The guidelines established by the New York State Workers Compensation Board are designed to assist healthcare professionals in the context of Cervical Artificial Disc Replacement. These directives aim to support physicians and healthcare practitioners in determining the appropriate course of action for individuals considering or undergoing cervical disc replacement procedures.
Healthcare professionals specializing in Cervical Artificial Disc Replacement can rely on the guidance provided by the Workers Compensation Board to make well-informed decisions about the most suitable approach for their patients.
It is crucial to emphasize that these guidelines are not meant to replace clinical judgment or professional expertise. The ultimate decision regarding Cervical Artificial Disc Replacement should involve collaboration between the patient and their healthcare provider.
Disc Herniation and Other Cervical Conditions
Operative treatment becomes a consideration only when the expected outcomes with surgery surpass those without. Those being evaluated for surgery should undergo a thorough neuromuscular examination to pinpoint pain sources that might respond to non-surgical methods or may not be effectively addressed through surgery. Making timely decisions for surgical intervention is crucial to prevent the deconditioning and increased disability of the cervical spine.
In cases where cervical fusion is being contemplated, it’s advised that patients abstain from smoking for a minimum of six weeks before surgery and during the healing period. Due to the higher risk of non-union and increased post-operative costs associated with smoking, it’s suggested that insurers cover a smoking cessation program peri-operatively.
General Indications for Surgery: Surgical intervention should be considered, and a consultation sought when symptom improvement has plateaued, and the remaining pain and functional disability are deemed unacceptable. Typically, surgical consultation is recommended after at least six months of non-surgical treatment in line with medical treatment guidelines. However, patients with significant and/or progressive neurologic deficits may be considered for surgical intervention earlier. The choice of hardware instrumentation is guided by anatomy, the patient’s pathology, and the surgeon’s clinical judgment.
Specific Surgical Indications
Myelopathy
Consider immediate surgical evaluation and treatment for patients showing clinical indications of myelopathy.
Cervical Radiculopathy
For acute, debilitating pain or severe/progressive neurological deficits, early intervention may be necessary. Surgical evaluation is recommended if arm pain persists or recurs with functional limitations after six weeks of conservative treatment, or if there’s progressive functional or static neurological deficit, supported by confirmatory imaging studies.
Persistent Non-Radicular Cervical Pain
While cervical fusion is a suitable option for neck pain caused by degeneration with radiculopathy, there’s no proof that fusion for neck pain alone yields better results than conservative care. In the absence of radiculopathy, it’s advised to exhaust conservative measures before considering surgery. The effectiveness of cervical vertebral fusion for non-radicular pain remains unestablished and shouldn’t be routinely recommended. Preoperative indications for fusion in non-radicular cervical pain patients should meet specific criteria.
If the non-surgical treatment plan doesn’t work, going for surgery might be necessary under these circumstances: when symptom improvement hits a plateau, and the remaining pain and functional issues are still unbearable after six to 12 weeks of active treatment, or after a more extended non-surgical program for patients dealing with complex problems. Also, if recurring symptoms significantly limit function, even when the non-surgical treatment provides relief, and each recurrence restores function, it’s a consideration. Just letting time pass without proper guidance isn’t seen as an active treatment approach.
Before contemplating surgery, it’s crucial to ensure all pain sources are identified and treated, and attempts with physical medicine and manual therapy have been made but failed to ease the symptoms. Additionally, imaging like X-rays, MRI, or CT scans should show disc issues or spinal instability, limited to just two levels. A psychosocial evaluation should also be conducted to address any complicating factors.
For anyone considering surgery, it’s advisable to quit smoking at least six weeks before the procedure and throughout the healing period. Smoking increases the risk of non-union and raises post-operative costs, so it’s suggested that insurance covers a smoking cessation program around the time of surgery.
Surgical Procedures
Recommended: This is suggested for specific patients based on clinical indications. The surgical procedures encompass:
Cervical Discectomy with or without Fusion:
Description: This procedure aims to alleviate pressure on one or more nerve roots or the spinal cord, and it can be done with or without a microscope. Possible complications involve graft dislodgment, infection, hemorrhage, CSF leak, hematoma, spinal cord injury leading to various degrees of paralysis, pseudarthrosis, in-hospital mortality, non-union of fusion, and donor site pain (autograft only). The anterior approach may lead to permanent or transient dysphonia, permanent or temporary dysphagia, denervation, esophageal perforation, and airway obstruction. Surgical indications include radiculopathy from disc herniation or spondylosis, spinal instability, or non-radicular neck pain meeting fusion criteria. Cervical plating may be employed during operative treatment to prevent graft displacement and enhance fusion rates.
Post-Operative Care: This may involve cervical bracing, physical therapy, and/or occupational therapy as needed. Early rehabilitation should include home programs with guidance on activities of daily living, sitting, posture, and a daily walking routine. Referral to a formal rehabilitation program becomes suitable once fusion is stable and without complications, focusing on cervical, scapular, and thoracic strengthening, and restoration of range of motion. Active treatment, which patients should have undergone before surgery, might necessitate a repeat of previously ordered sessions. The therapy program goals should include guidance on a long-term home-based exercise routine.
Cervical Corpectomy:
Description: This involves removing part or the entire vertebral body from the front of the spine, typically including at least a one-level discectomy and requiring a fusion procedure.
Complications: Possible issues include graft dislodgment, infection, hemorrhage, CSF leak, hematoma, spinal cord injury leading to various degrees of paralysis, pseudarthrosis, in-hospital mortality, non-union of fusion, and donor site pain (autograft only). The anterior approach might result in permanent or temporary dysphonia, permanent or transient dysphagia, denervation, esophageal perforation, and airway obstruction.
Surgical Indications: This procedure is recommended for single or multilevel spinal stenosis, spondylolisthesis, or severe kyphosis with cord compression.
Operative Treatment: Involves neural decompression, fusion with instrumentation, and possibly placing a halo vest to maintain cervical position.
Post-Operative Care: Depending on the number of vertebral bodies involved, healing time may be longer than a discectomy. Cervical bracing, physical therapy, and/or occupational therapy may be necessary based on clinical needs. Traditionally, halo vest care has been required, but advancements in cervical fusion techniques with instrumentation may allow for quicker mobilization. Early rehabilitation should include home programs covering activities of daily living, sitting, posture, and a daily walking routine.
Referral to a formal rehabilitation program with a focus on cervical, scapular, and thoracic strengthening is appropriate for most patients once the cervical spine is stable and without complications. The therapy program’s goals should include guidance on a long-term home-based exercise routine.
Cervical Laminectomy with or without Foraminotomy and/or Fusion
Description: This involves surgically removing the back part of a vertebra to access the spinal cord or nerve roots.
Complications: Possible issues include perineural fibrosis, kyphosis, nerve injury, post-surgical instability, CSF leak, infection, non-union of fusion, hardware failure, donor site pain (autograft only), paralysis, and, in severe cases, death.
Surgical Indications: This procedure is recommended for cases of neural compression.
Operative Treatment: Involves laminotomy, partial discectomy, nerve root decompression, and laminectomy.
Post-Operative Care: Depending on clinical needs, cervical bracing, physical therapy, and/or occupational therapy may be necessary. Cervical bracing might be suitable, usually for six to 12 weeks with fusion, although newer surgical techniques may not require prolonged immobilization.
Therapy: Early rehabilitation should include home programs covering activities of daily living, sitting, posture, and a daily walking routine. Referral to a formal rehabilitation program with a focus on cervical, scapular, and thoracic strengthening, as well as the restoration of range of motion, is appropriate for most patients once the cervical spine is stable and without complications. The therapy program’s goals should involve guidance on a long-term home-based exercise routine.
Cervical Laminoplasty:
Description: This technique expands the spinal canal size while keeping some of the posterior elements intact.
Complications: The potential drawback is a loss of cervical motion, and other risks may involve perineural fibrosis, kyphosis, nerve injury, post-surgical instability, CSF leak, infection, non-union of fusion, hardware failure, donor site pain (autograft only), paralysis, and, in severe cases, death.
Surgical Indications: It’s suitable for cervical spinal stenosis and/or spondylitic myelopathy but not recommended for cervical kyphosis.
Operative Treatment: A posterior approach, with or without instrumentation.
Post-Operative Care: Depending on clinical needs, cervical bracing, physical therapy, and/or occupational therapy may be necessary. Therapy may involve four to 12 weeks of cervical bracing. Early rehabilitation should include home programs covering activities of daily living, sitting, posture, and a daily walking routine. Referral to a formal rehabilitation program focusing on cervical, scapular, and thoracic strengthening, as well as the restoration of range of motion, is appropriate once the cervical spine is stable and without complications. Active treatment, which patients should have undergone before surgery, might require a repeat of previously ordered sessions. The therapy program’s goals should include guidance on a long-term, home-based exercise routine.
Percutaneous Discectomy:
Description: This is an invasive operative procedure for partially removing the disc through a needle under imaging control.
Complications: Possible issues include injuries to nerves or blood vessels, infection, and hematoma.
Surgical Indications: It’s recommended solely for suspected septic discitis to obtain diagnostic tissue. The procedure isn’t advised for contained disc herniations or bulges with associated radiculopathy due to a lack of evidence supporting long-term improvement.
Operative Treatment: Involves partial discectomy.
