Medical Necessity Assessment for C5-C6 Artificial Disc Replacement
Yes, surgical intervention is medically indicated for this patient, but C5-C6 artificial disc replacement is NOT the appropriate procedure given the clinical presentation. The patient requires anterior cervical decompression with fusion (ACDF) at multiple levels (C3-C4, C4-C5, C5-C6) rather than arthroplasty, due to the presence of cervical myelopathy, multilevel disease requiring osteophyte excision, and the need for concurrent fusion at adjacent levels.
Primary Rationale Against Artificial Disc Replacement
The presence of cervical myelopathy with spinal stenosis at multiple levels makes this patient a poor candidate for artificial disc replacement at C5-C6. While cervical arthroplasty has shown similar outcomes to ACDF in patients with radiculopathy alone, the evidence supporting its use in myelopathy is limited and the surgical plan involves multilevel anterior decompression with osteophyte excision 1.
Key Clinical Factors Precluding Arthroplasty:
Multilevel pathology requiring surgical intervention: The patient has significant compression at C3-C4, C4-C5, AND C5-C6, all requiring anterior osteophyte excision 2
Cervical myelopathy present: While one study showed arthroplasty can be performed in myelopathy patients with degenerative disc disease, those patients had myelopathy from disc herniation, not from large osteophytes requiring excision 1
Mixed surgical approach: The proposed plan involves osteophyte excision at three levels with arthroplasty at only one level, creating a biomechanically inconsistent construct 2
Age and pathology: At 48 years old with advanced spondylotic changes (large osteophytes causing esophageal compression), this represents more severe degenerative disease than typical arthroplasty candidates 2
Recommended Surgical Approach
Anterior cervical discectomy and fusion (ACDF) at C3-C4, C4-C5, and C5-C6 with instrumentation is the medically appropriate procedure. This addresses all pathology uniformly and provides the necessary stability after extensive anterior decompression 2.
Supporting Evidence for ACDF Over Arthroplasty:
Multilevel fusion with plating is recommended for 2-level cervical disc degeneration to improve arm pain, and this patient requires 3-level surgery 2
ACDF is effective for cervical radiculopathy with good or better outcomes in approximately 90% of patients using Odom's criteria 2
Anterior cervical decompression is recommended for symptomatic cervical radiculopathy resulting from cervical spondylosis with foraminal compromise 2
The addition of cervical plating is recommended to reduce pseudarthrosis risk and maintain lordosis, particularly important in multilevel constructs 2
Clinical Justification for Surgery
The patient has failed conservative management and demonstrates progressive neurological symptoms warranting surgical intervention. The combination of myelopathy, radiculopathy, dysphagia, and voice changes from anterior osteophytic compression represents clear surgical indications 2.
Failed Conservative Measures:
- Multiple rounds of physical therapy
- Anti-inflammatory medications
- Steroids
- Radiofrequency ablation (RFA)
- Epidural steroid injections (ESI)
Progressive Symptoms Indicating Urgency:
Worsening dysphagia and voice changes: These symptoms from esophageal compression by large anterior osteophytes require anterior decompression 2
Cervical myelopathy: Represents spinal cord compression requiring decompression to prevent permanent neurological injury 2
C5-C6 radiculopathy: Persistent despite conservative management 2
Common Pitfalls to Avoid
Do not proceed with artificial disc replacement when the surgical plan requires extensive multilevel anterior decompression with osteophyte excision. The biomechanical demands after removing large anterior osteophytes at three levels necessitate fusion for stability 2.
Avoid mixing fusion and arthroplasty in adjacent segments unless there is compelling evidence for hybrid constructs, which is not established in this clinical scenario 2.
Recognize that esophageal compression from anterior osteophytes requires complete osteophyte removal, which compromises the anterior column integrity and necessitates reconstruction with fusion rather than motion preservation 2.
Specific Surgical Recommendation
Perform anterior cervical discectomy and fusion with instrumentation at C3-C4, C4-C5, and C5-C6 including:
- Complete anterior osteophyte excision at all three levels to decompress the esophagus
- Neural decompression for myelopathy and radiculopathy
- Interbody graft placement at all three levels
- Anterior cervical plating for stability 2
This approach provides uniform treatment of all pathology, maintains spinal stability after extensive anterior column reconstruction, and has established efficacy for both myelopathy and radiculopathy 2.