, posterior or posterolateral approach, one vertebral segment; thoracic2413363
22214Osteotomy of spine, posterior or posterolateral approach, one vertebral segment; lumbar332455917
22216Osteotomy of spine, posterior or posterolateral approach, one vertebral segment; each additional vertebral segment (List separately in addition to primary procedure)12248911
22220Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; cervical23115958
22222Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; thoracic121
22224Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; lumbar6552344
22226Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; each additional vertebral segment1211224
22305Closed treatment of vertebral process fracture(s)65442555
22310Closed treatment of vertebral body fracture(s), without manipulation, requiring and including casting or bracing88171917213022
22315Closed treatment of vertebral fracture(s) and/or dislocation(s) requiring casting or bracing, with and including casting and/or bracing, with or without anesthesia, by manipulation or traction72535551062
22318Open treatment and/or reduction of odontoid fracture(s) and or dislocation(s) (including os odontoideum), anterior approach, including placement of internal fixation; without grafting34127967
22326Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, one fractured vertebra or dislocated segment; cervical5631510111414
22327Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, one fractured vertebra or dislocated segment; thoracic71151013131713
22328Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, one fractured vertebra or dislocated segment; each additional fractured vertebra or dislocated segment18610106710
22505Manipulation of spine requiring anesthesia, any region323869721
22520Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; thoracic1735294870809567
22521Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; lumbar3339285366117124133
22523Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, one vertebral body, unilateral or bilateral cannulation (eg, kyphoplasty); thoracic16458895
22524Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, one vertebral body, unilateral or bilateral cannulation (eg, kyphoplasty); lumbar2580109133
22525Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, one vertebral body, unilateral or bilateral cannulation (eg, kyphoplasty); each additional thoracic or lumbar vertebral body7244042
22526Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level33931
22527Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; one or more additional levels51415
22590Arthrodesis, posterior technique, craniocervical (occiput-C2)34268564
22595Arthrodesis, posterior technique, atlas-axis (C1–C2)35314911615
22600Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment27525285120175282277
22610Arthrodesis, posterior or posterolateral technique, single level; thoracic (with or without lateral transverse technique)1527363155527457
22612Arthrodesis, posterior or posterolateral technique, single level; lumbar (with or without lateral transverse technique)6081178202240365641752
22614Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment861682403013945589951076
22630Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar2257100125149212440479
22800Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments246121210
22802Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segments4621321011
22804Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral segments31
22818Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); single or 2 segments2121
22819Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); 3 or more segments11
22830Exploration of spinal fusion46162526357669
22840Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across one interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation)415269115144164378409
22841Internal spinal fixation by wiring of spinous processes234455616
22842Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments73121204229319424664708
22843Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 7 to 12 vertebral segments912122431235548
22844Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or more vertebral segments2511
22845Anterior instrumentation; 2 to 3 vertebral segments134232243264330422688684
22846Anterior instrumentation; 4 to 7 vertebral segments15303442748311293
22847Anterior instrumentation; 8 or more vertebral segments11143
22848Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum3331118
22849Reinsertion of spinal fixation device541310192936
22850Removal of posterior nonsegmental instrumentation (eg, Harrington rod)33559112722
22851Application of intervertebral biomechanical device(s) (eg, synthetic cage(s), threaded bone dowel(s), methylmethacrylate) to vertebral defect or interspace951432192853764419221081
22852Removal of posterior segmental instrumentation2212202918375152
22855Removal of anterior instrumentation67121813284029
22856Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), single interspace, cervical28
22857Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar21214
22862Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical1
22865Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar11
 CPT Uniques = 7890383500559617890120019102084

References

1. Weinstein JN, Lurie JD, Olson PR, Bronner KK, Fisher ES. United States’ trends and regional variations in lumbar spine surgery: 1992–2003. Spine. 2006 Nov 1;31(23):2707–2714. [PMC free article] [PubMed]
2. Andersson GB. Epidemiological features of chronic low-back pain. Lancet. 1999 Aug 14;354(9178):581–585. [PubMed]
3. Carey TS, Evans AT, Hadler NM, et al. Acute severe low back pain. A population-based study of prevalence and care-seeking. Spine. 1996;21(3):339–344. [PubMed]
4. Deyo RA, Mirza SK, Martin BI. Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002. Spine. 2006 Nov 1;31(23):2724–2727. [PubMed]
5. Freburger JK, Holmes GM, Agans RP, et al. The rising prevalence of chronic low back pain. Arch Intern Med. 2009 Feb 9;169(3):251–258. [PMC free article] [PubMed]
6. Loney PL, Stratford PW. The prevalence of low back pain in adults: a methodological review of the literature. Phys Ther. 1999 Apr;79(4):384–396. [PubMed]
7. Sinnott P, Wagner TH. Low back pain in VA users. Arch Intern Med. 2009 Jul 27;169(14):1338–1339. author reply 1339. [PubMed]
8. Sinnott P. Administrative delays and chronic disability in patients with acute occupational low back injury. J Occup Environ Med. 2009 Jun;51(6):690–699. [PubMed]
9. Dionne CE, Dunn KM, Croft PR, et al. A consensus approach toward the standardization of back pain definitions for use in prevalence studies. Spine (Phila Pa 1976) 2008 Jan 1;33(1):95–103. [PubMed]
10. Leboeuf-Yde C, Lauritsen JM. The prevalence of low back pain in the literature. A structured review of 26 Nordic studies from 1954 to 1993. Spine (Phila Pa 1976) 1995 Oct 1;20(19):2112–2118. [PubMed]
11. Andersson GB, Bombardier C, Cherkin DC, et al. An introduction to therapeutic trials for low back pain. Spine (Phila Pa 1976) 1994 Sep 15;19(18 Suppl):2066S–2067S. [PubMed]
12. Volinn E, Mayer J, Diehr P, Van Koevering D, Connell FA, Loeser JD. Small area analysis of surgery for low-back pain. Spine (Phila Pa 1976) 1992 May;17(5):575–581. [PubMed]
13. Cherkin DC, Deyo RA, Volinn E, Loeser JD. Use of the International Classification of Diseases (ICD-9-CM) to identify hospitalizations for mechanical low back problems in administrative databases. Spine. 1992;17(7):817–825. [PubMed]
14. Einstadter D, Kent DL, Fihn SD, Deyo RA. Variation in the rate of cervical spine surgery in Washington State. Med Care. 1993 Aug;31(8):711–718. [PubMed]
15. Hart AC, Stegman MS, editors. ICD-9-CM Expert. for Hospitals. 6. 2 & 3. Ingenix; 2007.
16. Taylor VM, Anderson GM, McNeney B, et al. Hospitalizations for back and neck problems: a comparison between the Province of Ontario and Washington State. Health Serv Res. 1998 Oct;33(4 Pt 1):929–945. [PMC free article] [PubMed]
17. Angevine PD, Arons RR, McCormick PC. National and regional rates and variation of cervical discectomy with and without anterior fusion, 1990–1999. Spine (Phila Pa 1976) 2003 May 1;28(9):931–939. discussion 940. [PubMed]
18. Dasinger LK, Krause N, Deegan LJ, Brand RJ, Rudolph L. Physical workplace factors and return to work after compensated low back injury: a disability phase-specific analysis. J Occup Environ Med. 2000;42(3):323–333. [PubMed]
19. Dasinger LK, Krause N, Thompson PJ, Brand RJ, Rudolph L. Doctor proactive communication, return-to-work recommendation, and duration of disability after a workers’ compensation low back injury. J Occup Environ Med. 2001 Jun;43(6):515–525. [PubMed]
20. Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9- CM administrative databases. J Clin Epidemiol. 1992 Jun;45(6):613–619. [PubMed]
21. Elam K, Taylor V, Ciol MA, Franklin GM, Deyo RA. Impact of a worker’s compensation practice guideline on lumbar spine fusion in Washington State. Med Care. 1997 May;35(5):417–424. [PubMed]
22. Krause N, Dasinger LK, Deegan LJ, Brand RJ, Rudolph L. Alternative approaches for measuring duration of work disability after low back injury based on administrative workers’ compensation data. Am J Ind Med. 1999;35(6):604–618. [PubMed]
23. Lavis JN, Malter A, Anderson GM, et al. Trends in hospital use for mechanical neck and back problems in Ontario and the United States: discretionary care in different health care systems. CMAJ. 1998 Jan 13;158(1):29–36. [PMC free article] [PubMed]
24. Martin BI, Turner JA, Mirza SK, Lee MJ, Comstock BA, Deyo RA. Trends in health care expenditures, utilization, and health status among US adults with spine problems, 1997–2006. Spine (Phila Pa 1976) 2009 Sep 1;34(19):2077–2084. [PubMed]
25. Vogt MT, Kwoh CK, Cope DK, Osial TA, Culyba M, Starz TW. Analgesic usage for low back pain: impact on health care costs and service use. Spine (Phila Pa 1976) 2005 May 1;30(9):1075–1081. [PubMed]
26. Motheral B, Brooks J, Clark MA, et al. A checklist for retrospective database studies--report of the ISPOR Task Force on Retrospective Databases. Value Health. 2003 Mar-Apr;6(2):90–97. [PubMed]
27. Shekelle PG, Markovich M, Louie R. Comparing the costs between provider types of episodes of back pain care. Spine. 1995 Jan 15;20(2):221–226. discussion 227. [PubMed]
28. Wasiak R, Pransky G, Verma S, Webster B. Recurrence of low back pain: definition-sensitivity analysis using administrative data. Spine (Phila Pa 1976) 2003 Oct 1;28(19):2283–2291. [PubMed]
29. Bener A, Rahman YS, Mitra B. Incidence and severity of head and neck injuries in victims of road traffic crashes: In an economically developed country. Int Emerg Nurs. 2009 Jan;17(1):52–59. [PubMed]
30. Fishman P, Von Korff M, Lozano P, Hecht J. Chronic care costs in managed care. Health Aff (Millwood) 1997 May-Jun;16(3):239–247. [PubMed]
31. Steenstra IA, Verbeek JH, Prinsze FJ, Knol DL. Changes in the incidence of occupational disability as a result of back and neck pain in the Netherlands. BMC Public Health. 2006;6:190. [PMC free article] [PubMed]
32. Baaj AA, Uribe JS, Nichols TA, et al. Health care burden of cervical spine fractures in the United States: analysis of a nationwide database over a 10-year period. J Neurosurg Spine. 2010 Jul;13(1):61–66. [PubMed]
33. Patel AA, Spiker WR, Daubs M, Brodke D, Cannon-Albright LA. Evidence for an inherited predisposition to lumbar disc disease. J Bone Joint Surg Am. 2011 Feb 2;93(3):225–229. [PubMed]
34. Deyo RA, Mirza SK, Martin BI, Kreuter W, Goodman DC, Jarvik JG. Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA. 2010 Apr 7;303(13):1259–1265. [PMC free article] [PubMed]
35. Patil PG, Turner DA, Pietrobon R. National trends in surgical procedures for degenerative cervical spine disease: 1990–2000. Neurosurgery. 2005 Oct;57(4):753–758. discussion 753–758. [PubMed]
36. Wang MC, Chan L, Maiman DJ, Kreuter W, Deyo RA. Complications and mortality associated with cervical spine surgery for degenerative disease in the United States. Spine (Phila Pa 1976) 2007 Feb 1;32(3):342–347. [PubMed]
37. Wang MC, Kreuter W, Wolfla CE, Maiman DJ, Deyo RA. Trends and variations in cervical spine surgery in the United States: Medicare beneficiaries, 1992 to 2005. Spine (Phila Pa 1976) 2009 Apr 20;34(9):955–961. discussion 962–953. [PubMed]
38. Wang MC, Laud PW, Macias M, Nattinger AB. Utility of a Combined CPT and ICD9-CM Code Algorithm in Classifying Cervical Spine Surgery for Degenerative Changes. Spine (Phila Pa 1976) 2011 Jan 17; [PubMed]
39. Wang MC, Laud PW, Macias M, Nattinger AB. Strengths and limitations of International Classification of Disease Ninth Revision Clinical Modification codes in defining cervical spine surgery. Spine (Phila Pa 1976) 2011 Jan 1;36(1):E38–44. [PubMed]
40. Martin BI, Deyo RA, Mirza SK, et al. Expenditures and health status among adults with back and neck problems. JAMA. 2008 Feb 13;299(6):656–664. [PubMed]
41. Elixhauser A, Steiner C, Palmer L. Clinical Classifications Software (CCS) 2009. 2009 http://www.hcup-us.ahrq.gov/toolssoftware/ccs/ccs.jspPublished Last Modified Date|. Accessed Dated Accessed|.
42. Elixhauser A, Andrews RM, Fox S. Clinical classifications for health policy research:Discharge statistics by principal diagnosis and procedure. Rockville, MD: Agency for Health Care Policy and Research; 1993.
43. Volinn E, Turczyn KM, Loeser JD. Theories of back pain and health care utilization. Neurosurg Clin N Am. 1991 Oct;2(4):739–748. [PubMed]
44. Childs JD, Cleland JA, Elliott JM, et al. Neck pain. J Orthop Sports Phys Ther. 2008 Sep;38(9):A1–A34. [PubMed]
45. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007 Oct 2;147(7):478–491. [PubMed]
46. Lipscomb HJ, Cameron W, Silverstein B. Back injuries among union carpenters in Washington State, 1989–2003. Am J Ind Med. 2008 Jun;51(6):463–474. [PubMed]
47. Barnett MJ, Wehring H, Perry PJ. Comparison of risk of cerebrovascular events in an elderly VA population with dementia between antipsychotic and nonantipsychotic users. J Clin Psychopharmacol. 2007 Dec;27(6):595–601. [PubMed]
48. Sloan KL, Sales AE, Willems JP, et al. Frequency of serum low-density lipoprotein cholesterol measurement and frequency of results < or=100 mg/dl among patients who had coronary events (Northwest VA Network Study) Am J Cardiol. 2001 Nov 15;88(10):1143–1146. [PubMed]
49. Yano EM, Soban LM, Parkerton PH, Etzioni DA. Primary care practice organization influences colorectal cancer screening performance. Health Serv Res. 2007 Jun;42(3 Pt 1):1130–1149. [PMC free article] [PubMed]
50. Stano M, Smith M. Chiropractic and medical costs of low back care. Med Care. 1996 Mar;34(3):191–204. [PubMed]