Is anterior discectomy and fusion at C6-7, supplemented by a posterior fusion, removal of anterior spinal instrumentation, and spine bone autograft medically indicated for a 59-year-old patient with scapular and radiating left arm pain, cervical radiculopathy, and lumbosacral spondylosis without myelopathy?

Medical Necessity Assessment for Anterior and Posterior Fusion at C6-7 with Hardware Removal and Bone Autograft

The proposed combined anterior and posterior fusion at C6-7 with removal of anterior instrumentation and bone autografting is medically indicated for this 59-year-old patient, as this represents revision surgery for anterior cervical pseudarthrosis—a recognized complication requiring surgical correction when symptomatic. 1, 2

Primary Indication: Revision for Failed Anterior Fusion

The removal of anterior spinal instrumentation combined with supplemental posterior fusion strongly suggests this is revision surgery for pseudarthrosis (failed fusion) at C6-7. 1

• Anterior cervical pseudarthrosis occurs in 4.8-26% of cases depending on the number of levels fused and use of instrumentation 2
• Symptomatic pseudarthrosis presenting with persistent or recurrent radicular symptoms constitutes a clear indication for revision surgery 1, 2
• The patient's persistent scapular and radiating left arm pain with cervical radiculopathy correlates with failed fusion at C6-7 2, 3

Surgical Approach Selection: Combined Anterior-Posterior Revision

For revision of anterior cervical pseudarthrosis, both posterior-only fusion and combined anterior revision with posterior supplementation are evidence-based approaches. 1

Posterior Supplementation Strategy

• Posterior fusion for anterior pseudarthrosis achieves solid arthrodesis in 80-100% of cases 1
• The addition of posterior instrumentation provides superior biomechanical stability, particularly important in revision scenarios where anterior bone graft has failed 1, 4
• Combined anterior hardware removal with posterior fusion addresses both the failed construct and provides fresh fusion substrate 1, 4

Hardware Removal Justification

• Removal of failed anterior instrumentation is indicated when the hardware is associated with persistent symptoms or when it compromises revision fusion success 1, 4
• Hardware removal carries risks of neurovascular injury during dissection through scarred tissue, but is necessary when the anterior construct has failed 4

Bone Autograft Utilization

Autogenous bone graft remains the gold standard for revision cervical fusion, particularly in pseudarthrosis cases where prior fusion attempts have failed. 1

• Autograft provides superior osteoinductive and osteoconductive properties compared to allograft in revision scenarios 1
• The use of autograft in posterior fusion procedures demonstrates fusion rates of 65-80% even in challenging revision cases 1
• Bone autograft is specifically recommended for posterolateral fusion supplementing anterior revision 1

Clinical Correlation Requirements Met

The patient's clinical presentation satisfies the criteria for surgical intervention in cervical radiculopathy. 2, 3

• Scapular and radiating left arm pain represents dermatomal distribution consistent with C6-7 pathology 2, 3
• Cervical radiculopathy with persistent symptoms despite prior surgical intervention indicates failed conservative and initial surgical management 2, 3
• The absence of myelopathy confirms this is radiculopathy-predominant pathology, appropriate for the proposed intervention 2, 3

Critical Distinction: Revision vs. Primary Surgery

This case fundamentally differs from primary cervical fusion because it represents management of surgical failure (pseudarthrosis), not initial treatment of degenerative disease. 1, 4

• Primary ACDF achieves 80-90% success rates for arm pain relief 2
• When primary fusion fails, revision surgery is indicated for symptomatic pseudarthrosis regardless of the duration of conservative management 1
• The lumbosacral spondylosis without myelopathy is an incidental finding and does not contraindicate cervical revision surgery 2

Procedural Complexity and Risk Considerations

Revision cervical spine surgery with hardware removal carries higher complication risks than primary surgery, justifying the combined approach. 4

• Hardware removal requires extensive dissection through scarred tissue with elevated neurovascular injury risk 4
• Combined anterior-posterior revision provides superior biomechanical stability compared to single-approach revision 1, 4
• The transitional nature of C6-7 (lower cervical spine) increases pseudarthrosis risk, supporting aggressive revision strategy 4

Common Pitfalls to Avoid

• Do not confuse this with primary multilevel fusion: The hardware removal indicates this is revision surgery for failed prior fusion 1, 4
• Do not require additional conservative management: Symptomatic pseudarthrosis is a surgical indication that does not respond to non-operative treatment 1, 2
• Do not perform anterior revision alone: Supplemental posterior fusion significantly improves fusion rates in revision scenarios 1
• Do not use allograft in revision cases: Autograft provides superior fusion rates when prior fusion attempts have failed 1