Is total disc replacement at C3-4 and C5-6 recommended for a patient with cervical degenerative disc disease, disc herniations, and spinal cord impingement at these non-contiguous levels, considering her high-risk status for osteoporosis and failed conservative management?

Total Disc Replacement at Non-Contiguous Levels C3-4 and C5-6 Should Be Denied; Recommend Anterior Cervical Discectomy and Fusion (ACDF) Instead

The request for total disc replacement at C3-4 and C5-6 must be denied because these levels are non-contiguous, which is an absolute contraindication per MCG criteria, and the patient has never been evaluated for osteoporosis despite multiple high-risk factors. The medically necessary alternative is anterior cervical discectomy and fusion (ACDF) at both levels with anterior cervical plating. 1

Critical Criterion Failures for Total Disc Replacement

Non-Contiguous Level Violation

• MCG guidelines explicitly require "1 or 2 contiguous-level artificial disks" for cervical disc arthroplasty to be considered medically necessary 1
• C3-4 and C5-6 are separated by the C4-5 level, making them non-contiguous and therefore an absolute contraindication to total disc replacement 1
• This criterion is non-negotiable and cannot be overridden by clinical severity 1

Unaddressed Osteoporosis Risk

• The patient has never undergone DEXA scanning despite having multiple high-risk factors: post-gastric sleeve surgery, likely vitamin D deficiency requiring supplementation, and female gender 1
• MCG criteria explicitly state "No osteoporosis" as a requirement for cervical disc arthroplasty 1
• Adequate bone quality is essential for endplate integrity and device fixation in total disc replacement 1
• A DEXA scan must be obtained and documented as normal before any cervical disc replacement could ever be reconsidered 1

Medically Necessary Alternative: ACDF at C3-4 and C5-6

Strong Evidence Supporting ACDF

• ACDF provides 80-90% success rates for arm pain relief in cervical radiculopathy with disc herniation and spinal cord compression 1
• Anterior cervical plating is specifically recommended for 2-level cervical disc degeneration to improve arm pain outcomes and reduce pseudarthrosis risk 1
• The patient meets all clinical criteria for ACDF: progressive myelopathy with spinal cord compression, failed conservative treatment >6 weeks, correlating neurological deficits (4/5 strength left deltoids and triceps), and failed injections 2, 1

Urgent Surgical Indication

• Acute myelopathy with spinal cord compression requires evaluation for surgical decompression 2
• MRI findings of "flattening of the spinal cord" at both C3-4 and C5-6 represent significant cord compression that warrants urgent intervention 2
• Progressive symptoms over 6 years with recent worsening and new motor deficits (4/5 strength) indicate evolving myelopathy 2
• Cervical kyphosis and retrolisthesis at both levels contribute to dynamic cord compression that worsens with upright positioning 2

Recommended Approval Path

Specific CPT Codes for Authorization

• Approve CPT 22551 (Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2) x2 levels 1
• Approve CPT 22845 (Anterior instrumentation; 2 to 3 vertebral segments) for anterior cervical plating 1
• This represents the standard of care for 2-level non-contiguous cervical disc disease with myelopathy 1

Clinical Rationale Supporting ACDF Over Conservative Management

Failed Conservative Treatment

• The patient has exhausted appropriate conservative measures: physical therapy >6 weeks, multiple cervical injections with diminishing effectiveness, NSAIDs contraindicated (post-gastric sleeve), Tylenol with minimal relief, heat/ice, massage, and chiropractic treatment 1
• Conservative treatment for cervical myelopathy with cord compression is inappropriate when neurological deficits are present 2, 3
• Symptomatic cervical myelopathy is itself an indication for surgical treatment 3

Progressive Neurological Deterioration

• Motor weakness (4/5 strength) in deltoids and triceps represents objective neurological deficit requiring intervention 2
• Bilateral symptoms with tingling extending to the scalp suggest multilevel cord involvement 2
• Worsening symptoms over 6 years with recent acceleration indicate progressive myelopathy that will not improve with further conservative care 2, 3

Common Pitfalls to Avoid

Misapplication of Total Disc Replacement Criteria

• Do not attempt to justify total disc replacement at non-contiguous levels based on clinical severity—the anatomic criterion is absolute 1
• Do not proceed with any cervical arthroplasty without documented normal bone density in high-risk patients 1
• Recognize that C3-4 level arthroplasty has significantly higher rates of heterotopic ossification (90.9% vs 58.4% at other levels), which would further complicate this case 4

Delayed Surgical Intervention in Myelopathy

• Do not continue conservative treatment when objective spinal cord compression with motor deficits is documented 2, 3
• Recognize that "flattening of the spinal cord" on MRI represents significant compression requiring decompression 2
• Understand that cervical myelopathy can progress to irreversible spinal cord injury if surgical decompression is delayed 2

Inadequate Preoperative Workup

• Always obtain DEXA scanning in patients with gastric bypass/sleeve surgery before any spinal instrumentation 1
• Document vitamin D and calcium levels in bariatric surgery patients, as deficiencies are nearly universal and affect bone healing 1

Peer-to-Peer Discussion Points

• The non-contiguous level configuration (C3-4 and C5-6) is an absolute contraindication to total disc replacement per MCG criteria 1
• ACDF with anterior plating is the evidence-based standard of care for this presentation, with 80-90% success rates 1
• The patient's progressive myelopathy with motor deficits and documented cord compression represents an urgent surgical indication 2
• Osteoporosis screening is mandatory before proceeding with any surgical plan given her high-risk status 1