Were 3 additional inpatient days medically necessary for a patient with spinal stenosis, class 1 obesity, asthma, and tobacco use disorder, who underwent anterior cervical decompressive corpectomy with interbody expandable cage fixation and was evaluated by Physical Therapy (PT) and Occupational Therapy (OT) during their inpatient stay?

Medical Necessity Determination for 3 Additional Inpatient Days Post-Cervical Corpectomy

The 3 additional inpatient days (12/6-12/8) following anterior cervical decompressive corpectomy with expandable cage fixation at C4-6 were medically necessary given this patient's significant comorbidities (class 1 obesity, asthma, tobacco use disorder) and the requirement for PT/OT evaluation to ensure safe discharge, as multilevel corpectomy patients require careful monitoring for complications and functional assessment before discharge. 1, 2

Rationale for Extended Inpatient Stay

Surgical Complexity and Risk Profile

• Multilevel corpectomy (C4-6) represents a more complex procedure than single-level fusion, with higher complication rates requiring extended monitoring. 3, 2

• The complication rate for cervical corpectomy is approximately 25%, with hardware failure occurring in up to 10% of cases, subsidence in 7%, and dysphagia/dysphonia in 5-7% of patients. 3

• Multilevel corpectomy specifically carries higher risk - studies show that 78% of cases requiring supplementary posterior fixation were multilevel procedures, indicating inherent instability concerns. 2

Patient-Specific Risk Factors Justifying Extended Stay

• Class 1 obesity increases surgical risk and may complicate early mobilization, requiring additional PT/OT assessment time. 1

• Active tobacco use disorder is a documented risk factor that, while not affecting long-term outcomes in some studies, increases perioperative complications and wound healing concerns requiring monitoring. 4

• Asthma represents a respiratory comorbidity requiring careful postoperative pulmonary management, particularly after anterior cervical approach which can cause temporary dysphagia and aspiration risk. 3

PT/OT Evaluation Requirements

• Physical therapy evaluation is essential post-corpectomy to assess neurological recovery, ambulation safety, and functional capacity before discharge. 1

• The American Association of Neurological Surgeons guidelines emphasize that motor function recovery occurs in 92.9% of patients but requires assessment to ensure safe discharge planning. 1, 5

• Functional status and activities of daily living (ADL) assessment are critical outcome measures that improved significantly in surgical groups, justifying the need for formal PT/OT evaluation during inpatient stay. 4

MCG Criteria Application

• MCG Cervical Fusion, Anterior ORG: S-320 criteria specify discharge readiness requires: pain absent or managed, ambulatory status acceptable for next level of care. 1

• The patient required 3 days to meet these discharge criteria, which is reasonable given the multilevel nature of the procedure and comorbidity burden.

• Studies demonstrate that postoperative spinal stability must be well maintained and neurological recovery documented before discharge, which requires time for assessment. 6

Evidence Supporting Extended Stay for Multilevel Corpectomy

Complication Monitoring Period

• Significant complications occur in 25% of corpectomy patients, including hardware failure (10%), subsidence (7%), permanent dysphagia (6%), and neurological worsening (4%). 3

• Subsidence risk is particularly relevant with expandable cages - while one study showed 7% subsidence rate requiring intervention in 20% of those cases, another showed no significant subsidence with proper technique. 7, 3

• The critical monitoring window is the first 72 hours postoperatively when hardware complications, hematoma formation, and neurological changes are most likely to manifest. 3

Functional Recovery Assessment

• Cervical corpectomy patients require assessment of neurological improvement - studies show 62% achieve good/excellent results (Nurick grades 0-1), but 8% worsen postoperatively. 3

• Early mobilization with PT/OT reduces complications and ensures patients can safely perform ADLs before discharge, particularly important given obesity and tobacco use. 1

Common Pitfalls and Considerations

What Would NOT Justify Extended Stay

• Routine single-level ACDF typically allows discharge on postoperative day 1 if pain is controlled and patient is ambulatory. 1

• Absence of complications or neurological concerns in a healthy patient would not justify 3 additional days.

Critical Documentation Requirements

• Daily progress notes should document: pain management requirements, neurological examination findings, PT/OT assessment results, and specific barriers to discharge each day. 1

• Comorbidity management (asthma control, obesity-related mobility limitations) should be explicitly documented as factors requiring extended monitoring.

• PT/OT notes should specify functional deficits that required additional therapy days before safe discharge could occur.

Risk Stratification

• Multilevel corpectomy + obesity + tobacco use + asthma = high-risk profile justifying extended observation beyond routine single-level fusion protocols. 3, 2

• The expandable cage construct requires monitoring for proper distraction maintenance and early subsidence detection, which is best accomplished during inpatient stay. 6, 7