Is a C5-C6 artificial disc replacement (ADR) medically necessary for a patient with spinal stenosis, cervical myelopathy, cervical degenerative disc disease (DDD), and cervical radiculopathy?

Medical Necessity Determination for C5-C6 Artificial Disc Replacement

Artificial disc replacement at C5-C6 is NOT medically necessary for this patient; instead, anterior cervical discectomy and fusion (ACDF) at C3-C4, C4-C5, and C5-C6 with anterior cervical plating is the appropriate surgical intervention. 1

Primary Contraindications to Artificial Disc Replacement

The presence of cervical myelopathy with multilevel spinal stenosis makes this patient a poor candidate for artificial disc replacement, as the evidence supporting arthroplasty in myelopathy is limited. 1 The clinical presentation includes:

• Cervical myelopathy with cord compression requiring decompression to prevent permanent neurological injury 1
• Impaired coordination and dexterity with hand weakness and dropping objects, which are classic myelopathic signs 1
• Multilevel pathology at C3-C4, C4-C5, and C5-C6 requiring surgical intervention at all three levels 1

The proposed mixed surgical approach—osteophyte excision at multiple levels with arthroplasty at only one level—creates a biomechanically inconsistent construct that is not supported by evidence. 1 Advanced spondylotic changes, including large osteophytes causing esophageal compression and dysphagia, represent more severe degenerative disease than typical arthroplasty candidates. 1

Recommended Surgical Approach: Multilevel ACDF

Anterior cervical discectomy and fusion at C3-C4, C4-C5, and C5-C6 with anterior cervical plating is the medically appropriate procedure because it addresses all pathology uniformly and provides necessary stability. 1 This recommendation is based on:

• Multilevel fusion with plating is recommended for 2-level cervical disc degeneration to improve arm pain, and this patient requires 3-level surgery 1
• ACDF is effective for cervical radiculopathy, with good or better outcomes in approximately 90% of patients using Odom's criteria 1
• Anterior cervical decompression is specifically recommended for symptomatic cervical radiculopathy resulting from cervical spondylosis with foraminal compromise 1
• The addition of cervical plating reduces pseudarthrosis risk and maintains lordosis, particularly important in multilevel constructs 1

Clinical Justification for Surgical Intervention

This patient has exhausted appropriate conservative management and demonstrates progressive neurological symptoms warranting surgical intervention:

• Failed conservative therapies including multiple rounds of physical therapy, anti-inflammatory medications, steroids, bilateral C2-C4 radiofrequency ablation (80% relief for 7-8 months), and left L5-S1 epidural steroid injection 1
• Worsening dysphagia and voice changes from esophageal compression by large anterior osteophytes at C3-C4, C4-C5, and C5-C6 requiring anterior decompression 1
• Progressive cervical myelopathy with impaired hand coordination, weakness, and dropping objects representing spinal cord compression 1
• Persistent C5-C6 radiculopathy with severe bilateral foraminal stenosis on MRI despite conservative management 1

Imaging Correlation

The MRI and CT findings directly support the need for multilevel anterior decompression:

• Severe bilateral foraminal stenosis at C5-C6 correlating with radicular symptoms 1
• Anterior osteophytes at C3-C4, C4-C5, and C5-C6 causing mass effect on the esophagus and dysphagia 1
• No significant central spinal canal stenosis but multilevel degenerative changes most pronounced at C5-C6 1

Surgical Outcomes Evidence

ACDF provides superior outcomes for this clinical presentation:

• 80-90% success rates for arm pain relief in cervical radiculopathy 1
• Rapid relief within 3-4 months of arm/neck pain, weakness, and sensory loss 1
• Motor function recovery maintained over 12 months following anterior decompression 1
• Multilevel fusion with instrumentation provides greater stability and improved outcomes 2

Critical Pitfalls to Avoid

Do not perform artificial disc replacement in patients with:

• Cervical myelopathy with cord compression 1
• Multilevel pathology requiring intervention at adjacent levels 1
• Advanced spondylotic changes with large osteophytes 1
• Mixed surgical constructs combining fusion and arthroplasty 1

The presence of myelopathy is an absolute contraindication to cervical disc arthroplasty, as these patients require uniform decompression and stabilization across all affected levels. 1, 3 Attempting arthroplasty at one level while performing osteophyte excision at adjacent levels creates biomechanical inconsistency and does not address the underlying pathophysiology. 1

Age and Device Considerations

While the patient's age (48 years) falls within FDA-approved ranges for various cervical disc devices (Mobi-C: 21-67 years; Prestige LP: 21-78 years; Simplify: <70 years), age eligibility alone does not establish medical necessity when contraindications exist. 1 The presence of myelopathy, multilevel pathology, and advanced spondylosis supersede age-based device criteria. 1