Clinical UM Guideline


Subject:  Cervical Fusion
Guideline #:  CG-SURG-42Current Effective Date:  06/27/2014
Status:NewLast Review Date:  05/15/2014

Description

Cervical fusion (also referred to as cervical spine fusion or spinal arthrodesis) refers to the surgical joining of two or more vertebrae at the cervical levels of the spine. Cervical fusion procedures may be performed alone or in conjunction with other procedures for the treatment of conditions including, but not limited to, symptomatic, progressive cervical radiculopathy, pseudarthrosis, or spondylotic myelopathy when conservative treatment options have been unsuccessful, to repair spinal fractures and dislocations, or to stabilize posttraumatic spinal instability.

This document addresses the clinical indications for anterior and posterior cervical fusion.

Note: Please see the following related documents for additional information:

Clinical Indications

Medically Necessary:

Cervical fusion is considered medically necessary for the treatment of an individual when one or more of the following indications are met:

  1. Symptomatic cervical radiculopathy documented when both of the following are met:
    1. The individual has a profound neurologic deficit at initial presentation, or progressive numbness or weakness, or unremitting radicular pain despite at least 6 weeks of appropriate conservative therapy (for example, nonsteroidal anti-inflammatory drugs [NSAIDs], oral corticosteroids, physical therapy); and
    2. Imaging studies (for example, computed tomography [CT] with myelogram or magnetic resonance imaging [MRI]) document nerve root compression; OR
  2. Symptomatic cervical pseudarthrosis and all of the following are met:
    1. The presence of hardware failure or at least 6 months have passed since the initial fusion; and
    2. Imaging studies (for example, CT, x-ray) document the pseudarthrosis; and
    3. There are persistent symptoms (for example, pain) despite appropriate conservative management; OR
  3. Symptomatic single level or multilevel spondylotic myelopathy, with or without kyphosis, and both of the following are met:
    1. The individual has corresponding clinical symptoms (for example, bowel or bladder incontinence, gait abnormality, frequent falls) and objective neurologic signs* (for example, hyperreflexia, Hoffman sign, increased tone or spasticity of the lower or upper extremities) (*Note: Long tract signs such as hyperreflexia may be absent in those with diabetes); and
    2. Imaging studies (for example, CT [with or without myelogram], MRI, x-ray) document cord compression due to one or more of the following:
      1. Herniated nucleus pulposus; or
      2. Osteophyte formation; OR
  4. Symptomatic nontraumatic cervical spondylosis with instability documented by radiographic findings and one or more of the following are met:
    1. Sagittal plane angulation of greater than 11 degrees between adjacent segments; or
    2. Subluxation or translation of greater than 3.5 millimeters (mm) on static lateral views or dynamic radiographs; OR
  5. Degenerative cervical kyphosis with spondylosis causing cord compression; OR
  6. Degenerative spinal segment that is adjacent to prior decompression or fusion procedure and one or both of the following are met:
    1. Symptomatic myelopathy corresponds clinically to adjacent level; or
    2. Symptomatic radiculopathy corresponds clinically to adjacent level and is unresponsive to nonoperative therapy; OR
  7. Infection of the cervical spine requiring decompression or debridement when vertebral body destruction or abscess is documented by an imaging study (for example, MRI); OR
  8. Nontraumatic atlantoaxial (C1-C2) instability, cord compression, or subluxation (greater than 5 mm as documented by imaging studies [for example, MRI]) in any of the following:
    1. Connective tissue disorders (for example, rheumatoid arthritis [RA]); or
    2. Down syndrome; or
    3. Os odontoideum; or
    4. Skeletal dysplasia (for example, congenital abnormality of C1-C2); OR
  9. Posttraumatic cervical instability (for example, fracture, subluxation/dislocation or major posterior ligamentous instability) as documented by imaging studies; OR
  10. Ossification of the posterior longitudinal ligament (OPLL), with or without kyphosis, associated with cervical stenosis and myelopathy; OR
  11. Spinal repair with fusion (for example, as part of a stabilization procedure due to extensive surgery) performed in conjunction with other procedures (for example, laminectomy) for abscess, dislocation, fracture, infection, neural decompression, or tumor; OR
  12. Tumor of the cervical spine (primary bone or metastatic tumor) causing cord compression, instability, or pathologic fracture and both of the following are met:
    1. Imaging studies (for example, MRI) document the diagnosis of tumor; and
    2. Excision of the lesion will result in further pathologic anatomy and symptoms; OR
  13. Deformity or progressive neck pain following prior posterior cervical decompressive laminectomy or laminoplasty.

Not Medically Necessary: 

Cervical fusion is considered not medically necessary when the criteria listed above are not met and for all other indications, including but not limited to:

  1. Neck pain in the absence of radiculopathy or myelopathy; or
  2. Referred pain in the absence of radiculopathy or myelopathy (for example, headache).
Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT 
22548Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 (atlas-axis), with or without excision of odontoid process
22551Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2
22552Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace
22554Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2
22585Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace [when specified as cervical]
22590Arthrodesis, posterior technique, craniocervical (occiput-C2)
22595Arthrodesis, posterior technique, atlas-axis (C1-C2)
22600Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment
22614Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment [when specified as cervical]
  
ICD-9 Procedure[For dates of service prior to 10/01/2015]
81.01Atlas-axis spinal fusion
81.02Other cervical fusion of the anterior column, anterior technique
81.03Other cervical fusion of the posterior column, posterior technique
81.31Refusion of atlas-axis spine
81.32Refusion of other cervical spine, anterior column, anterior technique
81.33Refusion of other cervical spine, posterior column, posterior technique
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
 All diagnoses
  
ICD-10 Procedure[For dates of service on or after 10/01/2015]
0RG0070-0RG00ZJFusion of occipital-cervical joint, open approach [anterior/posterior approach, with or without device; includes codes 0RG0070, 0RG0071, 0RG007J, 0RG00A0, 0RG00A1, 0RG00AJ, 0RG00J0, 0RG00J1, 0RG00JJ, 0RG00K0, 0RG00K1, 0RG00KJ, 0RG00Z0, 0RG00Z1, 0RG00ZJ]
0RG0470-0RG04ZJFusion of occipital-cervical joint, percutaneous endoscopic approach [anterior/posterior approach, with or without device; includes codes 0RG0470, 0RG0471, 0RG047J, 0RG04A0, 0RG04A1, 0RG04AJ, 0RG04J0, 0RG04J1, 0RG04JJ, 0RG04K0, 0RG04K1, 0RG04KJ, 0RG04Z0, 0RG04Z1, 0RG04ZJ]
0RG1070-0RG10ZJFusion of cervical vertebral joint, open approach [anterior/posterior approach, with or without device; includes codes 0RG1070, 0RG1071, 0RG107J, 0RG10A0, 0RG10A1, 0RG10AJ, 0RG10J0, 0RG10J1, 0RG10JJ, 0RG10K0, 0RG10K1, 0RG10KJ, 0RG10Z0, 0RG10Z1, 0RG10ZJ]
0RG1470-0RG14ZJFusion of cervical vertebral joint, percutaneous endoscopic approach [anterior/posterior approach, with or without device; includes codes 0RG1470, 0RG1471, 0RG147J, 0RG14A0, 0RG14A1, 0RG14AJ, 0RG14J0, 0RG14J1, 0RG14JJ, 0RG14K0, 0RG14K1, 0RG14KJ, 0RG14Z0, 0RG14Z1, 0RG14ZJ]
0RG2070-0RG20ZJFusion of 2 or more cervical vertebral joints, open approach [anterior/posterior approach, with or without device; includes codes 0RG2070, 0RG2071, 0RG207J, 0RG20A0, 0RG20A1, 0RG20AJ, 0RG20J0, 0RG20J1, 0RG20JJ, 0RG20K0, 0RG20K1, 0RG20KJ, 0RG20Z0, 0RG20Z1, 0RG20ZJ]
0RG2470-0RG24ZJFusion of 2 or more cervical vertebral joints, percutaneous endoscopic approach [anterior/posterior approach, with or without device; includes codes 0RG2470, 0RG2471, 0RG247J, 0RG24A0, 0RG24A1, 0RG24AJ, 0RG24J0, 0RG24J1, 0RG24JJ, 0RG24K0, 0RG24K1, 0RG24KJ, 0RG24Z0, 0RG24Z1, 0RG24ZJ]
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2015]
 All diagnoses
  
Discussion/General Information

Cervical (neck) fusion is a surgical technique which stabilizes and eliminates the motion between the adjacent vertebral segments of the spine by fusing two or more cervical vertebrae in the spinal column. The procedure involves permanent fusion (uniting together) of the adjacent vertebrae (segments) using bone graft material taken from another bone in the individual's body (autograft) or from a bone bank (allograft). These types of bone grafting material, with or without plating, have been suggested as the "gold standard" for cervical fusion. During cervical fusion procedures, the spine is accessed and the graft is placed from either the front (anterior approach), the back (posterior approach), or may involve a combination of both approaches. Cervical fusion may be performed with or without instrumentation, and may involve supplemental hardware such as plates, rods, screws, wires or cages that act as a splint until the bone graft fuses (heals). A systematic review of randomized controlled trials found no consistent evidence for use of cages over autograft for cervical spinal fusion (Jacobs, 2011). Other surgical procedures performed in conjunction with cervical fusion may include, but are not limited to, corpectomy, facetectomy, foraminectomy, foraminotomy, laminectomy, laminotomy, or laminoplasty. These procedures may be successful in treating most individuals with persistent pain and neurologic symptoms that have been unresponsive to nonsurgical treatment.

Disc degeneration is a complex biochemical process that occurs with the loss of normal water content within the disc resulting in the deterioration of the mechanical shock absorbing properties of the disc over time. This deterioration leads to bulging and decreased disc height. Degenerative disc disease (DDD) is most commonly a result of the effects of the natural aging process, specifically on the intervertebral discs, although various associated factors may accelerate the process. Degenerative cervical spine disorders, including DDD, will affect up to two-thirds of the population in their lifetime, 40% to 50% of people over the age of 40, and becomes increasingly common with advancing age. While often benign and episodic in nature, cervical disorders presenting as axial neck pain, radiculopathy, myelopathy, or a combination of these presentations, may become debilitating and result in symptomatic pain and neurologic outcomes. Nonsurgical, conservative therapy continues to play an important role in the treatment of individuals with self-limiting symptoms, including first-line treatment with cervical collar, oral medications (for example, corticosteroids, NSAIDs, and short-term muscle relaxants and/or narcotic analgesics), physical therapy (PT), and rest. For those individuals with persistent radicular complaints, neurologic deficits, or signs and symptoms of myelopathy, the most commonly used cervical spine decompressive procedures involve the anterior approach, with anterior cervical decompression or anterior cervical discectomy and fusion (ACDF), intended to relieve central and foraminal stenosis as well as soft disc herniation(s) (Todd, 2011). According to Todd (2011):

The location of pathology, patient anatomy and surgeon preference are all considerations in indicating these patients for specific surgical procedures... Segmental anterior fusions at multiple levels may provide a powerful corrective force in patients with kyphosis while at the same time decompressing the spinal cord.

The evidence published in the peer-reviewed medical literature consists of case series, consensus guidelines, prospective and retrospective comparative and outcome studies, systematic reviews, and a small volume of randomized controlled trials that evaluate cervical fusion and surgical techniques, with or without instrumentation and bone graft materials, for the treatment of various cervical spinal conditions (including, but not limited to: Chen, 2011; Cunningham, 2010; Dvorak, 2007; Faldini, 2010; Ghogawala, 2011; Harai, 2011; Herkowitz, 1990; Iwasaki, 2007; Koakulsu, 2010; Kwon, 2007; Lehmann, 2014; Papadopoulos, 2006; Raizman, 2009; Riew, 2007; Sakai, 2012; Seng, 2013; Siemionow, 2012).

Symptomatic Cervical Radiculopathy

Studies and consensus guidelines published by the American Association of Neurological Surgeons (AANS) and Congress of Neurological Surgeons and the North American Spine Society (NASS) suggest that both anterior cervical discectomy (ACD) and ACDF are comparable treatment strategies, producing similar clinical outcomes, in the treatment of single level cervical radiculopathy from degenerative disorders (Bono, 2011; Gebremariam, 2012; Matz, 2009b). The NASS evidence-based clinical guideline for the diagnosis and treatment of cervical radiculopathy from degenerative disorders (Bono, 2011) gives a grade B recommendation to both ACD and ACDF (Grade B: Fair evidence [Level II or III studies with consistent findings] for or against recommending intervention). The AANS and Congress of Neurological Surgeons systematic review (Matz, 2009b) used evidence-based medicine to identify the best techniques for anterior cervical nerve root decompression with cervical radiculopathy, stating:

Both ACD and ACDF are equivalent treatment strategies for 1-level disease with regard to functional outcome (Class II). Anterior cervical discectomy with fusion may achieve a more rapid reduction of neck and arm pain compared to ACD with a reduced risk of kyphosis, although functional outcomes may be similar. Anterior cervical discectomy with fusion is not a lasting means of increasing foraminal or disc height compared to ACD. Anterior cervical plating (ACDF with instrumentation) improves arm pain (but not other clinical parameters) better than ACDF in the treatment of 2-level disease (Class II). With respect to 1-level disease, plating may reduce the risk of pseudarthrosis and graft problems (Class III) but does not necessarily improve clinical outcome alone (Class II). Cervical arthroplasty is recommended as an alternative to ACDF in selected patients for control of neck and arm pain (Class II).

Matz and colleagues (2009a) published another consensus guideline on the indications for anterior cervical decompression for the treatment of cervical degenerative radiculopathy stating:

Anterior nerve root decompression via ACD, with or without fusion for radiculopathy, is associated with rapid relief (three to four months) of arm/neck pain, weakness, and/or sensory loss compared with physical therapy or cervical collar immobilization. ACD and ACDF are associated with long term (12 months) improvement in certain motor functions compared to physical therapy. Other rapid gains observed after anterior decompression, including diminished pain, improved sensation, and improved strength in certain muscle groups, are also maintained over the course of 12 months. However, comparable clinical improvements with PT or cervical immobilization therapy are also present in these clinical modalities (Class I).

Albert and Murrell (1999) reviewed the surgical management of cervical radiculopathy, stating:

Despite conservative nonoperative therapy, a large subset of patients will require surgical intervention. Indications for surgery include recalcitrant radiculopathy despite nonoperative treatment for more than 6 weeks and progressive motor deficit or disabling motor deficit (deltoid palsy, wrist drop) prior to 6 weeks. Anterior and posterior approaches have both yielded successful results in appropriately selected patients. Anterior cervical discectomy and fusion is the generally preferred treatment for radiculopathy when there is a significant component of axial neck pain, when the disease is centrally located, or when there is any degree of segmental kyphosis.

A Cochrane review and meta-analysis of randomized trials, however, found limited evidence that although surgery may provide pain relief sooner than nonoperative therapy (for example, physiotherapy or cervical collar) for individuals with cervical radiculopathy, there was no significant difference in outcomes at one year (Nikolaidis, 2010). Additional Cochrane reviews have been published evaluating surgery for cervical radiculomyelopathy (Fouyas, 2011), single or double-level anterior interbody fusion techniques for cervical DDD (Jacobs, 2011), and arthroplasty versus fusion in single-level cervical DDD (Boselie, 2013).

Symptomatic Cervical Myelopathy

Both anterior and posterior cervical surgical approaches exist for the treatment of cervical myelopathy and include, but are not limited to, ACDF, anterior corpectomy and fusion, and posterior cervical laminectomy with or without fusion. In individuals with single level compression, anterior cervical fusion has been shown to be effective for individuals with myelopathy (Geck, 2002). Mummaneni and colleagues (2009) compared the efficacy of different surgical techniques for the treatment of cervical spondylotic myelopathy (CSM), including ACDF, anterior cervical corpectomy with fusion (ACCF), laminectomy with fusion, and other techniques stating:

ACDF and ACCF appear to yield similar results in multilevel spine decompression for lesions at the disc level. The use of anterior plating allows for equivalent fusion rates between these techniques (Class III). ACDF, ACCF, laminectomy, laminoplasty, and laminectomy with arthrodesis all provide near-term functional improvement for CSM.

Anderson and colleagues (2009) published a systematic review to examine the efficacy of cervical laminectomy and fusion for the treatment of CSM. The authors state that "cervical laminectomy with fusion improves functional outcomes in individuals with CSM and OPLL, Class III." In contrast to laminectomy, cervical laminectomy with fusion is not associated with late deformity. Lawrence and colleagues (2012) reviewed indications, techniques, and outcomes for posterior surgery for cervical myelopathy, stating that laminectomy and fusion "seems to combine the early improvement in neurologic function seen with decompressive laminectomy with less late loss of function or kyphotic collapse and with a lower overall complication rate." Thus, "it has become the standard surgical treatment of patients with CSM due to multilevel stenosis and cord compression, to which other treatments are most commonly compared." In a systematic review and meta-analysis, Zhu and colleagues (2013) compared the clinical outcomes, complications, and surgical trauma between anterior and posterior approaches for the treatment of multilevel CSM. A total of eight nonrandomized controlled high quality studies were included in the meta-analysis; all studies were of high quality. The authors reported the anterior approach was associated with better postoperative neural function than the posterior approach in the treatment of multilevel CSM. There were no apparent differences in the neural function recovery rate. The complications and reoperation rates were significantly higher in the anterior group compared with the posterior group.

Acute Cervical Spine and Spinal Cord Injuries

Walters and colleagues (2013) published a guideline update for the management of acute cervical spine and spinal cord injuries. The guidelines include detailed recommendations for the diagnosis, including radiologic evaluation, and management of acute cervical spine injuries with cervical fusion, with and without combined procedures, such as decompression, occipital-cervical internal fixation, or laminectomy. The review includes 19 Level I recommendations in the guidelines, each supported by Class I medical evidence for radiologic assessment, cervical subaxial injury, and pediatric spinal injuries (not an all-inclusive list); and, additional Level II and III recommendations for surgical stabilization and fusion, based on specific fracture type, instability, and severity, for conditions including, but not limited to, traumatic atlanto-occipital dislocation injuries, C1 to C2 rotary subluxations, isolated fractures of the axis in adults (including fractures of the odontoid, traumatic spondylolisthesis of the axis [hangman's fracture]), os odontoideum, subaxial cervical spinal injuries, and acute central cervical spinal cord injuries. Aarabi and colleagues (2013) published an update on the medical evidence on the management of acute traumatic central cord syndrome (ATCCS) and the potential surgical treatment of this incomplete spinal cord injury in which the upper extremities are weaker than the lower extremities with variable involvement of the sensory system and variable effect on bladder function. The authors state that approximately 20% of individuals present with an acute disc herniation as the cause of ATCCS. Surgical intervention is recommended for this group. Another 30% of individuals with ATCCS have cervical spine skeletal injuries in the form of fracture subluxation injuries which require early re-alignment of the spinal column, closed or open, with spinal cord decompression. Class III medical evidence "suggests that surgery for ATCCS is safe and appears to be efficacious (in conjunction with medical management) for patients with focal cord compression, or to provide operative reduction and internal fixation and fusion of cervical spinal fracture dislocation injuries."

Other Cervical Spine Conditions

Cervical fusion procedures may be performed for other less common indications. The peer-reviewed medical literature includes, but is not limited to, case reports, comparative studies, retrospective studies, and review articles evaluating the use of cervical fusion in individuals with cervical spine conditions such as:

Summary

Cervical fusion is performed for many different clinical indications. Despite a lack of large randomized controlled clinical trials comparing fusion to nonsurgical interventions, evidenced-based consensus guidelines and peer-reviewed publications exist in the medical literature comparing surgical techniques and outcomes of cervical fusion procedures to each other. Cervical fusion does involve some risk associated with the procedure(s) and varies depending on the individual's age and overall health, diagnosis, and type of fusion procedure. Risks and complications of cervical fusion procedures include, but are not limited to, breakage of metal implants (if used), deep vein thrombosis (blood clots inside the veins of the legs), excessive bleeding, fusion failure (for example, pseudarthrosis), graft rejection, infection, nerve or spinal cord injury, pain in a bone graft site (donor site), and the risks of general anesthesia. Fountas and colleagues (2007) conducted a retrospective case review of 1,015 individuals undergoing first-time ACDF for cervical radiculopathy and/or myelopathy due to DDD and/or cervical spondylosis. The mortality rate was reported as 0.1% (n=1; death occurred secondary to an esophageal perforation). The overall morbidity rate was 19.3% (196 of 1,015 individuals). The most common complications were postoperative dysphagia (9.5%), hematoma (5.6%), and recurrent laryngeal nerve palsy (3.1%). Management of complications was successful in the vast majority of cases.

Definitions

Anterior: Referring to the front of the body.

Arthrodesis (also known as spinal fusion): A surgical procedure involving the joining of two or more cervical vertebrae (discs) together into one solid bony structure.

Arthroplasty: A surgical procedure in which an artificial joint replaces a damaged joint.

Axis fracture: Fracture of the second cervical (C2/axis) vertebra.

Burst fracture: Injury to the spine in which the vertebral body is severely compressed. Burst fractures typically result from severe trauma, such as a motor vehicle accident or a fall from a height. The degree of neurologic injury is usually due to the amount of force that is present at the time of the injury and the amount of compromise of the spinal canal.

Cervical spine: The neck region of the spine consisting of the first seven vertebrae.

Degenerative disc disease (DDD): A disease of a vertebral disc where the intervertebral disc breaks down and may result in pain and disability.

Herniated disc: A condition in which part, or all of the soft, jelly-like core material of an intervertebral disc bulges or ruptures out of its normal position; a herniated disc may exert pressure on the surrounding nerve root and/or the spinal cord resulting in back pain and nerve root irritation.

Instrumented fusion: A fusion procedure involving the use of plates, screws, cages or rods to increase the stability of the joint during the healing process.

Intervertebral discs: Soft tissues located between each vertebra, acting as cushions between the vertebrae during normal motion.

Laminectomy: A surgical procedure for treating spinal stenosis by relieving pressure on the spinal cord. The lamina of the vertebra is removed or trimmed to widen the spinal canal and create more space for the spinal nerves.

Myelopathy: Compression on the spinal cord that occurs when the spinal canal becomes restricted in the neck or upper back. This may be due to degeneration in the discs and facet joints (spondylotic myelopathy) or bone spur formation in the spinal canal (stenosis with myelopathy).

Neurologic: Having to do with the nervous system.

Ossification of the posterior longitudinal ligament (OPLL): A condition of abnormal calcification of the posterior longitudinal ligament, most commonly located at the cervical spine region. Compression of spinal cord caused by OPLL may lead to neurologic symptoms and in the cases with severe neurologic deficit, may require surgical treatments.

Posterior: The back or rear side of the body.

Pseudarthrosis: A condition in which failure of callus formation (nonunion) of bone fragments occurs at a fracture site or prior spinal fusion surgery site resulting in formation of a "false joint."

Radiculopathy: The irritation of a nerve root at any level of the spine which can be caused by compression, inflammation or protrusion of a disc. Cervical radiculopathy involves pain and neurological symptoms that can radiate along that nerve's pathway into the arm and hand. The most common causes include cervical DDD, herniated disc, and spinal stenosis; less frequent causes include conditions such as cervical fracture or tumor.

Recombinant human bone morphogenic protein (rhBMP): A substance that may be used to stimulate the growth of bone.

Spinal fusion: A surgical procedure to stabilize the spine by fusing together two or more spinal vertebrae (spine bones).

Spinal stenosis: Abnormal narrowing of the spinal canal diameter in the cervical area that may result in pressure (compression) on the spinal cord, spinal sac, or nerve toots stemming from the spinal cord.

Spondylolisthesis: A condition that occurs when one vertebra slips forward (out of position) onto the vertebra below it.

Spondylosis: A cervical spine condition involving degenerative changes to the bones, discs, and joints of the neck, caused by the normal wear-and-tear of aging. The discs of the cervical spine gradually break down, lose fluid, and become stiffer. Cervical spondylosis usually occurs in middle-aged and older adults. Cervical spondylosis with cervical myelopathy, commonly referred to as cervical spondylotic myelopathy (CSM), refers to impaired function of the spinal cord caused by degenerative changes of the discs and facet joints in the cervical spine.

Vertebrae: Bones that make up the spinal column, which surround and protect the spinal cord.

References

Peer Reviewed Publications: 

  1. Aarabi B, Hadley MN, Dhall SS, et al. Management of acute traumatic central cord syndrome (ATCCS). Neurosurgery. 2013; 72 (2 Suppl):195-204.
  2. Acosta FL, Chin CT, Quinones-Hinojosa A, et al. Diagnosis and management of adult pyogenic osteomyelitis of the cervical spine. Neurosurg Focus. 2004; 17(6):E2.
  3. Ahmed R, Traynelis VC, Menezes AH. Fusions at the craniovertebral junction. Childs Nerv Syst. 2008; 24(10):1209-1224.
  4. Albert TJ, Murrell SE. Surgical management of cervical radiculopathy. J Am Acad Orthop Surg. 1999; 7(6):368-376.
  5. Arvin B, Fournier-Gosselin MP, Fehlings MG. Os odontoideum: etiology and surgical management. Neurosurgery. 2010; 66(3 Suppl):22-31.
  6. Bambakidis NC, Feiz-Erfan I, Klopfenstein JD, Sonntag VK. Indications for surgical fusion of the cervical and lumbar motion segment. Spine (Phila Pa 1976). 2005; 30(16 Suppl):S2-S6.
  7. Chen Y, Guo Y, Lu X, et al. Surgical strategy for multilevel severe ossification of posterior longitudinal ligament in the cervical spine. J Spinal Disord Tech. 2011; 24(1):24-30.
  8. Choi BY, Song KJ, Chang H. Ossification of the posterior longitudinal ligament: a review of literature. Asian Spine J. 2011; 5(4):267-276.
  9. Coyne TJ, Fehlings MG, Wallace MC, et al. C1-C2 posterior cervical fusion: long-term evaluation of results and efficacy. Neurosurgery. 1995; 37(4):688-692; discussion 692-693.
  10. Cunningham MR, Hershman S, Bendo J. Systematic review of cohort studies comparing surgical treatments for cervical spondylotic myelopathy. Spine (Phila Pa 1976). 2010; 35(5):537-543.
  11. Dvorak MF, Fisher CG, Aarabi B, et al. Clinical outcomes of 90 isolated unilateral facet fractures, subluxations, and dislocations treated surgically and nonoperatively. Spine (Phila Pa 1976). 2007; 32(26):3007-3013.
  12. Faldini C, Leonetti D, Nanni M, et al. Cervical disc herniation and cervical spondylosis surgically treated by Cloward procedure: a 10-year minimum follow-up study. J. Orthop Traumatol. 2010; 11:99-103.
  13. Fehlings MG, David KS, Vialle L, et al. Decision making in the surgical treatment of cervical spine metastases. Spine (Phila Pa 1976). 2009; 34(22 Suppl):S108-117.
  14. Fountas KN, Kapsalaki EZ, Nikolakakos LG, et al. Anterior cervical discectomy and fusion associated complications. Spine (Phila Pa 1976). 2007; 32(21):2310-2317.
  15. Gebremariam L, Koes BW, Peul WC, Huisstede BM. Evaluation of treatment effectiveness for the herniated cervical disc: a systematic review. Spine (Phila Pa 1976). 2012; 37(2):E109-E118.
  16. Geck MJ, Eismont FJ. Surgical options for the treatment of cervical spondylotic myelopathy. Orthop Clin North Am. 2002; 33(2):329-348.
  17. Ghogawala Z, Martin B, Benzel EC, et al. Comparative effectiveness of ventral vs dorsal surgery for cervical spondylotic myelopathy. Neurosurgery. 2011; 68(3):622-630; discussion 630-631.
  18. Hadjipavlou AG, Mader JT, Necessary JT, Muffoletto AJ. Hematogenous pyogenic spinal infections and their surgical management. Spine (Phila Pa 1976). 2000; 25(13):1668-1679.
  19. Hankinson TC, Anderson RC. Craniovertebral junction abnormalities in Down syndrome. Neurosurgery. 2010; 66(3 Suppl):32-38.
  20. Herkowitz HN, Kurz LT, Overholt DP. Surgical management of cervical soft disc herniation. A comparison between the anterior and posterior approach. Spine (Phila Pa 1976). 1990; 15(10):1026-1030.
  21. Hirai T, Okawa A, Arai Y, et al. Middle-term results of a prospective comparative study of anterior decompression with fusion and posterior decompression with laminoplasty for the treatment of cervical spondylotic myelopathy. Spine (Phila Pa 1976). 2011; 36(23):1940-1947.
  22. Hong JT, Yi JS, Kim JT, et al. Clinical and radiologic outcome of laminar screw at C2 and C7 for posterior instrumentation--review of 25 cases and comparison of C2 and C7 intralaminar screw fixation. World Neurosurg. 2010; 73(2):112-118; discussion e15.
  23. Iwasaki M, Okuda S, Miyauchi A, et al. Surgical strategy for cervical myelopathy due to ossification of the posterior longitudinal ligament. Part 2. Advantages of anterior decompression and fusion over laminoplasty. Spine (Phila Pa 1976). 2007; 32(6):654-660.
  24. Jacobson ME, Khan SN, An HS. C1-C2 posterior fixation: indications, technique, and results. Orthop Clin North Am. 2012; 43(1):11-8, vii.
  25. Koakutsu T, Morozumi N, Ishii Y, et al. Anterior decompression and fusion versus laminoplasty for cervical myelopathy caused by soft disc herniation: a prospective multicenter study. J Orthop Sci. 2010; 15(1):71-78.
  26. Komotar RJ, Mocco J, Kaiser MG. Surgical management of cervical myelopathy: indications and techniques for laminectomy and fusion. Spine J. 2006; 6(6 Suppl):252S-267S.
  27. Krauss WE, Bledsoe JM, Clarke MJ, et al. Rheumatoid arthritis of the craniovertebral junction. Neurosurgery. 2010; 66(3 Suppl):83-95.
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  29. Kwon BK, Vaccaro AR, Grauer JN, et al. Subaxial cervical spine trauma. J Am Acad Orthop Surg. 2006; 14(2):78-89.
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Government Agency, Medical Society, and Other Authoritative Publications: 

  1. American Association of Neurological Surgeons (AANS). Guidelines repository for neurosurgery. Available at: http://aans.org/Education%20and%20Meetings/Clinical%20Guidelines.aspx. Accessed on March 18, 2014.
  2. Anderson PA, Matz PG, Groff MW, et al. Joint Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons and Congress of Neurological Surgeons. Laminectomy and fusion for the treatment of cervical degenerative myelopathy. J Neurosurg Spine. 2009; 11(2):150-156.
  3. Bono CM, Ghiselli G, Gilbert TJ, et al. North American Spine Society. An evidence-based clinical guideline for the diagnosis and treatment of cervical radiculopathy from degenerative disorders. Spine J. 2011; 11(1):64-72.
  4. Boselie TF, Willems PC, van Mameren H, et al. Arthroplasty versus fusion in single-level cervical degenerative disc disease: a Cochrane Review. Spine (Phila Pa 1976). 2013; 38(17):E1096-E1107.
  5. Fouyas IP, Statham PFX, Sandercock PAG, Lynch C. Surgery for cervical radiculomyelopathy. Cochrane Database Syst Rev. 2001; (3):CD001466.
  6. Jacobs W, Willems PC, van Limbeek J, et al. Single or double-level anterior interbody fusion techniques for cervical degenerative disc disease. Cochrane Database Syst Rev. 2011;(1):CD004958.
  7. Matz PG, Holly LT, Groff MW, et al. Joint Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons and Congress of Neurological Surgeons. Indications for anterior cervical decompression for the treatment of cervical degenerative radiculopathy. J Neurosurg Spine. 2009a; 11(2):174-182.
  8. Matz PG, Ryken TC, Groff MW, et al. Joint Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons and Congress of Neurological Surgeons. Techniques for anterior cervical decompression for radiculopathy. J Neurosurg Spine. 2009b; 11(2):183-197.
  9. Mummaneni PV, Kaiser MG, Matz PG, et al. Joint Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons and Congress of Neurological Surgeons. Cervical surgical techniques for the treatment of cervical spondylotic myelopathy. J Neurosurg Spine. 2009a; 11(2):130-141.
  10. Mummaneni PV, Kaiser MG, Matz PG, et al. Joint Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons and Congress of Neurological Surgeons. Preoperative patient selection with magnetic resonance imaging, computed tomography, and electroencephalography: does the test predict outcome after cervical surgery? J Neurosurg Spine. 2009b; 11(2):119-129.
  11. Nikolaidis I, Fouyas IP, Sandercock PA, Statham PF. Surgery for cervical radiculopathy or myelopathy. Cochrane Database Syst Rev. 2010;(1):CD001466.
  12. Ryken TC, Heary RF, Matz PG, et al. Joint Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons and Congress of Neurological Surgeons. Cervical laminectomy for the treatment of cervical degenerative myelopathy. J Neurosurg Spine. 2009d; 11(2):142-149.
  13. Shears E, Armitstead CP. Surgical versus conservative management for odontoid fractures. Cochrane Database Syst Rev. 2008;(4):CD005078.
  14. Walters BC, Hadley MN, Hurlbert RJ, et al. Guidelines for the management of acute cervical spine and spinal cord injuries: 2013 update. Neurosurgery. 2013; 60(1 Suppl):82-91.
  15. Washington State Department of Labor and Industries. Medical treatment guidelines. Cervical spinal fusion for degenerative disc disease. Olympia, WA: January 1, 2014. Available at: http://www.lni.wa.gov/ClaimsIns/Providers/TreatingPatients/ByCondition/CervicalSpinalFusion.asp. Accessed on March 18, 2014.
Websites for Additional Information
  1. American Academy of Orthopedic Surgeons (AAOS). OrthoInfo. Spinal fusion. June 2010. Available at: http://orthoinfo.aaos.org/topic.cfm?topic=A00348. Accessed on March 18, 2014.
  2. American Association of Neurological Surgeons (AANS). Patient information. Available at: http://aans.org/Patient%20Information.aspx. Accessed on March 18, 2014.
  3. North American Spine Society (NASS). KnowYourBack.org. Cervical stenosis, myelopathy and radiculopathy. May 19, 2009. Available at: http://www.knowyourback.org/Pages/SpinalConditions/DegenerativeConditions/CStenosis_Myelopathy_Radiculopathy.aspx. Accessed on March 18, 2014.
Index

Cervical Arthrodesis
Cervical Fusion

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

History

Status

Date

Action

New

05/15/2014

 

Medical Policy & Technology Assessment Committee (MPTAC) review. Initial document development.