Is anterior cervical discectomy and fusion surgery, including spinal bone autograft, medically necessary for a 62-year-old male with cervical radiculopathy and lumbar radiculopathy, history of cervical spine surgery, worsening symptoms, and MRI findings of severe spinal canal stenosis and abnormal signal volume loss of the cord?

Medical Necessity Determination for Anterior Cervical Discectomy and Fusion

Yes, anterior cervical discectomy and fusion (ACDF) with instrumentation and spinal bone autograft is medically necessary for this 62-year-old male with progressive cervical radiculopathy, severe spinal canal stenosis, abnormal cord signal, and failed prior cervical surgery, and inpatient admission is appropriate given the complexity of revision surgery with multilevel pathology. 1

Primary Surgical Indications Met

This patient meets all critical criteria for surgical intervention:

• Progressive neurological symptoms including worsening tingling and numbness in the left arm despite prior surgical intervention, which represents failure of previous treatment 1
• Severe spinal canal stenosis documented on MRI with abnormal signal volume loss of the cord, indicating significant neural compression that warrants urgent decompression 1
• History of prior cervical spine surgery with postoperative changes visible on MRI, suggesting either pseudarthrosis or adjacent segment disease requiring revision 2, 1
• Clinical-radiographic correlation between the patient's left arm symptoms and MRI findings of severe stenosis, which is essential for establishing surgical necessity 1

The American Association of Neurological Surgeons recommends surgical intervention for patients with significant functional deficit impacting quality of life, which this patient clearly demonstrates with progressive symptoms despite prior surgery 1. The presence of abnormal cord signal on MRI is particularly concerning, as it suggests myelopathic changes that can lead to irreversible neurological deterioration if left untreated 1.

Evidence Supporting ACDF Over Conservative Management

Surgical intervention is appropriate without additional conservative therapy given this patient's clinical presentation:

• The patient has already undergone prior cervical spine surgery, indicating previous failure of both conservative management and initial surgical intervention 2, 1
• ACDF provides rapid relief (within 3-4 months) of arm/neck pain, weakness, and sensory loss compared to continued conservative treatment 1, 3
• Success rates for ACDF range from 80-90% for arm pain relief, with 90.9% functional improvement in patients with cervical radiculopathy 1
• The natural history of untreated cervical myelopathy (suggested by abnormal cord signal) shows 55-70% of patients experience progressive deterioration without intervention 1

While 75-90% of patients with acute cervical radiculopathy improve with conservative management 1, 3, this patient represents a surgical candidate due to prior surgery failure and progressive symptoms with myelopathic features.

Multilevel Fusion Justification (CPT 22551,22552)

The procedure codes indicate multilevel ACDF, which is justified when:

• Each level demonstrates moderate to severe stenosis on MRI that correlates with clinical symptoms 1
• Postoperative changes from prior surgery may necessitate extending the fusion to adjacent levels to address pseudarthrosis or adjacent segment disease 2
• Severe spinal canal stenosis at multiple levels requires comprehensive decompression to prevent continued neurological deterioration 1

For multilevel fusions, instrumentation provides greater stability and improved outcomes with high strength of evidence 1. The addition of anterior cervical plating reduces pseudarthrosis risk from 4.8% to 0.7% and improves fusion rates from 72% to 91% in two-level disease 1.

Instrumentation Medical Necessity (CPT 22846,22853)

Anterior cervical plating is medically necessary for this multilevel revision case:

• The American College of Neurosurgery recommends anterior cervical plating for multilevel cervical disc degeneration to improve arm pain, with moderate strength of evidence 1
• Instrumentation reduces the risk of pseudarthrosis and graft problems, and helps maintain cervical lordosis, which is critical in revision surgery 1
• For multilevel fusions, instrumentation provides greater stability and improved outcomes 1
• In revision cases with prior surgery failure, the risk of pseudarthrosis is higher, making plate fixation essential for achieving solid fusion 2

The evidence from revision surgery series demonstrates that anterior plate stabilization in conjunction with bone grafting achieves excellent or good outcomes in 83.3% of patients undergoing revision ACDF 2.

Spinal Bone Autograft Medical Necessity (CPT 20936)

Autogenous bone graft is medically necessary and represents the gold standard for achieving solid arthrodesis:

• The American College of Surgeons recommends autogenous bone graft as the gold standard for achieving solid arthrodesis 1
• In revision surgery with prior fusion failure, autograft provides superior osteogenic, osteoinductive, and osteoconductive properties compared to allograft alone 2
• Structural autograft (CPT 20936) provides immediate structural support and maintains disc height, which is critical for foraminal decompression 1

While allograft can achieve fusion rates of 93.4% at 24 months in primary instrumented ACDF 1, revision cases with prior surgery failure benefit from the enhanced biological activity of autograft. The combination of autograft with anterior plating achieves fusion rates of 94-97% in revision surgery 2.

Critical caveat: If iliac crest autograft harvest is planned, the patient should be counseled about the 20% rate of prolonged donor site pain 1. Local autograft from the surgical site may be sufficient and avoids this morbidity.

Inpatient Level of Care Justification

Inpatient admission is medically necessary for this case based on:

• Revision surgery complexity following prior cervical spine surgery, which carries higher risk of complications including recurrent laryngeal nerve injury, esophageal injury, and vascular injury 2
• Multilevel fusion requiring extended operative time and increased blood loss risk 1
• Severe spinal canal stenosis with cord signal changes indicating potential for postoperative neurological monitoring needs 1
• Age 62 years with potential comorbidities requiring perioperative medical management 4, 5

Revision anterior cervical surgery has a complication rate of approximately 5%, with transient hoarseness occurring in 10.5% of patients 2. The complexity of dissecting through scar tissue from prior surgery and the need for multilevel decompression with instrumentation justifies inpatient observation for at least 23 hours postoperatively.

Expected Outcomes and Realistic Expectations

The patient should be counseled on the following evidence-based outcomes:

• Motor function recovery occurs in 92.9% of patients, with long-term improvements maintained over 12 months 1
• Strength improvements are maintained over 12 months but may not achieve 100% return to baseline 1
• Good or better outcomes occur in 99% of patients using Odom's criteria 1
• Revision surgery success rates are slightly lower than primary ACDF, with excellent or good outcomes in 83.3% of revision cases 2
• Re-operation rates range from 7.45-10.53% at 2-year follow-up 6

Critical Pitfalls to Avoid

Before proceeding with surgery, ensure the following:

• Flexion-extension radiographs must be obtained to definitively rule out segmental instability and guide the extent of fusion 1
• Nicotine cessation documentation is critical if the patient smokes, as nicotine significantly impairs fusion rates and increases pseudarthrosis risk 7
• Correlation of lumbar radiculopathy symptoms must be addressed separately, as the cervical surgery will not improve lumbar symptoms 1
• Bone density assessment should be considered in this 62-year-old patient to evaluate implant stability and fusion success rates 1

The presence of both cervical and lumbar radiculopathy requires careful clinical correlation to ensure the cervical pathology is the primary source of the patient's upper extremity symptoms 1. The lumbar radiculopathy may require separate evaluation and treatment.

Algorithmic Decision Framework

For any patient being considered for ACDF, follow this sequence:

1. Confirm clinical-radiographic correlation: Do the MRI findings of stenosis match the dermatomal distribution of symptoms? 1
2. Verify conservative management failure: Has the patient completed at least 6 weeks of structured therapy (unless progressive myelopathy is present)? 1, 3
3. Assess surgical urgency: Are there progressive neurological deficits or myelopathic features requiring urgent intervention? 1
4. Determine fusion levels: Does each proposed level demonstrate moderate to severe stenosis on imaging? 1
5. Plan instrumentation: Is this multilevel disease or revision surgery requiring plate fixation? 1
6. Select graft material: Is autograft available and appropriate, or is allograft with bone graft substitute acceptable? 1, 6

In this case, all criteria are met for proceeding with multilevel ACDF with instrumentation and autograft in an inpatient setting.