Is CPT 22551 medically necessary for a patient with a 3-column C5 fracture with flexion and teardrop morphology?

Medical Necessity of CPT 22551 for C5 Three-Column Flexion Teardrop Fracture

CPT 22551 (anterior cervical corpectomy with fusion and plating) is absolutely medically necessary for this 19-year-old patient with a displaced three-column C5 flexion teardrop fracture, facet subluxation, canal stenosis, and retrolisthesis. This injury pattern represents one of the most unstable cervical spine injuries with high risk for permanent neurological devastation if not surgically stabilized.

Why This Surgery Is Mandatory

Three-column flexion teardrop fractures are highly unstable injuries that fail both the anterior spine under compression and the posterior spine in tension, requiring surgical stabilization to prevent catastrophic neurological deterioration. 1 The presence of canal stenosis from retropulsion, facet subluxation, and retrolisthesis further confirms complete spinal instability requiring immediate surgical intervention. 2

Critical Injury Components Demanding Surgery

• Three-column involvement: This fracture pattern disrupts all three spinal columns (anterior, middle, and posterior), creating complete spinal instability 1
• Canal compromise with retropulsion: Mild canal stenosis from retrolisthesis places the spinal cord at immediate risk 2
• Facet subluxation: The asymmetric C5-6 facet widening and lateral subluxation indicate ligamentous disruption and rotational instability 3
• Paraspinal hematoma: The developing paraspinal hematoma at C5 confirms significant soft tissue injury 3

Evidence Supporting Anterior Corpectomy and Fusion

Anterior corpectomy with plating (CPT 22551) is superior to non-operative management for unstable cervical flexion teardrop fractures, achieving better sagittal alignment restoration (3.5° vs 11.4° kyphosis), lower failure rates, and avoiding the 21% failure rate seen with halo immobilization. 1 In a comparative study of 45 patients with identical injury patterns, the halo vest group experienced 5 failures (4 requiring subsequent surgery), while the anterior corpectomy group had zero failures and significantly better alignment maintenance. 1

Surgical Approach Rationale

• Anterior corpectomy addresses the primary pathology: The C5 vertebral body is fractured and retropulsed into the canal, requiring removal and reconstruction 4, 1
• Direct decompression: Anterior approach allows direct visualization and removal of retropulsed bone fragments compressing the spinal cord 2
• Restoration of anterior column height: Corpectomy with strut graft and plating restores vertebral body height and corrects kyphotic deformity 1
• Immediate rigid stabilization: Anterior plating provides immediate biomechanical stability across the injury zone 4, 1

Timing Is Critical

Surgery should be performed emergently (within 24 hours) to prevent secondary neurological injury from ongoing spinal cord compression and instability. 2 Although this patient currently has no neurological deficits, the combination of canal stenosis, three-column instability, and facet subluxation places her at extreme risk for delayed neurological deterioration with any minor movement or secondary injury. 2

Why Delay Is Dangerous

• 67-96% of patients with this fracture pattern present with neurological deficits 1, indicating this patient is fortunate but remains at imminent risk
• Flexion teardrop fractures have historically resulted in permanent quadriplegia in the vast majority of cases 3
• Delays in surgical decompression lead to worse neurological outcomes 2

Alternative Treatments Are Inadequate

Halo vest immobilization is contraindicated for this injury pattern due to unacceptably high failure rates (21%) and inability to maintain alignment. 1 The study comparing halo vest to anterior surgery found that halo treatment resulted in:

• Mean kyphosis of 11.4° (vs 3.5° with surgery) 1
• 5 of 24 patients (21%) requiring subsequent surgical conversion 1
• Inability to control rotational instability from facet disruption 1

Posterior-only approaches are insufficient because they fail to address the anterior column defect, retropulsed bone fragments, and disc disruption at both C4-5 and C5-6 levels. 5 While posterior reduction techniques have been described, they are appropriate only for specific fracture patterns without significant anterior column comminution or canal compromise. 5

Specific Technical Considerations

The C5 corpectomy with C4-6 fusion (as performed) is the appropriate construct because:

• The fracture involves the entire C5 vertebral body requiring complete corpectomy 4, 1
• Adjacent level disc injuries at both C4-5 and C5-6 necessitate fusion across these levels 3
• Spanning one level above and below the corpectomy provides adequate fixation points for plate stability 4, 1

Common Pitfalls to Avoid

• Underestimating injury severity: The "mild" canal stenosis and "mild" subluxation descriptors belie the catastrophic instability of three-column failure 1
• Delaying surgery for "observation": Any delay risks irreversible spinal cord injury from the unstable spine 2
• Attempting non-operative management: This injury pattern has proven unacceptably high failure rates with conservative treatment 1
• Inadequate fusion construct: Single-level fusion would fail to address the multi-level ligamentous injury 3

Expected Outcomes

Surgical stabilization with anterior corpectomy and plating provides excellent outcomes with restoration of spinal alignment, prevention of neurological deterioration, and return to normal function. 4, 1 A case series of adolescents with identical injuries treated with C5-6 anterior fusion demonstrated full functional recovery at 12-month follow-up. 4 The comparative study showed no major intraoperative or postoperative complications in the surgical group. 1

This surgery is not elective—it is life-altering and potentially life-saving intervention for a devastating injury that would otherwise result in permanent quadriplegia in the majority of cases.