Is C6-7 anterior cervical discectomy and arthroplasty medically necessary for a patient with a right paracentral disc herniation at C6-7 and persistent neck and radiating right arm symptoms despite conservative management?

C6-7 Anterior Cervical Discectomy and Arthroplasty is Medically Necessary

Yes, C6-7 anterior cervical discectomy and arthroplasty is medically necessary for this 39-year-old male with a right paracentral disc herniation at C6-7 causing persistent radiculopathy despite comprehensive conservative management. 1, 2

Clinical Justification for Surgical Intervention

This patient meets all established criteria for surgical intervention:

• Adequate conservative management has failed: The patient has completed an appropriate trial of over-the-counter anti-inflammatories, prescription medications, muscle relaxers, activity modification, regular icing, and physical therapy—meeting the minimum 6-week conservative therapy requirement before surgical consideration 2, 3

• Radiographic-clinical correlation is established: MRI demonstrates a right paracentral disc herniation at C6-7 that directly corresponds to the patient's right-sided neck pain and radiating arm symptoms 2, 4

• Surgical intervention provides superior outcomes at this stage: While 75-90% of cervical radiculopathy patients improve with conservative management, this patient has already failed such treatment 2. Anterior cervical decompression provides more rapid relief (within 3-4 months) of arm/neck pain, weakness, and sensory loss compared to continued conservative therapy, with 80-90% success rates for arm pain relief 2, 4

Arthroplasty vs. Fusion: The Evidence-Based Choice

Cervical arthroplasty is specifically recommended as an alternative to ACDF in selected patients for control of neck and arm pain (Class II evidence). 1

Why Arthroplasty is Appropriate Here:

• Age consideration: At 39 years old, this patient is an ideal candidate for motion preservation, as he has decades of potential adjacent segment stress ahead 3, 5

• Single-level disease: The guidelines establish that both anterior cervical discectomy with fusion (ACDF) and arthroplasty are equivalent treatment strategies for 1-level disease with regard to functional outcomes 1

• Motion preservation benefits: Arthroplasty preserves segmental motion and potentially reduces stress on adjacent levels, which is particularly valuable in a young patient 3, 5

• Equivalent clinical outcomes: Short- and medium-term studies demonstrate cervical disc replacement to be at least as effective as ACDF for clinical outcomes in degenerative cervical spondylosis 6

Critical Prerequisites for Arthroplasty:

Before proceeding, the following must be confirmed:

• Flexion-extension radiographs are required to definitively rule out segmental instability at C6-7, as static MRI cannot adequately assess this 2

• Absence of contraindications: No inflammatory spondyloarthropathy, osteoporosis, previous cervical surgery at C6-7, or active infection 3

• FDA-approved device must be used 3

Addressing the Lumbar Findings

The stable L4-5 fusion construct is irrelevant to the cervical pathology. The patient's primary complaint is neck pain with right arm radiation, and imaging confirms cervical pathology at C6-7 that correlates with these symptoms 2. The lumbar findings do not contraindicate cervical surgery.

Common Pitfalls to Avoid

• Do not delay surgery unnecessarily: This patient has already completed adequate conservative management. The 90% success rate with conservative therapy applies to the acute phase; once conservative measures have failed, surgical intervention is indicated 2

• Do not perform fusion if arthroplasty is appropriate: In a 39-year-old with single-level disease and no contraindications, arthroplasty offers motion preservation without compromising clinical outcomes 1, 3, 5

• Ensure proper patient selection: Arthroplasty requires careful patient selection with absence of segmental instability, which must be confirmed with flexion-extension films 2, 3

Expected Outcomes

• Arm pain relief: 80-90% success rate 2, 4
• Functional improvement: 90.9% of patients achieve functional improvement following surgical intervention 2
• Timeline: More rapid relief within 3-4 months compared to continued conservative management 2
• Motion preservation: Maintained segmental motion at the treated level 3, 5