Is cervical artificial disc replacement (CERV ARTIFIC DISKECTOMY) medically indicated for a male patient with a history of significant spinal cord injury and prior surgical intervention, presenting with worsening cervical myelopathy, neck pain, radiating arm pain, fine motor skill deterioration, and unsteady gait, with a left-sided paracentral C4-5 disc herniation and moderate multilevel degenerative disc disease and facet arthropathy on MRI, who has failed physical therapy?

Cervical Artificial Disc Replacement is NOT Medically Indicated for This Patient

Cervical artificial disc replacement (arthroplasty) is contraindicated in this patient due to his history of significant prior spinal cord injury from previous cervical surgery, multilevel degenerative disease with facet arthropathy, and presentation with progressive myelopathy—all of which represent absolute or relative contraindications to motion-preserving technology. 1, 2, 3

Critical Contraindications Present

History of Significant Spinal Cord Injury

• Prior spinal cord injury from previous cervical surgery is an absolute contraindication to cervical disc arthroplasty 1
• The risk of recurrent spinal cord herniation through anterior surgical defects exists, particularly in patients with prior ACDF procedures 4
• This patient's documented "significant spinal cord injury after prior surgical intervention" places him at unacceptable risk for further neurological deterioration with motion-preserving devices 4

Multilevel Facet Arthropathy

• Moderate multilevel facet arthropathy is a contraindication to cervical disc arthroplasty, as the FDA-approved indications specifically exclude patients with significant facet joint disease 5
• Facet arthropathy indicates that the pathology extends beyond the disc space, making motion preservation inappropriate and potentially harmful 3, 5
• The presence of facet degeneration suggests that fusion, not motion preservation, is the appropriate surgical strategy 6

Progressive Myelopathy

• This patient presents with worsening cervical myelopathy (fine motor deterioration, unsteady gait, progressive arm weakness), which requires urgent decompression rather than motion preservation 1
• The natural history of cervical spondylotic myelopathy shows that 55-70% of patients experience progressive deterioration without intervention 7

The Appropriate Surgical Intervention

Anterior Cervical Decompression and Fusion (ACDF) is Indicated

• ACDF provides rapid relief (within 3-4 months) of arm/neck pain, weakness, and sensory loss with 80-90% success rates for arm pain relief and 90.9% functional improvement 1
• For this patient's left-sided paracentral C4-5 disc herniation with correlating left arm weakness, ACDF directly addresses the compressive pathology without crossing neural elements 1
• Motor function recovery occurs in 92.9% of patients, with long-term improvements maintained over 12 months 1

Why Fusion Over Arthroplasty

• The combination of prior spinal cord injury, multilevel facet arthropathy, and progressive myelopathy makes motion elimination (fusion) the only safe option 1, 3, 5
• Even in younger patients where motion preservation would theoretically be preferred, these contraindications override any potential benefits of arthroplasty 3, 5
• Hybrid procedures (combining arthroplasty and fusion) are only appropriate in highly selected cases without the contraindications present in this patient 6

Conservative Management Has Failed

• This patient has attempted physical therapy but experienced worsening symptoms, meeting the threshold for surgical intervention 1
• While 75-90% of cervical radiculopathy patients improve with conservative management, this patient's progressive myelopathy with motor weakness indicates failed conservative therapy 1
• Progressive neurological deficits, particularly myelopathy with gait instability and fine motor deterioration, warrant urgent surgical decompression 7, 1

Critical Clinical Algorithm

Step 1: Confirm that imaging findings correlate with clinical symptoms

• Left-sided C4-5 disc herniation correlates with left arm weakness and radicular pain 1

Step 2: Assess for contraindications to arthroplasty

• ✓ Prior spinal cord injury (absolute contraindication) 1
• ✓ Multilevel facet arthropathy (contraindication) 5
• ✓ Progressive myelopathy (requires fusion, not motion preservation) 7, 1

Step 3: Determine appropriate surgical approach

• ACDF at C4-5 is the indicated procedure, not cervical disc arthroplasty 1
• Anterior cervical plating should be considered to reduce pseudarthrosis risk and maintain cervical lordosis 1

Common Pitfalls to Avoid

• Do not pursue motion preservation in patients with prior spinal cord injury—the risk of recurrent neurological injury is unacceptable 1, 4
• Do not perform arthroplasty in the presence of significant facet arthropathy—this violates FDA-approved indications and clinical guidelines 5
• Do not delay surgical intervention in progressive myelopathy—the natural history shows continued deterioration in untreated patients 7
• Ensure flexion-extension radiographs are obtained preoperatively to rule out segmental instability, though this patient's contraindications already preclude arthroplasty 1