Is C4-5 C5-6 C6-7 anterior cervical discectomy and fusion with implants and plating, harvesting autologous iliac crest bone graft, medically indicated for an older adult patient with neck pain radiating down to both arms with numbness and tingling, a history of conservative management including physical therapy, medication, and procedures, and imaging showing reversal of normal cervical lordotic curvature and severe stenosis at multiple levels with deformation of the cord?

Medical Necessity Determination for Multi-Level ACDF with Autologous Iliac Crest Bone Graft

Yes, the proposed C4-5, C5-6, C6-7 anterior cervical discectomy and fusion with instrumentation and plating is medically indicated for this patient with bilateral radiculopathy, severe multilevel stenosis with cord deformation, and failed conservative management. However, the harvesting of autologous iliac crest bone graft is NOT medically necessary and adds significant morbidity without improving fusion outcomes when combined with interbody cages and anterior plating. 1, 2

Surgical Indication: Clearly Met

The patient meets all established criteria for surgical intervention based on American Association of Neurological Surgeons guidelines: 1

• Documented cervical radiculopathy with bilateral arm numbness and tingling corresponding to imaging findings 1
• Severe spinal canal stenosis at multiple levels with cord deformation (myelopathy indicator) 1
• Failed conservative management including physical therapy and medications for at least 6 weeks 1
• Imaging confirmation of severe stenosis with cord compression at the proposed surgical levels 1

The presence of cord deformation at multiple levels indicates myelopathy, which represents a more urgent surgical indication than radiculopathy alone, as progressive cord compression can lead to irreversible neurological damage. 1

Multi-Level ACDF Approach: Appropriate

Three-level ACDF (C4-5, C5-6, C6-7) is the correct surgical approach for this patient's pathology: 1, 3

• Anterior cervical discectomy and fusion is recommended for patients with 2-3 level disc pathology causing severe spinal canal stenosis 1
• The anterior approach provides direct decompression of the spinal cord and nerve roots while restoring cervical lordosis 3
• ACDF with instrumentation achieves superior arm pain relief compared to ACDF without instrumentation (Class II evidence) 1

Anterior Plating: Medically Necessary

The use of anterior cervical plating is strongly recommended for multi-level ACDF: 1, 2

• Anterior plating reduces the risk of pseudarthrosis in multi-level fusions 1
• Plating maintains lordosis and improves fusion rates, particularly important in 3-level constructs 1
• For 2-level ACDF, the nonunion rate with allograft alone is 63% compared to 17% with autograft, but this gap is eliminated when anterior plating is added 4

Interbody Cages: Medically Necessary

Synthetic interbody cages (titanium or PEEK) are medically necessary and achieve excellent fusion rates: 2

• PEEK cages achieve 100% fusion rates at 12 months with 97% good-to-excellent clinical outcomes 2
• Titanium cages achieve 98% fusion rates at 12 months with 83% good-to-excellent clinical outcomes 4, 2
• Cages maintain foraminal height better than structural bone grafts, which is critical for sustained neural decompression 2
• Cages provide immediate structural stability while avoiding the morbidity of structural autograft harvest 2

Autologous Iliac Crest Bone Graft: NOT Medically Necessary

The harvesting of autologous iliac crest bone graft is NOT medically necessary in this case and introduces significant donor site morbidity without improving fusion outcomes: 2, 5

Evidence Against Iliac Crest Harvest:

When interbody cages and anterior plating are already utilized, adding iliac crest autograft provides no fusion benefit: 2

• The combination of allograft with interbody cages achieves fusion rates of 91-95% for multilevel cervical fusion, equivalent to autograft alone 2
• American Association of Neurological Surgeons guidelines state that "autograft bone harvested from iliac crest, allograft bone from cadaveric sources, or titanium cages with or without autologous graft are all recommended options" (Class II evidence) 2
• Guidelines specifically note that "graft harvest morbidity and patient preference should be considered when selecting the type of graft" 2

Significant Donor Site Morbidity:

Iliac crest harvest causes substantial complications that negatively impact quality of life: 5, 6

• 90% of patients experience pain at the iliac crest donor site 5
• 22% of patients have persistent hip pain at 1 year postoperatively 2, 5
• Significantly lower mental health scores on validated quality of life instruments (SF-36 and Cervical Spine Outcomes Questionnaires) at >12 months follow-up 5
• Longer operative duration (285 minutes vs. 238 minutes, p = 0.026) 5
• Major complications in 5.8% of cases including herniation of abdominal contents, vascular injuries, deep infections, neurologic injuries, and iliac wing fractures 6
• Minor complications in 10% of cases including superficial infections, seromas, and hematomas 6

Recommended Graft Strategy

The optimal graft strategy for this 3-level ACDF is: 2

1. Interbody cages (titanium or PEEK) at each level for structural support and disc height maintenance 2
2. Allograft bone (CPT 20930) packed within the cages for osteoconductivity 2
3. Anterior cervical plating across all three levels for stability 1

This combination achieves equivalent fusion rates (91-95%) to autograft without the donor site morbidity, shorter operative time, and superior patient satisfaction. 2, 5

Alternative Autograft Sources (If Autograft Desired)

If the surgeon prefers autologous bone for biological enhancement, local autograft from cervical osteophytes removed during decompression should be used instead of iliac crest harvest: 2

• Local autograft from osteophytes achieves equivalent fusion rates without donor site morbidity 2
• Clavicular autograft is another alternative that yields optimal fusion rates with minimal donor site complications and high patient satisfaction 7

Common Pitfalls to Avoid

Do not default to iliac crest harvest based on historical practice patterns: 5, 8

• Autologous iliac crest graft was the "gold standard" for decades, but this practice warrants scrutiny now that alternatives with equivalent outcomes are available 5, 8
• Patient dissatisfaction with donor site morbidity has driven the search for alternative techniques 8
• The continued use of iliac crest harvest in the presence of equivalent alternatives cannot be justified on evidence-based grounds 5

For multi-level fusions, the risk of pseudarthrosis increases significantly without anterior plating: 4

• Two-level allograft fusion without plating has a 63% nonunion rate compared to 17% with autograft 4
• This gap is eliminated when anterior plating is added to the construct 1