Is cervical arthroplasty at C5-C6 and C6-C7 medically indicated for a patient with neck pain radiating down the back and MRI findings of multiple disc herniations at C5-C6 and C6-C7?

Medical Necessity Determination for Cervical Arthroplasty at C5-C6 and C6-C7

This cervical arthroplasty is NOT medically indicated because the patient has not completed the required minimum 6 weeks of documented conservative treatment, which is an absolute prerequisite for surgical intervention in cervical radiculopathy. 1

Critical Missing Requirement

The patient lacks documented duration and specifics of conservative therapies, which is mandatory before proceeding with any anterior cervical decompression procedure. 1 The MCG criteria explicitly state "Failure of nonoperative treatment (eg, NSAIDs, narcotic or non-narcotic analgesics, physical therapy, spinal manipulation therapy) - NOT MET," confirming this deficiency.

• Non-operative management achieves 75-90% symptomatic improvement in cervical radiculopathy patients, making it the appropriate initial approach. 1
• Physical therapy demonstrates statistically significant clinical improvement and achieves comparable outcomes to surgical interventions at 12 months, though surgery provides more rapid relief within 3-4 months. 1
• The American Association of Neurological Surgeons requires documented failure of at least 6 weeks of structured conservative therapy including specific dates, frequency, and response to treatment before surgical candidacy can be established. 1

Clinical Indications That ARE Met

The patient does meet several important clinical criteria that would support surgery once conservative management is properly documented:

• Appropriate clinical presentation: Neck pain radiating to back with bilateral lower extremity paresthesias and "electric shock" sensations correlate with the imaging findings of severe spinal canal narrowing at C5-C6 and C6-C7. 2
• Radiographic confirmation: MRI demonstrates multiple disc herniations with severe narrowing of the spinal canal at both levels, meeting the moderate-to-severe pathology threshold. 3, 1
• Neurologic symptoms: The presence of bilateral lower extremity paresthesias suggests spinal cord impingement, which the MCG criteria recognize as an indication for admission. 2

Why Arthroplasty Specifically May Not Be Optimal

Even after conservative management is documented, cervical arthroplasty may not be the most appropriate surgical choice for this patient's presentation:

• Multilevel disease consideration: The patient has significant pathology at two contiguous levels (C5-C6 and C6-C7). While cervical arthroplasty is FDA-approved for 1-2 contiguous levels, the evidence base is strongest for single-level disease. 4, 5
• Spinal cord compression: The presence of bilateral lower extremity symptoms and "electric shock" sensations traveling down the spine suggests myelopathic features, not just radiculopathy. Anterior cervical discectomy and fusion (ACDF) may be more appropriate than arthroplasty when cord compression is present. 2, 1
• Severe canal stenosis: With "severe narrowing of spinal canal at both levels," the patient may have anatomic constraints that make arthroplasty less suitable than fusion. 6

Evidence for Arthroplasty When Properly Indicated

If conservative management is documented and arthroplasty remains the chosen approach, the evidence shows:

• Cervical disc arthroplasty demonstrates equivalent or superior outcomes to ACDF for properly selected patients with 80-90% success rates for arm pain relief. 1, 5
• At 7-year follow-up, ProDisc-C patients had significantly lower rates of secondary surgical procedures (7% vs 18%) compared to ACDF patients. 4
• Long-term studies show good device survival, preserved motion (mean 8.2° segmental range of motion), and acceptable rates of adjacent segment disease. 7
• Arthroplasty is most appropriate for healthy younger patients with single-level degenerative disc disease without significant instability, osteoporosis, or prior cervical surgery at the affected level. 5, 8

Inpatient Admission Justification

The 2-day inpatient admission (x2 bed days) IS medically justified based on the surgical complexity and neurologic findings:

• The MCG criteria for admission are met due to "other neurologic abnormality suggesting spinal cord impingement," evidenced by bilateral lower extremity paresthesias and electric shock sensations. 2
• Two-level cervical arthroplasty is a complex procedure requiring postoperative monitoring for neurologic status, drain management, and prophylactic antibiotics as documented in the case. 9
• Standard postoperative course for cervical arthroplasty includes discharge on postoperative day 1 or 2, supporting the requested 2-day stay. 9

Critical Path Forward

Non-certification is recommended with the following requirements before resubmission:

1. Document at least 6 weeks of conservative management including physical therapy sessions (dates, frequency, specific exercises), medication trials (NSAIDs, analgesics with dosages and duration), activity modifications, and patient response to each intervention. 1
2. Obtain flexion-extension cervical radiographs to definitively rule out segmental instability, which is a contraindication to arthroplasty. 1, 6
3. Clarify the neurologic examination to distinguish between radiculopathy (arm symptoms) versus myelopathy (bilateral leg symptoms with cord compression), as this determines whether arthroplasty or fusion is more appropriate. 1
4. Consider ACDF instead of arthroplasty given the multilevel disease, severe canal stenosis, and possible myelopathic features, as ACDF provides more rapid relief (3-4 months) and has stronger evidence for two-level disease with instrumentation. 2, 1