Description
Degenerative cervical spine disorders, while often benign and episodic in nature, can become debilitating, resulting in axial pain and neurological damage to the spinal cord. Compression on the nerve root and / or spinal cord may be caused by (1) a herniated disc with or without extrusion of disc fragments and/or (2) degenerative cervical spondylosis.

Spine surgery is a complex area of medicine. Operative treatment is indicated only when the natural history of an operatively treatable problem is better than the natural history of the problem without operative treatment. Choice of surgical approach is based on anatomy, the candidate’s pathology, and the surgeon's experience and preference. All operative interventions must be based on a positive correlation with clinical findings, the natural history of the disease, the clinical course, and diagnostic tests or imaging results.

Anterior surgical approaches
Anterior surgical approaches to cervical spine decompression emerged in the 1950s in response to technical limitations experienced with posterior approaches, including restricted access to and exposure of midline bony spurs and disc fragments. Anterior approaches include anterior cervical discectomy and fusion. Discectomy is removal of all or part of a herniated or ruptured disc or spondolytic bony spur to alleviate pressure on the nerve roots or on the spinal cord in individuals with symptomatic radiculopathy. Discectomy is most often combined with fusion to stabilize the spine.

Posterior surgical approaches
Posterior surgical approaches include laminectomy, laminoplasty, and laminoforaminotomy (also known as posterior discectomy). Laminectomy is the removal of the bone between the spinal process and facet pedicle junction to expose the neural elements of the spine. This allows for the inspection of the spinal canal, identification and removal of pathological tissue, and decompression of the cord and roots. Laminoplasty is the opening of the lamina to enlarge the spinal canal. There are several laminoplasty techniques; all aim to alleviate cord compression by reconstructing the spinal canal. Laminoplasty is commonly performed to decompress the spinal cord in those with degenerative spinal stenosis.

Laminoforaminotomy (also known as posterior discectomy) is the creation of a small window in the lamina to facilitate removal of arthritic bone spurs and herniated disc material pressing on the nerve root as it exits through the foramen. The opening of the foramen is widened so that the nerve exits without being compressed.

Policy 

Anterior Cervical Decompression With Fusion (ACDF) — Single Level

The following criteria must be met*:

• Positive clinical findings of myelopathy with evidence of progressive neurologic deficits consistent with spinal cord compression - immediate surgical evaluation is indicated (AA0S, 2013; Bono, 2011; Cunningham, 2010; Holly, 2009; Matz, 2009a; Matz, 2009b; Matz, 2009d; Matz, 2009e; Mummaneni, 2009; Tetreault, 2013; Yalamanchili, 2012; Zhu, 2013). Symptoms may include:
  • Upper extremity weakness;
  • Unsteady gait related to myelopathy/balance or generalized lower extremity weakness;
  • Disturbance with coordination;
  • Hyperreflexia;
  • Hoffmann sign;
  • Positive Babinski sign and/or clonus; OR 
• Progressive neurological deficit (motor deficit, bowel or bladder dysfunction) with evidence of spinal cord or nerve root compression on Magnetic Resonance Imaging (MRI) or Computed Tomography (CT) imaging - immediate surgical evaluation is indicated. (Bono, 2011; Matz, 2009b; Tetreault, 2013); OR

When ALL of the following criteria are met (Bono, 2011: Nikolaidis, 2010):  

• Cervical radiculopathy or myelopathy from ruptured disc, spondylosis, spinal instability, or deformity; AND
• Persistent or recurrent symptoms/pain with functional limitations that are unresponsive to at least 6 weeks of appropriate conservative treatment; AND  
• Documented failure of at least 6 consecutive weeks in the last 6 months of any 2 of the following physician-directed conservative treatments:
  • Analgesics, steroids, and/or NSAIDs
  • Structured program of physical therapy
  • Structured home exercise program prescribed by a physical therapist, chiropractic provider or physician
  • Epidural steroid injections and or selective nerve root block; AND 
• Imaging studies confirm the presence of spinal cord or spinal nerve root compression (disc herniation or foraminal stenosis) at the level corresponding with the clinical findings (Bono, 2011). Imaging studies may include:
  • MRI (preferred study for assessing cervical spine soft tissue); OR
  • CT with or without myelography — indicated in patients in whom MRI is contraindicated; preferred for examining bony structures, or in patients presenting with clinical symptoms or signs inconsistent with MRI findings (e.g., foraminal compression not seen on MRI).

*Cervical spine decompression with fusion as first-line treatment without conservative care measures in the following clinical cases (Matz, 2009b; Tetreault, 2013; Zhu, 2013; White, 1987):

• As outlined above for myelopathy or progressive neurological deficit scenarios.
• Significant spinal cord or nerve root compression due to tumor, infection or trauma.
• Fracture or instability on radiographic films measuring:
  • Sagittal plane angulation of greater than 11 degrees at a single interspace or greater than 3.5mm anterior subluxation in association with radicular/cord dysfunction; OR
  • Subluxation at the (C1) level of the atlantodental interval of more than 3 mm in an adult and 5 mm in a child.

Not Recommended (Nikolaidis, 2010; van Middelkoop, 2012):

• In asymptomatic or mildly symptomatic cases of cervical spinal stenosis.
• In cases of neck pain alone, without neurological deficits, and no evidence of significant spinal nerve root or cord compression on MRI or CT. See V. Cervical Fusion for Treatment of Axial Neck Pain Criteria  

Anterior Cervical Decompression With Fusion (ACDF) — Multiple Level

The following criteria must be met*:

• Positive clinical findings of myelopathy with evidence of progressive neurologic deficits consistent with worsening spinal cord compression — immediate surgical evaluation is indicated (AA0S, 2013; Bono, 2011; Cunningham, 2010; Holly, 2009; Matz, 2009a; Matz, 2009b; Matz, 2009d; Matz, 2009e; Mummaneni, 2009; Tetreault, 2013; Yalamanchili, 2012; Zhu, 2013). Symptoms may include:
  • Upper extremity weakness;
  • Unsteady gait related to myelopathy/balance or generalized lower extremity weakness;
  • Disturbance with coordination;
  • Hyperreflexia;
  • Hoffmann sign;
  • Positive Babinski sign and or clonus; OR 
• Progressive neurological deficit (motor deficit, bowel or bladder dysfunction) with corresponding evidence of spinal cord or nerve root compression on an MRI or CT scan images - immediate surgical evaluation is indicated (Bono, 2011; Matz, 2009b; Tetreault, 2013); OR

When ALL of the following criteria are met (Bono, 2011; Nikolaidis, 2010):

• Cervical radiculopathy or myelopathy due to ruptured disc, spondylosis, spinal instability, or deformity; AND  
• Persistent or recurrent pain/symptoms with functional limitations that are unresponsive to at least 6 weeks of conservative treatment; AND
• Documented failure of at least 6 consecutive weeks in the last 6 months of any 2 of the following physician-directed conservative treatments:
  • Analgesics, steroids, and/or NSAIDs
  • Structured program of physical therapy 
  • Structured home exercise program prescribed by a physical therapist, chiropractic provider or physician 
  • Epidural steroid injections and or selective nerve root block; AND　
• Imaging studies confirm the presence of spinal cord or spinal nerve root compression (disc herniation or foraminal stenosis) at multiple levels corresponding with the clinical findings. Imaging studies may include any of the following (Bono, 2011):
  • MRI (preferred study for assessing cervical spine soft tissue); OR
  • CT with or without myelography - indicated in patients in whom MRI is contraindicated; preferred for examining bony structures, or in patients presenting with clinical symptoms or signs inconsistent with MRI findings (e.g., foraminal compression not seen on MRI) 

Cervical spine decompression with fusion performed as first-line treatment without conservative care measures in the following clinical cases (Matz, 2009b; Tetreault, 2013; White, 1987; Zhu, 2013):

• As outlined above for myelopathy or progressive neurological deficit scenarios.
• Significant spinal cord or nerve root compression due to tumor, infection or trauma.
• Fracture or instability on radiographic films measuring:
  • Sagittal plane angulation of greater than 11 degrees at a single interspace or greater than 3.5mm anterior subluxation in association with radicular/cord dysfunction; OR
  • Subluxation at the (C1) level of the atlantodental interval of more than 3 mm in an adult and 5 mm in a child.

Not Recommended (Nikolaidis, 2010; Van Middelkoop, 2012):

• In asymptomatic or mildly symptomatic cases of cervical spinal stenosis.  
• In cases of neck pain alone, without neurological deficits, and no evidence of significant spinal nerve root or cord compression on MRI or CT. See V. Cervical Fusion for Treatment of Axial Neck Pain Criteria. 

Cervical Posterior Decompression With Fusion — Single Level

The following criteria must be met*:

• Positive clinical findings of myelopathy with evidence of progressive neurologic deficits consistent with worsening spinal cord compression — immediate surgical evaluation is indicated (AA0S, 2013; Cunningham, 2010; Fehlings, 2013; Holly, 2009; Matz, 2009d; Mummaneni, 2009; Tetreault, 2013; Yalamanchili, 2012; Zhu, 2013).
• Symptoms may include:
  • Upper extremity weakness;
  • Unsteady gait related to myelopathy/balance or generalized lower extremity weakness;
  • Disturbance with coordination;
  • Hyperreflexia;
  • Hoffmann sign;
  • Positive Babinski sign and / or clonus; OR 
• Progressive neurological deficit (motor deficit, bowel or bladder dysfunction) with corresponding evidence of spinal cord or nerve root compression on an MRI or CT scan images - immediate surgical evaluation is indicated (Bono, 2011; Matz, 2009b; Tetreault, 2013); OR

When ALL of the following criteria are met (Bono, 2011; Nikolaidis, 2010):  

• Cervical radiculopathy or myelopathy from ruptured disc, spondylosis, spinal instability, or deformity; AND
• Persistent or recurrent symptoms/pain with functional limitations that are unresponsive to at least 6 weeks of conservative treatment; AND
• Documented failure of at least 6 consecutive weeks in the last 6 months of any 2 of the following physician-directed conservative treatments:
  • Analgesics, steroids, and/or NSAIDs
  • Structured program of physical therapy
  • Structured home exercise program prescribed by a physical therapist, chiropractic provider or physician
  • Epidural steroid injections and or selective nerve root block; AND  
• Imaging studies confirm the presence of spinal cord or spinal nerve root compression (disc herniation or foraminal stenosis) at single level corresponding with the clinical findings (Bono, 2011). Imaging studies may include:
  • MRI (preferred study for assessing cervical spine soft tissue); OR
  • CT with or without myelography — indicated in patients in whom MRI is contraindicated; preferred for examining bony structures, or in patients presenting with clinical symptoms or signs inconsistent with MRI findings (e.g., foraminal compression not seen on MRI); AND

Cervical spine decompression with fusion performed as first-line treatment without conservative care measures in the following clinical cases (Fehlings, 2013; Tetreault, 2013; White, 1987; Zhu, 2013):  

• As outlined above for myelopathy or progressive neurological deficit scenarios.
• Significant spinal cord or nerve root compression due to tumor, infection or trauma.
• Fracture or instability on radiographic films measuring:
  • Sagittal plane angulation of greater than 11 degrees at a single interspace or greater than 3.5mm anterior subluxation in association with radicular/cord dysfunction; OR
  • Subluxation at the (C1) level of the atlantodental interval of more than 3 mm in an adult and 5 mm in a child.  

Not Recommended (Nikolaidis, 2010; Wang, 2011):

• In asymptomatic or mildly symptomatic cases of cervical spinal stenosis.
• In cases of neck pain alone, without neurological deficits, and no evidence of significant spinal nerve root or cord compression on MRI or CT. See V. Cervical Fusion for Treatment of Axial Neck Pain Criteria. 　

Cervical Posterior Decompression with Fusion - Multiple Levels

The following criteria must be met*:

• Positive clinical findings of myelopathy with evidence of progressive neurologic deficits consistent with worsening spinal cord compression — immediate surgical evaluation is indicated (AA0S, 2013; Cunningham, 2010; Fehlings, 2013; Holly, 2009; Matz, 2009d; Mummaneni, 2009; Tetreault, 2013; Yalamanchili, 2012; Zhu, 2013).
• Symptoms may include:
  • Upper extremity weakness;
  • Unsteady gait related to myelopathy/balance or generalized lower extremity weakness;
  • Disturbance with coordination;
  • Hyperreflexia;
  • Hoffmann sign;
  • Positive Babinski sign and / or clonus; OR 
• Progressive neurological deficit (motor deficit, bowel or bladder dysfunction) with corresponding evidence of spinal cord or nerve root compression on an MRI or CT scan images — immediate surgical evaluation is indicated (Bono, 2011; Matz, 2009b; Tetreault, 2013); OR   

When ALL of the following criteria are met (Bono, 2011; Nikolaidis, 2010):

• Cervical radiculopathy or myelopathy from ruptured disc, spondylosis, spinal instability, or deformity; AND
• Persistent or recurrent symptoms/pain with functional limitations that are unresponsive to at least 6 weeks of conservative treatment; AND
• Documented failure of at least 6 consecutive weeks in the last 6 months of any 2 of the following physician-directed conservative treatments:
  • Analgesics, steroids, and/or NSAIDs;
  • Structured program of physical therapy;
  • Structured home exercise program prescribed by a physical therapist, chiropractic provider or physician;
  • Epidural steroid injections and or facet injections /selective nerve root block; AND
• Imaging studies indicate significant spinal cord or spinal nerve root compression at multiple levels corresponding with the clinical finding. Imaging studies may include (Bono, 2011): MRI (preferred study for assessing cervical spine soft tissue); OR
• CT with or without myelography — indicated in patients in whom MRI is contraindicated; preferred for examining bony structures, or in patients presenting with clinical symptoms or signs inconsistent with MRI findings (e.g., foraminal compression not seen on MRI); AND 　

*Cervical spine decompression with fusion performed as first-line treatment without conservative care measures in the following clinical cases (Fehlings, 2013; Tetreault, 2013; White, 1987; Zhu, 2013):

• As outlined above for myelopathy or progressive neurological deficit scenarios.  
• Significant spinal cord or nerve root compression due to tumor, infection or trauma.  
• Fracture or instability on radiographic films measuring:
  • Sagittal plane angulation of greater than 11 degrees at a single interspace or greater than 3.5mm anterior subluxation in association with radicular/cord dysfunction; OR
  • Subluxation at the (C1) level of the atlantodental interval of more than 3 mm in an adult and 5 mm in a child 　

Not Recommended (Nikolaidis, 2010; Wang, 2011):

• In asymptomatic or mildly symptomatic cases of cervical spinal stenosis.
• In cases of neck pain alone, without neurological deficits, and no evidence of significant spinal nerve root or cord compression on MRI or CT. See: Cervical Fusion for Treatment of Axial Neck Pain Criteria.  

Cervical Fusion for Treatment of Axial Neck Pain

In patients with non-radicular cervical pain for whom fusion is being considered, ALL of the following criteria must be met (Riew, 2010):  

• Improvement of the symptoms has failed or plateaued, and the residual symptoms of pain and functional disability are unacceptable at the end of 6 to 12 consecutive months of appropriate, active treatment, or at the end of longer duration of non-operative programs for debilitated patients with complex problems [NOTE: Mere passage of time with poorly guided treatment is not considered an active treatment program]; AND
• All pain generators are adequately defined and treated; AND  
• All physical medicine and manual therapy interventions are completed; AND  
• X-ray, MRI, or CT demonstrating disc pathology or spinal instability; AND  
• Spine pathology limited to one or two levels unless other complicating factors are involved; AND  
• Psychosocial evaluation for confounding issues addressed

NOTE: The effectiveness of three-level or greater cervical fusion for non-radicular pain has not been established (Van Middelkoop, 2012).

Cervical Posterior Decompression

The following criteria must be met*:

• Positive clinical findings of myelopathy with evidence of progressive neurologic deficits consistent with worsening spinal cord compression — immediate surgical evaluation is indicated (AA0S, 2013; Bono, 2011; Heary, 2009; Mummaneni, 2009; Ryken, 2009; Tetreault, 2013; Wang, 2013; Yalamanchili, 2012; Zhu, 2013). Symptoms may include:
  • Upper extremity weakness;
  • Unsteady gait related to myelopathy/balance or generalized lower extremity weakness;
  • Disturbance with coordination;
  • Hyperreflexia;
  • Hoffmann sign;
  • Positive Babinski sign and / or clonus; OR
• Progressive neurological deficit (motor deficit, bowel or bladder dysfunction) with corresponding evidence of spinal cord or nerve root compression on an MRI or CT scan images - immediate surgical evaluation is indicated (Tetreault, 2013; Wang, 2013); OR  

When ALL of the following criteria are met (Bono, 2011):

• Cervical radiculopathy from ruptured disc, spondylosis, or deformity; AND  
• Persistent or recurrent symptoms/pain with functional limitations that are unresponsive to at least 6 weeks of appropriate conservative treatment; AND
• Documented failure of at least 6 consecutive weeks in the last 6 months of any 2 of the following physician-directed conservative treatments:
  • Analgesics, steroids, and/or NSAIDs
  • Structured program of physical therapy
  • Structured home exercise program prescribed by a physical therapist, chiropractic provider or physician　
  • Epidural steroid injections and or facet injections /selective nerve root block; AND
• Imaging studies confirm the presence of spinal cord or spinal nerve root compression at the level(s) corresponding with the clinical findings (Bono, 2011; Sahai, 2019). Imaging studies may include any of the following:
  • MRI (preferred study for assessing cervical spine soft tissue); OR
  • CT with or without myelography— indicated in patients in whom MRI is contraindicated; preferred for examining bony structures, or in patients presenting with clinical symptoms or signs inconsistent with MRI findings (e.g., foraminal compression not seen on MRI)

Cervical decompression performed as first-line treatment without conservative care in the following clinical cases (Ryken, 2009; Tetreault, 2013; Wang, 2013; Zhu, 2013):

• As outlined above for myelopathy or progressive neurological deficit scenarios.
• Spinal cord or nerve root compression due to tumor, infection or trauma. 

Not Recommended (Nikolaidis, 2010; Wang, 2011):

• In asymptomatic or mildly symptomatic cases.  
• In cases of neck pain alone, without neurological deficits and abnormal imaging findings. See E. Cervical Fusion for Treatment of Axial Neck Pain Criteria.
• In patients with kyphosis or at risk for development of postoperative kyphosis.

Cervical Artificial Disc Replacement (Single or Two Level)

Indications for cervical artificial disc replacement are as follows (Bono, 2011; Cheng, 2009; Davis, 2015; Gornet, 2019; Lavelle, 2019; Matz, 2009e):

• Skeletally mature patient; AND
• Patient has intractable radiculopathy caused by one or two level disease (either herniated disc or spondolytic osteophyte) located at C3-C7; AND
• Persistent or recurrent symptoms/pain with functional limitations that are unresponsive to at least 6 weeks of appropriate conservative treatment; AND
• Documented failure of at least 6 consecutive weeks in the last 6 months of any 2 of the following physician-directed conservative treatments:
  • Analgesics, steroids, and/or NSAIDs,
  • Structured program of physical therapy,
  • Structured home exercise program prescribed by a physical therapist, chiropractic provider or physician,
  • Epidural steroid injections and or facet injections /selective nerve root block;  AND
• Imaging studies confirm the presence of compression at the level(s) corresponding with the clinical findings (MRI or CT); AND
• Use of an FDA-approved prosthetic intervertebral discs.

Cervical Artificial Disc Replacement is NOT indicated when any of the following clinical scenarios exists (Davis, 2015):

• Symptomatic multiple level disease affecting 3 or more levels
• Infection (at site of implantation or systemic)
• Osteoporosis or osteopenia
• Instability
  • Translation greater than 3mm difference between lateral flexion-extension views at the symptomatic levels;
  • 11 degrees of angular difference between lateral flexion-extension views at the symptomatic levels 
• Sensitivity or allergy to implant materials
• Severe spondylosis defined as (Davis, 2015):
  • > 50% disc height loss compared to minimally or non-degenerated levels; OR
  • Bridging osteophytes; OR
  • Absence of motion on lateral flexion-extension views at the symptomatic site
• Severe facet arthropathy
• Ankylosing spondylitis
• Rheumatoid arthritis
• Previous fracture with anatomical deformity
• Ossification of the posterior longitudinal ligament (OPLL)
• Active cervical spine malignancy

Cervical Fusion without Decompression 

Cervical fusion without decompression will be reviewed on a case-by-case basis. Atraumatic instability due to Down Syndrome-related spinal deformity, rheumatoid arthritis, or basilar invagination are uncommon, but may require cervical fusion (Trumees, 2017).  

Cervical Anterior Decompression (without fusion) 

All requests for anterior decompression without fusion will be reviewed on a case-by-case basis (Bono, 2011; Botelho, 2012; Gebremariam, 2012; Matz, 2009a; Matz, 2009e).

References 

1. American Academy of Orthopaedic Surgeons (AAOS). Cervical Spondylotic Myelopathy: Surgical Treatment Options. Reviewed November 2009. Available at: http://orthoinfo.aaos.org/topic.cfm?topic=A00539. Accessed August 26, 2013.
2. Anderson, P.A., Matz, P.G., Groff, M.W., Heary, R.F., Holly, L.T., Kaiser, M.G., … Resnick, D.K., Joint Section on Disorders of the Spine and Peripheral Nerves [trunc]. (2007). Laminectomy and fusion for the treatment of cervical degenerative myelopathy. Neurosurg Spine, 11, 150-6. Retrieved from http://www.guideline.gov/content.aspx?id=24481&search=posterior+cervical+laminectomy.
3. Bartels RH, van Tulder MW, Moojen WA, Arts MP, Peul WC. Laminoplasty and laminectomy for cervical sponydylotic myelopathy: a systematic review. Eur Spine J. 2013. Epub ahead of print. April 11, 2013. Available at: http://link.springer.com/article/10.1007%2Fs00586-013-2771-z. Accessed August 26, 2013.
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5. Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Artificial intervertebral disc arthroplasty for treatment of degenerative disc disease of the cervical spine. TEC Assessments. 2007;Volume 22:Tab 12.
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10. Botelho RV, Dos Santos Buscariolli Y, de Barros Vasconcelos Fernandes Serra MV, Bellini MN, Bernardo WM. The choice of the best surgery after single level anterior cervical spine discectomy: a systematic review. Open Orthop J. 2012;6:121-128.
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16. Coric D, Cassis J, Carew JD, et al. Prospective study of cervical arthroplasty in 98 patients involved in 1 of 3 separate investigational device exemption studies from a single investigational site with a minimum 2-year follow-up. Clinical article. J Neurosurg Spine. Dec 2010;13(6):715-721. PMID 21121748
17. Coric D, Kim PK, Clemente JD, et al. Prospective randomized study of cervical arthroplasty and anterior cervical discectomy and fusion with long-term follow-up: results in 74 patients from a single site. J Neurosurg Spine. Jan 2013;18(1):36-42. PMID 23140129
18. Coric D, Nunley PD, Guyer RD, et al. Prospective, randomized, multicenter study of cervical arthroplasty: 269 patients from the Kineflex|C artificial disc investigational device exemption study with a minimum 2-year follow-up: clinical article. J Neurosurg Spine. Oct 2011;15(4):348-358. PMID 21699471
19. Cunningham MR, Hershman S, Bendo J. Systematic review of cohort studies comparing surgical treatments for cervical spondylotic myelopathy. Spine (Phila Pa 1976). 2010;35(5):537-543.
20. Davis RJ, Kim KD, Hisey MS, et al. Cervical total disc replacement with the Mobi-C cervical artificial disc compared with anterior discectomy and fusion for treatment of 2-level symptomatic degenerative disc disease: a prospective, randomized, controlled multicenter clinical trial. J Neurosurg Spine. Nov 2013;19(5):532-545. PMID 24010901
21. Davis RJ, Nunley PD, Kim KD, et al. Two-level total disc replacement with Mobi-C cervical artificial disc versus anterior discectomy and fusion: a prospective, randomized, controlled multicenter clinical trial with 4-year follow-up results. J Neurosurg Spine. Jan 2015;22(1):15-25. PMID 25380538
22. Delamarter RB, Murrey D, Janssen ME, et al. Results at 24 months from the prospective, randomized, multicenter Investigational Device Exemption trial of ProDisc-C versus anterior cervical discectomy and fusion with 4-year follow-up and continued access patients. SAS J. 2010;4(4):122-128. PMID 25802660
23. Delamarter RB, Zigler J. Five-year reoperation rates, cervical total disc replacement versus fusion, results of a prospective randomized clinical trial. Spine (Phila Pa 1976). Nov 2 2013;38(9):711-717. PMID 23124255
24. Fan H, Wu S, Wu Z, et al. Implant failure of Bryan cervical disc due to broken polyurethane sheath: a case report. Spine (Phila Pa 1976). Jun 1 2012;37(13):E814-816. PMID 22210017
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26. Goffin J, Van Calenbergh F, van Loon J, et al. Intermediate follow-up after treatment of degenerative disc disease with the Bryan Cervical Disc Prosthesis: single-level and bi-level. Spine (Phila Pa 1976). Dec 15 2003;28(24):2673-2678. PMID 14673368
27. Goffin J, van Loon J, Van Calenbergh F, et al. A clinical analysis of 4- and 6-year follow-up results after cervical disc replacement surgery using the Bryan Cervical Disc Prosthesis. J Neurosurg Spine. Mar 2010;12(3):261-269. PMID 20192625
28. Gornet MF, Burkus JK, Shaffrey ME, et al. Cervical disc arthroplasty with PRESTIGE LP disc versus anterior cervical discectomy and fusion: a prospective, multicenter investigational device exemption study. J Neurosurg Spine. Jul 31 2015:1-16. PMID 26230424
29. Guyer RD, Shellock J, MacLennan B, et al. Early failure of metal-on-metal artificial disc prostheses associated with lymphocytic reaction: diagnosis and treatment experience in four cases. Spine (Phila Pa 1976). Apr 1 2011;36(7):E492-497. PMID 21252827
30. Hacker FM, Babcock RM, Hacker RJ. Very late complications of cervical arthroplasty: results of 2 controlled randomized prospective studies from a single investigator site. Spine (Phila Pa 1976). Dec 15 2013;38(26):2223-2226. PMID 24335628
31. Hadley MN. The real value of cervical arthroplasty? [editorial]. J Neurosurg Spine. Oct 2011;15(4):345-346; discussion 346-347. PMID 21699472
32. Heary RF, Ryken TC, Matz PG, et al.; Joint Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons and Congress of Neurological Surgeons. Cervical laminoforaminotomy for the treatment of cervical degenerative radiculopathy. J Neurosurg Spine. 2009;11(2):198-202.
33. Heller JG, Sasso RC, Papadopoulos SM, et al. Comparison of BRYAN cervical disc arthroplasty with anterior cervical decompression and fusion: clinical and radiographic results of a randomized, controlled, clinical trial. Spine (Phila Pa 1976). Jan 15 2009;34(2):101-107. PMID 19112337
34. Hisey MS, Bae HW, Davis RJ, et al. Prospective, randomized comparison of cervical total disk replacement versus anterior cervical fusion: results at 48 months follow-up. J Spinal Disord Tech. May 2015;28(4):E237-243. PMID 25310394
35. Hisey MS, Bae HW, Davis R, et al. Multi-center, prospective, randomized, controlled investigational device exemption clinical trial comparing Mobi-C Cervical Artificial Disc to anterior discectomy and fusion in the treatment of symptomatic degenerative disc disease in the cervical spine. Int J Spine Surg. 2014;8. PMID 25694918
36. Hisey MS, Zigler JE, Jackson R, et al. Prospective, randomized comparison of one-level Mobi-C Cervical Total Disc replacement vs. anterior cervical discectomy and fusion: results at 5-year follow-up. Int J Spine Surg. 2016;10:10. PMID 27162712
37. Holly LT, Matz PG, Anderson PA, et al.; Joint Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons and Congress of Neurological Surgeons. Clinical prognostic indicators of surgical outcome in cervical spondylotic myelopathy. J Neurosurg Spine. 2009;11(2):112-118.
38. Huppert J, Beaurain J, Steib JP, et al. Comparison between single- and multi-level patients: clinical and radiological outcomes 2 years after cervical disc replacement. Eur Spine J. Sep 2011;20(9):1417-1426. PMID 21336970
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40. Janssen ME, Zigler JE, Spivak JM, et al. ProDisc-C Total Disc replacement versus anterior cervical discectomy and fusion for single-level symptomatic cervical disc disease: seven-year follow-up of the prospective randomized U.S. Food and Drug Administration Investigational Device Exemption Study. J Bone Joint Surg Am. Nov 4 2015;97(21):1738-1747. PMID 26537161
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Additional Information
A comprehensive assimilation of factors should lead to a specific diagnosis with positive identification of the pathologic condition(s).

• Early intervention may be required in acute incapacitating pain or in the presence of progressive neurological deficits.
• Operative treatment is indicated when the natural history of surgically treated lesions is better than the natural history for non-operatively treated lesions.
• Patients may present with localized pain or severe pain in combination with numbness, extremity weakness, loss of coordination, gait issues, or bowel and bladder complaints. Nonoperative treatment continues to play an important role in the care of patients with degenerative cervical spine disorders. If these symptoms progress to neurological deficits, from corresponding spinal cord or nerve root compression, than surgical intervention may be warranted.
• All patients being considered for surgical intervention should first undergo a comprehensive neuromusculoskeletal examination to identify those pain generators that may either respond to non-surgical techniques, or may be refractory to surgical intervention.
• In situations requiring the possible need for operation, a second opinion may be necessary. Psychological evaluation is strongly encouraged when surgery is being performed for isolated axial pain to determine if the patient will likely benefit from the treatment.
• It is imperative for the clinician to rule out non-physiologic modifiers of pain presentation, or non-operative conditions mimicking radiculopathy, myelopathy or spinal instability (peripheral compressive neuropathy, chronic soft tissue injuries, and psychological conditions), prior to consideration of elective surgical intervention. Significant depression or psychiatric disorder may be a reason for denial as risk of failure is elevated.

Degenerative cervical spine disorders, while often benign and episodic in nature, can become debilitating, resulting in axial pain and neurological damage to the spinal cord. Compression on the nerve root and / or spinal cord may be caused by (1) a herniated disc with or without extrusion of disc fragments and/or (2) degenerative cervical spondylosis.

Anterior Approaches – Additional Information:

• Anterior surgical approaches to cervical spine decompression emerged in the 1950s in response to technical limitations experienced with posterior approaches, including restricted access to and exposure of midline bony spurs and disc fragments.
• The first reports in the literature describe anterior cervical discectomy combined with a spinal fusion procedure (ACDF). Fusion was added to address concerns about potential for loss of spinal stability and disc space height, leading to late postoperative complications such as kyphosis and radicular pain (Sonntag and Klara, 1996; Dowd and Wirth, 1999; Matz et al., 2009a; Matz et al., 2009b; Denaro and Di Martino, 2011; Botelho et al., 2012; van Middelkoop et al., 2012).
• Anterior cervical fusion (ACF) accounted for approximately 80% of cervical spine procedures performed in the United States between 2002 and 2009, while posterior cervical fusion (PCF) accounted for 8.5% of these procedures (Oglesby et al., 2013).
• Anterior Cervical Discectomy and Fusion (ACDF) – removal of all or part of a herniated or ruptured disc or spondolytic bony spur to alleviate pressure on the nerve roots or on the spinal cord in patients with symptomatic radiculopathy. Discectomy is most often combined with fusion to stabilize the spine.

Posterior Approaches
Laminectomy – removal of the bone between the spinal process and facet pedicle junction to expose the neural elements of the spine’ this allows for the inspection of the spinal canal, identification and removal of pathological tissue, and decompression of the cord and roots.

Laminoplasty – the opening of the lamina to enlarge the spinal canal. There are several laminoplasty techniques; all aim to alleviate cord compression by reconstructing the spinal canal. Laminoplasty is commonly performed to decompress the spinal cord in patients with degenerative spinal stenosis.

Laminoforaminotomy (also known as posterior discectomy) – the creation of a small window in the lamina to facilitate removal of arthritic bone spurs and herniated disc material pressing on the nerve root as it exits through the foramen. The procedure widens the opening of the foramen so that the nerve exits without being compressed.

Coding Section 

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

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