Description
Degenerative cervical spine disorders, while often benign and episodic in nature, can become debilitating, resulting in axial pain and neurological damage to the spinal cord. Compression on the nerve root and / or spinal cord may be caused by (1) a herniated disc with or without extrusion of disc fragments and/or (2) degenerative cervical spondylosis.

Spine surgery is a complex area of medicine. Operative treatment is indicated only when the natural history of an operatively treatable problem is better than the natural history of the problem without operative treatment. Choice of surgical approach is based on anatomy, the candidate’s pathology, and the surgeon's experience and preference. All operative interventions must be based on a positive correlation with clinical findings, the natural history of the disease, the clinical course, and diagnostic tests or imaging results.

Anterior surgical approaches
Anterior surgical approaches to cervical spine decompression emerged in the 1950s in response to technical limitations experienced with posterior approaches, including restricted access to and exposure of midline bony spurs and disc fragments. Anterior approaches include anterior cervical discectomy and fusion. Discectomy is removal of all or part of a herniated or ruptured disc or spondolytic bony spur to alleviate pressure on the nerve roots or on the spinal cord in individuals with symptomatic radiculopathy. Discectomy is most often combined with fusion to stabilize the spine.

Posterior surgical approaches
Posterior surgical approaches include laminectomy, laminoplasty, and laminoforaminotomy (also known as posterior discectomy). Laminectomy is the removal of the bone between the spinal process and facet pedicle junction to expose the neural elements of the spine. This allows for the inspection of the spinal canal, identification and removal of pathological tissue, and decompression of the cord and roots. Laminoplasty is the opening of the lamina to enlarge the spinal canal. There are several laminoplasty techniques; all aim to alleviate cord compression by reconstructing the spinal canal. Laminoplasty is commonly performed to decompress the spinal cord in those with degenerative spinal stenosis.

Laminoforaminotomy (also known as posterior discectomy) is the creation of a small window in the lamina to facilitate removal of arthritic bone spurs and herniated disc material pressing on the nerve root as it exits through the foramen. The opening of the foramen is widened so that the nerve exits without being compressed.

Policy 

Anterior Cervical Decompression With Fusion (ACDF) — Single Level

The following criteria must be met*:

• Positive clinical findings of myelopathy with evidence of progressive neurologic deficits consistent with spinal cord compression - immediate surgical evaluation is indicated (AA0S, 2013; Bono, 2011; Cunningham, 2010; Holly, 2009; Matz, 2009a; Matz, 2009b; Matz, 2009d; Matz, 2009e; Mummaneni, 2009; Tetreault, 2013; Yalamanchili, 2012; Zhu, 2013). Symptoms may include:
  • Upper extremity weakness.
  • Unsteady gait related to myelopathy/balance or generalized lower extremity weakness.
  • Disturbance with coordination.
  • Hyperreflexia.
  • Hoffmann sign.
  • Positive Babinski sign and/or clonus. 
• Progressive neurological deficit (motor deficit, bowel or bladder dysfunction) with evidence of spinal cord or nerve root compression on Magnetic Resonance Imaging (MRI) or Computed Tomography (CT) imaging — immediate surgical evaluation is indicated. (Bono, 2011; Matz, 2009b; Tetreault, 2013); OR

When ALL of the following criteria are met (Bono, 2011: Nikolaidis, 2010):  

• Cervical radiculopathy or myelopathy from ruptured disc, spondylosis, spinal instability, or deformity; AND
• Persistent or recurrent symptoms/pain with functional limitations that are unresponsive to at least 6 weeks of appropriate conservative treatment; AND  
• Documented failure of at least 6 consecutive weeks in the last 6 months of any 2 of the following physician-directed conservative treatments:
  • Analgesics, steroids, and/or NSAIDs
  • Structured program of physical therapy
  • Structured home exercise program prescribed by a physical therapist, chiropractic provider or physician
  • Epidural steroid injections and or selective nerve root block 
• Imaging studies confirm the presence of spinal cord or spinal nerve root compression (disc herniation or foraminal stenosis) at the level corresponding with the clinical findings (Bono, 2011). Imaging studies may include:
  • MRI (preferred study for assessing cervical spine soft tissue).
  • CT with or without myelography — indicated in patients in whom MRI is contraindicated; preferred for examining bony structures, or in patients presenting with clinical symptoms or signs inconsistent with MRI findings (e.g., foraminal compression not seen on MRI).

*Cervical spine decompression with fusion as first-line treatment without conservative care measures in the following clinical cases (Matz, 2009b; Tetreault, 2013; Zhu, 2013; White, 1987):

• As outlined above for myelopathy or progressive neurological deficit scenarios
• Significant spinal cord or nerve root compression due to tumor, infection or trauma
• Fracture or instability on radiographic films measuring:
  • Sagittal plane angulation of greater than 11 degrees at a single interspace or greater than 3.5mm anterior subluxation in association with radicular/cord dysfunction
  • Subluxation at the (C1) level of the atlantodental interval of more than 3 mm in an adult and 5 mm in a child

Not Recommended (Nikolaidis, 2010; van Middelkoop, 2012):

• In asymptomatic or mildly symptomatic cases of cervical spinal stenosis
• In cases of neck pain alone, without neurological deficits, and no evidence of significant spinal nerve root or cord compression on MRI or CT. See V. Cervical Fusion for Treatment of Axial Neck Pain Criteria  

Anterior Cervical Decompression With Fusion (ACDF) — Multiple Level

The following criteria must be met*:

• Positive clinical findings of myelopathy with evidence of progressive neurologic deficits consistent with worsening spinal cord compression — immediate surgical evaluation is indicated (AA0S, 2013; Bono, 2011; Cunningham, 2010; Holly, 2009; Matz, 2009a; Matz, 2009b; Matz, 2009d; Matz, 2009e; Mummaneni, 2009; Tetreault, 2013; Yalamanchili, 2012; Zhu, 2013). Symptoms may include:
  • Upper extremity weakness.
  • Unsteady gait related to myelopathy/balance or generalized lower extremity weakness.
  • Disturbance with coordination.
  • Hyperreflexia.
  • Hoffmann sign.
  • Positive Babinski sign and or clonus.
• Progressive neurological deficit (motor deficit, bowel or bladder dysfunction) with corresponding evidence of spinal cord or nerve root compression on an MRI or CT scan images — immediate surgical evaluation is indicated (Bono, 2011; Matz, 2009b; Tetreault, 2013).

When ALL of the following criteria are met (Bono, 2011; Nikolaidis, 2010):

• Cervical radiculopathy or myelopathy due to ruptured disc, spondylosis, spinal instability, or deformity 
• Persistent or recurrent pain/symptoms with functional limitations that are unresponsive to at least 6 weeks of conservative treatment
• Documented failure of at least 6 consecutive weeks in the last 6 months of any 2 of the following physician-directed conservative treatments:
  • Analgesics, steroids, and/or NSAIDs
  • Structured program of physical therapy 
  • Structured home exercise program prescribed by a physical therapist, chiropractic provider or physician 
  • Epidural steroid injections and or selective nerve root block
• Imaging studies confirm the presence of spinal cord or spinal nerve root compression (disc herniation or foraminal stenosis) at multiple levels corresponding with the clinical findings. Imaging studies may include any of the following (Bono, 2011):
  • MRI (preferred study for assessing cervical spine soft tissue)
  • CT with or without myelography — indicated in patients in whom MRI is contraindicated; preferred for examining bony structures, or in patients presenting with clinical symptoms or signs inconsistent with MRI findings (e.g., foraminal compression not seen on MRI) 

Cervical spine decompression with fusion performed as first-line treatment without conservative care measures in the following clinical cases (Matz, 2009b; Tetreault, 2013; White, 1987; Zhu, 2013):

• As outlined above for myelopathy or progressive neurological deficit scenarios
• Significant spinal cord or nerve root compression due to tumor, infection or trauma
• Fracture or instability on radiographic films measuring:
  • Sagittal plane angulation of greater than 11 degrees at a single interspace or greater than 3.5mm anterior subluxation in association with radicular/cord dysfunction
  • Subluxation at the (C1) level of the atlantodental interval of more than 3 mm in an adult and 5 mm in a child

Not Recommended (Nikolaidis, 2010; Van Middelkoop, 2012):

• In asymptomatic or mildly symptomatic cases of cervical spinal stenosis
• In cases of neck pain alone, without neurological deficits, and no evidence of significant spinal nerve root or cord compression on MRI or CT. See V. Cervical Fusion for Treatment of Axial Neck Pain Criteria. 

Cervical Posterior Decompression With Fusion — Single Level

The following criteria must be met*:

• Positive clinical findings of myelopathy with evidence of progressive neurologic deficits consistent with worsening spinal cord compression — immediate surgical evaluation is indicated (AA0S, 2013; Cunningham, 2010; Fehlings, 2013; Holly, 2009; Matz, 2009d; Mummaneni, 2009; Tetreault, 2013; Yalamanchili, 2012; Zhu, 2013).
• Symptoms may include:
  • Upper extremity weakness.
  • Unsteady gait related to myelopathy/balance or generalized lower extremity weakness.
  • Disturbance with coordination.
  • Hyperreflexia.
  • Hoffmann sign.
  • Positive Babinski sign and/or clonus.
• Progressive neurological deficit (motor deficit, bowel or bladder dysfunction) with corresponding evidence of spinal cord or nerve root compression on an MRI or CT scan images — immediate surgical evaluation is indicated (Bono, 2011; Matz, 2009b; Tetreault, 2013).

When ALL of the following criteria are met (Bono, 2011; Nikolaidis, 2010):  

• Cervical radiculopathy or myelopathy from ruptured disc, spondylosis, spinal instability, or deformity
• Persistent or recurrent symptoms/pain with functional limitations that are unresponsive to at least 6 weeks of conservative treatment
• Documented failure of at least 6 consecutive weeks in the last 6 months of any 2 of the following physician-directed conservative treatments:
  • Analgesics, steroids, and/or NSAIDs
  • Structured program of physical therapy
  • Structured home exercise program prescribed by a physical therapist, chiropractic provider or physician
  • Epidural steroid injections and or selective nerve root block
• Imaging studies confirm the presence of spinal cord or spinal nerve root compression (disc herniation or foraminal stenosis) at single level corresponding with the clinical findings (Bono, 2011). Imaging studies may include:
  • MRI (preferred study for assessing cervical spine soft tissue).
  • CT with or without myelography — indicated in patients in whom MRI is contraindicated; preferred for examining bony structures, or in patients presenting with clinical symptoms or signs inconsistent with MRI findings (e.g., foraminal compression not seen on MRI).

Cervical spine decompression with fusion performed as first-line treatment without conservative care measures in the following clinical cases (Fehlings, 2013; Tetreault, 2013; White, 1987; Zhu, 2013):  

• As outlined above for myelopathy or progressive neurological deficit scenarios
• Significant spinal cord or nerve root compression due to tumor, infection or trauma
• Fracture or instability on radiographic films measuring:
  • Sagittal plane angulation of greater than 11 degrees at a single interspace or greater than 3.5mm anterior subluxation in association with radicular/cord dysfunction
  • Subluxation at the (C1) level of the atlantodental interval of more than 3 mm in an adult and 5 mm in a child

Not Recommended (Nikolaidis, 2010; Wang, 2011):

• In asymptomatic or mildly symptomatic cases of cervical spinal stenosis
• In cases of neck pain alone, without neurological deficits, and no evidence of significant spinal nerve root or cord compression on MRI or CT. See V. Cervical Fusion for Treatment of Axial Neck Pain Criteria. 　

Cervical Posterior Decompression with Fusion — Multiple Levels

The following criteria must be met*:

• Positive clinical findings of myelopathy with evidence of progressive neurologic deficits consistent with worsening spinal cord compression — immediate surgical evaluation is indicated (AA0S, 2013; Cunningham, 2010; Fehlings, 2013; Holly, 2009; Matz, 2009d; Mummaneni, 2009; Tetreault, 2013; Yalamanchili, 2012; Zhu, 2013).
• Symptoms may include:
  • Upper extremity weakness.
  • Unsteady gait related to myelopathy/balance or generalized lower extremity weakness.
  • Disturbance with coordination.
  • Hyperreflexia.
  • Hoffmann sign.
  • Positive Babinski sign and/or clonus. 
• Progressive neurological deficit (motor deficit, bowel or bladder dysfunction) with corresponding evidence of spinal cord or nerve root compression on an MRI or CT scan images — immediate surgical evaluation is indicated (Bono, 2011; Matz, 2009b; Tetreault, 2013)

When ALL of the following criteria are met (Bono, 2011; Nikolaidis, 2010):

• Cervical radiculopathy or myelopathy from ruptured disc, spondylosis, spinal instability, or deformity
• Persistent or recurrent symptoms/pain with functional limitations that are unresponsive to at least 6 weeks of conservative treatment
• Documented failure of at least 6 consecutive weeks in the last 6 months of any 2 of the following physician-directed conservative treatments:
  • Analgesics, steroids, and/or NSAIDs
  • Structured program of physical therapy
  • Structured home exercise program prescribed by a physical therapist, chiropractic provider or physician
  • Epidural steroid injections and or facet injections /selective nerve root block
• Imaging studies indicate significant spinal cord or spinal nerve root compression at multiple levels corresponding with the clinical finding. Imaging studies may include (Bono, 2011): MRI (preferred study for assessing cervical spine soft tissue)
• CT with or without myelography — indicated in patients in whom MRI is contraindicated; preferred for examining bony structures, or in patients presenting with clinical symptoms or signs inconsistent with MRI findings (e.g., foraminal compression not seen on MRI)

*Cervical spine decompression with fusion performed as first-line treatment without conservative care measures in the following clinical cases (Fehlings, 2013; Tetreault, 2013; White, 1987; Zhu, 2013):

• As outlined above for myelopathy or progressive neurological deficit scenarios
• Significant spinal cord or nerve root compression due to tumor, infection or trauma  
• Fracture or instability on radiographic films measuring:
  • Sagittal plane angulation of greater than 11 degrees at a single interspace or greater than 3.5mm anterior subluxation in association with radicular/cord dysfunction
  • Subluxation at the (C1) level of the atlantodental interval of more than 3 mm in an adult and 5 mm in a child 　

Not Recommended (Nikolaidis, 2010; Wang, 2011):

• In asymptomatic or mildly symptomatic cases of cervical spinal stenosis
• In cases of neck pain alone, without neurological deficits, and no evidence of significant spinal nerve root or cord compression on MRI or CT. See: Cervical Fusion for Treatment of Axial Neck Pain Criteria

Cervical Fusion for Treatment of Axial Neck Pain

In patients with non-radicular cervical pain for whom fusion is being considered, ALL of the following criteria must be met (Riew, 2010):  

• Improvement of the symptoms has failed or plateaued, and the residual symptoms of pain and functional disability are unacceptable at the end of 6 to 12 consecutive months of appropriate, active treatment, or at the end of longer duration of non-operative programs for debilitated patients with complex problems [NOTE: Mere passage of time with poorly guided treatment is not considered an active treatment program]
• All pain generators are adequately defined and treated
• All physical medicine and manual therapy interventions are completed  
• X-ray, MRI, or CT demonstrating disc pathology or spinal instability  
• Spine pathology limited to one or two levels unless other complicating factors are involved  
• Psychosocial evaluation for confounding issues addressed

NOTE: The effectiveness of three-level or greater cervical fusion for non-radicular pain has not been established (Van Middelkoop, 2012).

Cervical Posterior Decompression

The following criteria must be met*:

• Positive clinical findings of myelopathy with evidence of progressive neurologic deficits consistent with worsening spinal cord compression — immediate surgical evaluation is indicated (AA0S, 2013; Bono, 2011; Heary, 2009; Mummaneni, 2009; Ryken, 2009; Tetreault, 2013; Wang, 2013; Yalamanchili, 2012; Zhu, 2013). Symptoms may include:
  • Upper extremity weakness.
  • Unsteady gait related to myelopathy/balance or generalized lower extremity weakness.
  • Disturbance with coordination.
  • Hyperreflexia.
  • Hoffmann sign.
  • Positive Babinski sign and / or clonus.
• Progressive neurological deficit (motor deficit, bowel or bladder dysfunction) with corresponding evidence of spinal cord or nerve root compression on an MRI or CT scan images — immediate surgical evaluation is indicated (Tetreault, 2013; Wang, 2013).

When ALL of the following criteria are met (Bono, 2011):

• Cervical radiculopathy from ruptured disc, spondylosis, or deformity
• Persistent or recurrent symptoms/pain with functional limitations that are unresponsive to at least 6 weeks of appropriate conservative treatment
• Documented failure of at least 6 consecutive weeks in the last 6 months of any 2 of the following physician-directed conservative treatments:
  • Analgesics, steroids, and/or NSAIDs
  • Structured program of physical therapy
  • Structured home exercise program prescribed by a physical therapist, chiropractic provider or physician　
  • Epidural steroid injections and or facet injections /selective nerve root block
• Imaging studies confirm the presence of spinal cord or spinal nerve root compression at the level(s) corresponding with the clinical findings (Bono, 2011; Sahai, 2019). Imaging studies may include any of the following:
  • MRI (preferred study for assessing cervical spine soft tissue)
  • CT with or without myelography— indicated in patients in whom MRI is contraindicated; preferred for examining bony structures, or in patients presenting with clinical symptoms or signs inconsistent with MRI findings (e.g., foraminal compression not seen on MRI)

Cervical decompression performed as first-line treatment without conservative care in the following clinical cases (Ryken, 2009; Tetreault, 2013; Wang, 2013; Zhu, 2013):

• As outlined above for myelopathy or progressive neurological deficit scenarios
• Spinal cord or nerve root compression due to tumor, infection or trauma

Not Recommended (Nikolaidis, 2010; Wang, 2011)

• In asymptomatic or mildly symptomatic cases
• In cases of neck pain alone, without neurological deficits and abnormal imaging findings. See E. Cervical Fusion for Treatment of Axial Neck Pain Criteria
• In patients with kyphosis or at risk for development of postoperative kyphosis

Cervical Artificial Disc Replacement (Single or Two Level)

Indications for cervical artificial disc replacement are as follows (Bono, 2011; Cheng, 2009; Davis, 2015; Gornet, 2019; Lavelle, 2019; Matz, 2009e):

• Skeletally mature patient
• Patient has intractable radiculopathy caused by one or two level disease (either herniated disc or spondolytic osteophyte) located at C3-C7
• Persistent or recurrent symptoms/pain with functional limitations that are unresponsive to at least 6 weeks of appropriate conservative treatment
• Documented failure of at least 6 consecutive weeks in the last 6 months of any 2 of the following physician-directed conservative treatments:
  • Analgesics, steroids, and/or NSAIDs
  • Structured program of physical therapy
  • Structured home exercise program prescribed by a physical therapist, chiropractic provider or physician
  • Epidural steroid injections and or facet injections /selective nerve root block
• Imaging studies confirm the presence of compression at the level(s) corresponding with the clinical findings (MRI or CT)
• Use of an FDA-approved prosthetic intervertebral discs

Cervical Artificial Disc Replacement is NOT indicated when any of the following clinical scenarios exists (Davis, 2015):

• Symptomatic multiple level disease affecting 3 or more levels
• Infection (at site of implantation or systemic)
• Osteoporosis or osteopenia
• Instability
  • Translation greater than 3mm difference between lateral flexion-extension views at the symptomatic levels;
  • 11 degrees of angular difference between lateral flexion-extension views at the symptomatic levels 
• Sensitivity or allergy to implant materials
• Severe spondylosis defined as (Davis, 2015):
  • > 50% disc height loss compared to minimally or non-degenerated levels
  • Bridging osteophytes
  • Absence of motion on lateral flexion-extension views at the symptomatic site
• Severe facet arthropathy
• Ankylosing spondylitis
• Rheumatoid arthritis
• Previous fracture with anatomical deformity
• Ossification of the posterior longitudinal ligament (OPLL)
• Active cervical spine malignancy

Cervical Fusion Without Decompression

Cervical fusion without decompression will be reviewed on a case-by-case basis. Atraumatic instability due to Down Syndrome-related spinal deformity, rheumatoid arthritis, or basilar invagination are uncommon, but may require cervical fusion (Trumees, 2017).  

Cervical Anterior Decompression (Without Fusion)

All requests for anterior decompression without fusion will be reviewed on a case-by-case basis (Bono, 2011; Botelho, 2012; Gebremariam, 2012; Matz, 2009a; Matz, 2009e).

References 

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40. Yuan H, Yu H, Liu L, Zheng B, Wang L, Wang H. Risk Factors for Predicting Increased Surgical Drain Output in Patients After Anterior Cervical Decompression and Fusion. World Neurosurg. Aug 2022;164:e980-e991. doi:10.1016/j.wneu.2022.05.075
41. Sonntag VK, Klara P. Controversy in spine care. Is fusion necessary after anterior cervical discectomy? Spine (Phila Pa 1976). May 1 1996;21(9):1111-3. doi:10.1097/00007632-199605010-00025
42. Dowd GC, Wirth FP. Anterior cervical discectomy: is fusion necessary? J Neurosurg. Jan 1999;90(1 Suppl):8-12. doi:10.3171/spi.1999.90.1.0008
43. Denaro V, Di Martino A. Cervical spine surgery: an historical perspective. Clin Orthop Relat Res. Mar 2011;469(3):639-48. doi:10.1007/s11999-010-1752-3
44. Oglesby M, Fineberg SJ, Patel AA, Pelton MA, Singh K. Epidemiological trends in cervical spine surgery for degenerative diseases between 2002 and 2009. Spine (Phila Pa 1976). Jun 15 2013;38(14):1226-32. doi:10.1097/BRS.0b013e31828be75d

Additional Information
A comprehensive assimilation of factors should lead to a specific diagnosis with positive identification of the pathologic condition(s).

• Early intervention may be required in acute incapacitating pain or in the presence of progressive neurological deficits.
• Operative treatment is indicated when the natural history of surgically treated lesions is better than the natural history for non-operatively treated lesions.
• Patients may present with localized pain or severe pain in combination with numbness, extremity weakness, loss of coordination, gait issues, or bowel and bladder complaints. Nonoperative treatment continues to play an important role in the care of patients with degenerative cervical spine disorders. If these symptoms progress to neurological deficits, from corresponding spinal cord or nerve root compression, than surgical intervention may be warranted.
• All patients being considered for surgical intervention should first undergo a comprehensive neuromusculoskeletal examination to identify those pain generators that may either respond to non-surgical techniques, or may be refractory to surgical intervention.
• In situations requiring the possible need for operation, a second opinion may be necessary. Psychological evaluation is strongly encouraged when surgery is being performed for isolated axial pain to determine if the patient will likely benefit from the treatment.
• It is imperative for the clinician to rule out non-physiologic modifiers of pain presentation, or non-operative conditions mimicking radiculopathy, myelopathy or spinal instability (peripheral compressive neuropathy, chronic soft tissue injuries, and psychological conditions), prior to consideration of elective surgical intervention. Significant depression or psychiatric disorder may be a reason for denial as risk of failure is elevated.

Degenerative cervical spine disorders, while often benign and episodic in nature, can become debilitating, resulting in axial pain and neurological damage to the spinal cord. Compression on the nerve root and / or spinal cord may be caused by (1) a herniated disc with or without extrusion of disc fragments and/or (2) degenerative cervical spondylosis.

Anterior Approaches — Additional Information:

• Anterior surgical approaches to cervical spine decompression emerged in the 1950s in response to technical limitations experienced with posterior approaches, including restricted access to and exposure of midline bony spurs and disc fragments.
• The first reports in the literature describe anterior cervical discectomy combined with a spinal fusion procedure (ACDF). Fusion was added to address concerns about potential for loss of spinal stability and disc space height, leading to late postoperative complications such as kyphosis and radicular pain (Sonntag and Klara, 1996; Dowd and Wirth, 1999; Matz et al., 2009a; Matz et al., 2009b; Denaro and Di Martino, 2011; Botelho et al., 2012; van Middelkoop et al., 2012).
• Anterior cervical fusion (ACF) accounted for approximately 80% of cervical spine procedures performed in the United States between 2002 and 2009, while posterior cervical fusion (PCF) accounted for 8.5% of these procedures (Oglesby et al., 2013).
• Anterior Cervical Discectomy and Fusion (ACDF) – removal of all or part of a herniated or ruptured disc or spondolytic bony spur to alleviate pressure on the nerve roots or on the spinal cord in patients with symptomatic radiculopathy. Discectomy is most often combined with fusion to stabilize the spine.

Posterior Approaches
Laminectomy — Removal of the bone between the spinal process and facet pedicle junction to expose the neural elements of the spine’ this allows for the inspection of the spinal canal, identification and removal of pathological tissue, and decompression of the cord and roots.

Laminoplasty — The opening of the lamina to enlarge the spinal canal. There are several laminoplasty techniques; all aim to alleviate cord compression by reconstructing the spinal canal. Laminoplasty is commonly performed to decompress the spinal cord in patients with degenerative spinal stenosis.

Laminoforaminotomy (also known as posterior discectomy) — The creation of a small window in the lamina to facilitate removal of arthritic bone spurs and herniated disc material pressing on the nerve root as it exits through the foramen. The procedure widens the opening of the foramen so that the nerve exits without being compressed.

Coding Section 

Code	Number	Description
CPT	0092T	Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), each additional interspace, cervical (List separately in addition to code for primary procedure) (code deleted 12/31/14)
	0095T	Removal of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure)
	0098T	Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure)
	0375T	Total disc arthroplasty (artificial disc), anterior approach, including  discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), cervical, three or more levels  (new code 01/01/15)
	20939 (effective 1/1/2018)	Bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision (List separately in addition to code for primary procedure)
	22548	Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 (atlas-axis), with or without excision of odontoid process
	22551	Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2
	22552	Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace (List separately in addition to code for separate procedure)
	22554	Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2
	22585	Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in addition to code for primary procedure)
	22590	Arthrodesis, posterior technique, craniocervical (occiput-C2)
	22595	Arthrodesis, posterior technique, atlas-axis (C1-C2)
	22600	Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment
	22614	Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for primary procedure)
	22856	Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); single interspace, cervical
	22858	Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); second level, cervical (List separately in addition to code for primary procedure) (new code 01/01/15)
	22861	Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical
	22862	Total disc arthroplasty (artificial disc), anterior approach
	22864	Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical
	22865	Single Spinal Instrumentation procedures on the Spine (Vertebral Column)
	63001	Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (e.g., spinal stenosis), 1 or 2 vertebral segments; cervical
	63015	Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (e.g., spinal stenosis), more than 2 vertebral segments; cervical
	63020	Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, cervical
	63035	Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional interspace, cervical or lumbar (List separately in addition to code for primary procedure)
	63040	Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, re-exploration, single interspace; cervical
	63043	Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional cervical interspace (List separately in addition to code for primary procedure)
	63045	Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [e.g., spinal or lateral recess stenosis]), single vertebral segment; cervical
	63048	Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [e.g., spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure)
	63050	Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments;
	63051	Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments; with reconstruction of the posterior bony elements (including the application of bridging bone graft and non-segmental fixation devices [eg, wire, suture, mini-plates], when performed)
	63075	Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace
	63076	Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, each additional interspace (List separately in addition to code for primary procedure)
ICD-9 Diagnosis	722.0	Displacement of cervical intervertebral disc without myelopathy
	722.4	Degeneration of cervical intervertebral disc
ICD-9 Procedure	84.62	Insertion of total spinal disc prosthesis, cervical
	84.66	Revision or replacement of artificial spinal disc prosthesis, cervical
ICD-10-CM (effective 10/1/15)	M5020	Other cervical disc displacement, unspecified cervical region
	M5030	Other cervical disc degeneration, unspecified cervical region
ICD-10-PCS (effective 10/1/15)	0RR30JZ	Open replacement of cervical vertebral disc with synthetic substitute
	0RR50JZ	Open replacement of cervicothoracic vertebral disc with synthetic substitute
Type of Service
Place of Service

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community,and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2016 Forward     

06/03/2024	Annual review, no change to policy intent.
10/11/2023	Interim review to update references. No change to policy intent.
07/10/2023	Annual review, no change to policy intent.
06/26/2023	Updating date.  No other changes.
06192023	Adding codes to coding section 22857, 22862 and 22865.
07/06/2022	Annual review, no change to policy intent.
07/15/2021	Annual review, no change to policy intent.
05/13/2020	Interim review, updating conservative treatment language to include "in the last 6 months." Also changing annual review to July.
03/02/2020	Annual review, no change to policy intent. Restating what conservative treatment is required prior to surgery for clarity. No other changes made.
06/24/2019	Interim review to remove a statement related to smoking. No other changes made.
03/04/2019	Annual review, no change to policy intent. Correcting a typographical error.
07/18/2018	Interim review, removing verbiage related to smoking and nicotine.
03/19/2018	Annual review, no change to policy intent.
12/7/2017	Updating policy with 2018 coding. No other changes.
04/03/2017	Major revision to policy to incorporate artificial disc procedures in policy. Updating title, policy, rationale, references and coding.
03/01/2017	Annual review, no change to policy intent.
03/21/2016	NEW POLICY