Description
Operative treatment is indicated only when the natural history of surgically treated lesions is better than the natural history for non-operatively treated lesions. 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. All individuals being considered for surgical intervention should receive a comprehensive neuromusculoskeletal examination to identify pain generators that may either respond to non-surgical techniques or may be refractory to surgical intervention.

General Information

• It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted.
• The guideline criteria in the following sections were developed utilizing evidence-based and peer-reviewed resources from medical publications and societal organization guidelines as well as from widely accepted standard of care, best practice recommendations.

Purpose
This guideline outlines the key surgical treatments and indications for common cervical spinal disorders and is based upon the best available evidence. Spine surgery is a complex area of medicine, and this document breaks out the clinical indications by surgical type.

This guideline does not address spinal deformity surgeries or the clinical indications for spinal deformity surgery.

Scope
Spinal surgeries should be performed only by those with extensive and specialized surgical training (neurosurgery, orthopedic surgery). Choice of surgical approach is based on anatomy, pathology, and the surgeon's experience and preference.

Instrumentation, bone formation or grafting materials, including biologics, should be used at the surgeon’s discretion; however, use should be limited to FDA approved indications regarding the specific devices or biologics.

Special Note
In order for surgeries to be considered medically necessary there must be clear medical records that demonstrate a clear surgical plan that matches the request for surgery.

BACKGROUND
*Conservative Treatment
Non-operative conservative treatment should include a multimodality approach consisting of at least one (1) active and one (1) inactive component targeting the affected spinal region.

• Active Modalities
  • Physical therapy
  • Physician-supervised home exercise program (HEP)**
  • Chiropractic Care 
• Inactive Modalities
  • Medications (e.g., NSAIDs, steroids, analgesics)
  • Injections (e.g., epidural steroid injection, selective nerve root block)
  • Medical devices (e.g., TENS unit, bracing)

**Home Exercise Program (HEP)
The following two elements are required to meet conservative therapy guidelines for HEP:

• Documentation of an exercise prescription/plan provided by a physician, physical therapist, or chiropractor; AND
• Follow-up documentation regarding completion of HEP after the required 6-week timeframe or inability to complete HEP due to a documented medical reason (i.e., increased pain or inability to physically perform exercises)

Policy 
IINDICATIONS
Anterior Cervical Discectomy with Fusion (ACDF) - Single Level
When one of the two following criteria are met (1–8):

• Positive clinical findings of myelopathy with evidence of progressive neurologic deficits consistent with spinal cord compression - immediate surgical evaluation is indicated. Symptoms may include⁷:
  • 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

When ALL of the following criteria are met ^6–8:

• Cervical radiculopathy or myelopathy from ruptured disc, spondylosis, spinal instability, or deformity
• Failure of conservative treatment* for a minimum of six (6) weeks within the last six (6) months;

NOTE - Failure of conservative treatment is defined as one of the following:

• Lack of meaningful improvement after a full course of treatment; OR
• Progression or worsening of symptoms during treatment; OR
• Documentation of a medical reason the member is unable to participate in treatment

Closure of medical or therapy offices, patient inconvenience, or noncompliance without explanation does not constitute “inability to complete” treatment.

• 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. Imaging studies may include:
  • MRI (preferred study for assessing cervical spine soft tissue)
  • CT with or without myelography— indicated in individuals in whom MRI is contraindicated; preferred for examining bony structures, or in individuals presenting with clinical symptoms or signs inconsistent with MRI findings (e.g., foraminal compression not seen on MRI)

As first-line treatment without conservative care measures in the following clinical cases^1,2,6,9:

• 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 3.5 mm 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 recommended¹⁰:

• 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

Anterior Cervical Discectomy with Fusion (ACDF) – Multiple Levels
When one of the two following criteria are met^1–8:

• Positive clinical findings of myelopathy with evidence of progressive neurologic deficits consistent with worsening spinal cord compression – immediate surgical evaluation is indicated. 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

When ALL of the following criteria are met ^6–8:

• Cervical radiculopathy or myelopathy due to ruptured disc, spondylosis, spinal instability, or deformity
• Failure of conservative treatment* for a minimum of six (6) weeks within the last six (6) months;

NOTE - Failure of conservative treatment is defined as one of the following:

• Lack of meaningful improvement after a full course of treatment; OR
• Progression or worsening of symptoms during treatment; OR
• Documentation of a medical reason the member is unable to participate in treatment

Closure of medical or therapy offices, patient inconvenience, or noncompliance without explanation does not constitute “inability to complete” treatment.

• 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:
  • MRI (preferred study for assessing cervical spine soft tissue)
  • CT with or without myelography - indicated in individuals in whom MRI is contraindicated; preferred for examining bony structures, or in individuals presenting with clinical symptoms or signs inconsistent with MRI findings (e.g., foraminal compression not seen on MRI)

As first-line treatment without conservative care measures in the following clinical cases^1,2,6,9:

• 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 3.5 mm 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 recommended¹⁰:

• 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 Posterior Decompression with Fusion (CPDF) - Single Level
When one of the two following criteria are met ^1–8,11:

• Positive clinical findings of myelopathy with evidence of progressive neurologic deficits consistent with worsening spinal cord compression - immediate surgical evaluation is indicated. 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

When ALL of the following criteria are met ^8,12,13:

• Cervical radiculopathy or myelopathy from ruptured disc, spondylosis, spinal instability, or deformity OR documented pseudarthrosis of prior ACDF/Cervical Artificial Disc Replacement (CADR) - one of the most common indications for a Single Level or Multi Levels CPDF is a failed anterior procedure
• Failure of conservative treatment* for a minimum of six (6) weeks within the last six (6) months;

NOTE - Failure of conservative treatment is defined as one of the following:

• Lack of meaningful improvement after a full course of treatment; OR
• Progression or worsening of symptoms during treatment; OR
• Documentation of a medical reason the member is unable to participate in treatment

Closure of medical or therapy offices, patient inconvenience, or noncompliance without explanation does not constitute “inability to complete” treatment.

• 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. Imaging studies may include:
  • MRI (preferred study for assessing cervical spine soft tissue)
  • CT with or without myelography – indicated in individuals in whom MRI is contraindicated; preferred for examining bony structures, or in individuals presenting with clinical symptoms or signs inconsistent with MRI findings (e.g., foraminal compression not seen on MRI)

As first-line treatment without conservative care measures in the following clinical cases ^1,2,6,9,11:

• 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 3.5 mm 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 ¹⁰:

• 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 Posterior Decompression with Fusion (CPDF) – Multiple Levels
When one of the two following criteria are met ^1–8,11:

• Positive clinical findings of myelopathy with evidence of progressive neurologic deficits consistent with worsening spinal cord compression – immediate surgical evaluation is indicated. 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

When ALL of the following criteria are met ^8,12,13:

• Cervical radiculopathy or myelopathy from ruptured disc, spondylosis, spinal instability, or deformity OR documented pseudarthrosis of prior anterior ACDF/CADR surgery
• Failure of conservative treatment* for a minimum of six (6) weeks within the last six (6) months;

NOTE - Failure of conservative treatment is defined as one of the following:

• Lack of meaningful improvement after a full course of treatment; OR
• Progression or worsening of symptoms during treatment; OR
• Documentation of a medical reason the member is unable to participate in treatment

Closure of medical or therapy offices, patient inconvenience, or noncompliance without explanation does not constitute “inability to complete” treatment.

• Imaging studies indicate significant spinal cord or spinal nerve root compression at multiple levels corresponding with the clinical findings. Imaging studies may include:
  • MRI (preferred study for assessing cervical spine soft tissue)
  • CT with or without myelography - indicated in individuals in whom MRI is contraindicated; preferred for examining bony structures, or in individuals presenting with clinical symptoms or signs inconsistent with MRI findings (e.g., foraminal compression not seen on MRI)

As first-line treatment without conservative care measures in the following clinical cases ^1,2,6,9,11:

• 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 3.5 mm 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 ¹⁰:

• 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
Fusion In Individuals with Non-Radicular Cervical Pain
ALL of the following criteria must be met ^14,15:

• 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 those debilitated 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.

Cervical Posterior Decompression
The following criteria must be met*^1,2,4–8,16:

• Positive clinical findings of myelopathy with evidence of progressive neurologic deficits consistent with worsening spinal cord compression - immediate surgical evaluation is indicated. 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

When ALL of the following criteria are met⁸:

• Cervical radiculopathy from ruptured disc, spondylosis, or deformity
• Failure of conservative treatment* for a minimum of six (6) weeks within the last six (6) months;

NOTE - Failure of conservative treatment is defined as one of the following:

• Lack of meaningful improvement after a full course of treatment; OR
• Progression or worsening of symptoms during treatment; OR
• Documentation of a medical reason the member is unable to participate in treatment

Closure of medical or therapy offices, patient inconvenience, or noncompliance without explanation does not constitute “inability to complete” treatment.

• Imaging studies confirm the presence of spinal cord or spinal nerve root compression at the level(s) corresponding with the clinical findings. Imaging studies may include any of the following:
  • MRI (preferred study for assessing cervical spine soft tissue)
  • CT with or without myelography— indicated in individuals in whom MRI is contraindicated; preferred for examining bony structures, or in individuals 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^1,2,6,16:

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

Not Recommended¹⁰:

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

Cervical Artificial Disc Replacement (Single or Two Level) ^8,17,18
When all of the following criteria are met:

• Skeletally mature individual
• Intractable radiculopathy caused by one-or-two-level disease (either herniated disc or spondolytic osteophyte) located at C3-C7
• Failure of conservative treatment* for a minimum of six (6) weeks within the last six (6) months;

NOTE - Failure of conservative treatment is defined as one of the following:

• Lack of meaningful improvement after a full course of treatment; OR
• Progression or worsening of symptoms during treatment; OR
• Documentation of a medical reason the member is unable to participate in treatment

Closure of medical or therapy offices, patient inconvenience, or noncompliance without explanation does not constitute “inability to complete” treatment.

• Imaging studies confirm the presence of compression at the level(s) corresponding with the clinical findings (MRI or CT) or a failed Cervical Disc Arthroplasty Implant as evidenced by a post-operative image showing a previously placed cervical disc arthroplasty noted to have implant malposition or failure as evidenced by one or more of the following ^19,20:
  • Subsidence
  • Loosening
  • Infection
  • Dislocation
  • Subluxation
  • Vertebral body fracture
  • Dislodgement
• Use of an FDA-approved prosthetic intervertebral discs

Contraindications

• Symptomatic multiple level disease affecting 3 or more levels
• Infection (at site of implantation or systemic)
• Osteoporosis or osteopenia
• Instability
  • Translation greater than 3 mm 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:
  • >50% disc-height loss compared to minimally or non-degenerated levels; OR
  • Bridging osteophytes; OR
  • 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. A traumatic instability due to Down Syndrome-related spinal deformity, rheumatoid arthritis, or basilar invagination are uncommon, but may require cervical fusion.

Cervical Anterior Decompression (Without Fusion) 
All requests for anterior decompression without fusion will be reviewed on a case-by-case basis.

RISK FACTORS AND CONSIDERATIONS ^21–24

• Early intervention may be required in acute incapacitating pain or with progressive neurological deficits
• Individuals may present with pain, numbness, extremity weakness, loss of coordination, gait issues, or bowel and bladder complaints. Non-operative treatment is an important role in the care of individuals with degenerative cervical spine disorders. If these symptoms progress to neurological deficits, from corresponding spinal cord or nerve root compression, surgical intervention may be warranted.
• Obesity is an identified risk factor for surgical site infection. For individuals undergoing posterior cervical decompression with or without fusion for a diagnosis other than myelopathy, BMI should be less than 40 kg/m2. These cases will be reviewed on a case-by-case basis and may be denied given the increased risk of infection.
• If operative intervention is being considered, especially procedures that require a fusion, it is required the person refrain from smoking/nicotine for at least six weeks prior to surgery and during the time of healing. Cessation must be confirmed by a negative cotinine test prior to surgery approval.
• In situations requiring possible need for an operation, a second opinion may be necessary. Psychological evaluation is strongly encouraged before surgery is performed for isolated axial pain to determine if the individual 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.

SUMMARY OF EVIDENCE
Comparison of anterior and posterior approaches for functional improvement in cervical myelopathy: A systematic review and meta-analysis of 33,025 patients (11)
Study Design: Systematic review and meta-analysis. 
Target Population: 33,025 patients with cervical myelopathy. 
Key Factors:
●    Objective: To compare the risks and benefits of anterior and posterior surgical techniques for cervical myelopathy.
●    Methods: Systematic search across databases including PubMed, Scopus, and Web of Science. Studies were selected based on predefined inclusion criteria and assessed using NOS and Rob-2 tools.
●    Results: The anterior approach was associated with better neurological recovery, greater improvement in Cobb’s angle, and statistically significant decreases in VAS and NDI scales compared to the posterior approach. It also led to fewer complications, less pain, reduced blood loss, and shorter hospital stays.
●    Conclusions: The anterior approach for cervical myelopathy may improve nerve function, correct spinal curvature more effectively, and lead to fewer complications compared to the posterior approach.

Comparison of Anterior Surgery Versus Posterior Surgery for the Treatment of Multilevel Cervical Spondylotic Myelopathy: A Meta-Analysis ⁴
Study Design: Meta-analysis. 
Target Population: 2,712 patients with multilevel cervical spondylotic myelopathy (MCSM). 
Key Factors:
Objective: To evaluate the impact of anterior versus posterior surgical approaches on outcomes in MCSM.
Methods: Comprehensive search across electronic databases including MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials. Studies were assessed using the Newcastle-Ottawa Scale score.
Results: No significant difference between the two groups in preoperative and postoperative JOA scores, JOA recovery rate, or neck VAS score. However, the anterior surgery group had significantly lower NDI scores, blood loss, and shorter length of stay, but higher rates of complications. The anterior surgery group also had better recovery of cervical lordosis but limited postoperative mobility.
Conclusion: No clear advantage of one surgical approach over the other for MCSM in terms of neurological function recovery. The anterior approach was associated with improved NDI scores, lower blood loss, shorter length of stay, and better recovery of cervical lordosis.

The Essence of Clinical Practice Guidelines for Cervical Spondylotic Myelopathy, 2020⁷
Study Design: Clinical practice guidelines. 
Target Population: Patients with cervical spondylotic myelopathy (CSM). 
Key Factors:

• Objective: To provide guidelines for the management of CSM.
• Epidemiology: CSM is common in men aged 50 years and older, with an incidence of several people per 100,000 population.
• Natural History: Patients with severe and progressive symptoms need surgery. Mild cases require appropriate care and monitoring.
• Pathology: CSM arises from static and dynamic compression factors affecting the spinal cord, with circulatory disturbances also involved.
• Diagnosis: Sensory disturbance of the upper limbs and motor dysfunction of the upper and lower limbs are common. Imaging studies and neurological examination are important for proper diagnosis.
• Treatment: Conservative treatment is primarily for mild cases. Surgery is suitable for progressive myelopathy. Surgical methods include anterior decompression and fusion (ADF), laminoplasty, and posterior decompression with fusion (PDF).
• Prognosis: Good postoperative recovery of lower limb motor function leads to a sufficient prognosis

ANALYSIS OF EVIDENCE
Shared Findings ^4,7,11:

• Both Aleid et al. 2025 and Bao et al. 2025 agree that the anterior approach generally results in lower blood loss and shorter hospital stays.
• All three studies acknowledge that both anterior and posterior approaches have their own sets of advantages and disadvantages, and the choice of approach should be tailored to the individual patient’s condition 

Differing Findings ^4,7,11:

• Aleid et al. 2025 emphasizes the superiority of the anterior approach in terms of neurological recovery and functional improvement.
• Bao et al. 2025 highlights that there is no clear advantage of one approach over the other in terms of neurological function recovery, but the anterior approach has better outcomes in terms of NDI scores and cervical lordosis.
• Nagoshi 2024 provides a more balanced view, recommending that the choice of surgical method should be based on the specific pathology and patient condition, without favoring one approach over the other.

In summary, while there are some differences in the conclusions drawn by these studies, they all highlight the importance of tailoring the surgical approach to the individual patient's condition and the specific pathology involved. The anterior approach generally shows better outcomes in terms of blood loss, hospital stay, and cervical lordosis, but it also has higher complication rates compared to the posterior approach. The guidelines emphasize the need for a balanced and patient-specific approach to treatment.

References 

1. Guo S, Lin T, Wu R, Wang Z, Chen G. The Pre-Operative Duration of Symptoms: The Most Important Predictor of Post-Operative Efficacy in Patients with Degenerative Cervical Myelopathy. Brain Sci. 2022; 12: 1088. 10.3390/brainsci12081088.

2. Kwok S S S, Cheung J P Y. Surgical decision-making for ossification of the posterior longitudinal ligament versus other types of degenerative cervical myelopathy: anterior versus posterior approaches. BMC Musculoskelet Disord. 2020; 21: 823. 10.1186 /s12891-020-03830-0.

3. Luyao H, Xiaoxiao Y, Tianxiao F, Yuandong L, Ping W. Management of Cervical Spondylotic Radiculopathy: A Systematic review. Global Spine J. Oct 2022; 12: 1912-1924. 10.1177/21925682221075290.

4. Nunna R, Khalid S, Chiu R, Parola R, Fessler R et al. Anterior vs Posterior Approach in Multilevel Cervical Spondylotic Myelopathy: A Nationwide Propensity-Matched Analysis of Complications, Outcomes, and Narcotic Use. Int J Spine Surg. Feb 2022; 16: 88-94. 10.14444/8198.

5. Park D, Jenne J, Bode K, Throckmorton T, Fischer S. Cervical Spondylotic Myelopathy: Surgical Treatment Options. OrthoInfo. 2022; Accessed: September 4, 2024. https://orthoinfo.aaos.org/en/treatment/cervical-spondylotic-myelopathysurgical-treatment-options/.

6. Tetreault L, Karpova A, Fehlings M. Predictors of outcome in patients with degenerative cervical spondylotic myelopathy undergoing surgical treatment: results of a systematic review. Eur Spine J. Apr 2015; 24 Suppl 2: 236-51. 10.1007/s00586-013-2658-z.

7. Xu Y, Chen F, Wang Y, Zhang J, Hu J. Surgical approaches and outcomes for cervical myelopathy with increased signal intensity on T2-weighted MRI: a meta-analysis. J Orthop Surg Res. 2019; 14: 224. 10.1186/s13018-019-1265-z.

8. North American Spine Society. Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders. 2010; Retrieved 2023, from NASS Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care.

9. Lebl D R, Bono C M. Update on the Diagnosis and Management of Cervical Spondylotic Myelopathy. Journal of the American Academy of Orthopaedic Surgeons. 2015; 23: 648-660. 10.5435/JAAOS-D-14-00250.

10. Nikolaidis I, Fouyas I P, Sandercock P A, Statham P F. Surgery for cervical radiculopathy or myelopathy. Cochrane Database Syst Rev. 2010; 2010: Cd001466. 10.1002/14651858.CD001466.pub3.

11. Spitnale M, Grabowski G. Classification in Brief: Subaxial Cervical Spine Injury Classification and Severity Score System. Clin Orthop Relat Res. Oct 2020; 478: 2390-2398. 10.1097/corr.0000000000001463.

12. Audat Z, Fawareh M, Radydeh A, Obeidat M, Odat M et al. Anterior versus posterior approach to treat cervical spondylotic myelopathy, clinical and radiological results with long period of follow-up. SAGE Open Med. 2018; 6: 2050312118766199. 10.1177/2050312118766199.

13. Riew K, Ecker E, Dettori J. Anterior cervical discectomy and fusion for the management of axial neck pain in the absence of radiculopathy or myelopathy. Evid Based Spine Care J. Dec 2010; 1: 45-50. 10.1055/s-0030-1267067.

14. Harrop J S, Gonzalez G A, Qasba R K, Porto G, Wainwright J V et al. Does axial cervical pain improve with surgical fusion? A meta-analysis. Journal of Neurosurgery: Spine. 2023; 1-10. 10.3171/2023.4.SPINE23185.

15. Revesz D, Charalampidis A, Gerdhem P. Effectiveness of laminectomy with fusion and laminectomy alone in degenerative cervical myelopathy. Eur Spine J. May 2022; 31: 1300-1308. 10.1007/s00586-022-07159-1.

16. Eseonu K, Laurent E, Bishi H, Raja H, Ravi K. A Retrospective Comparative Study of Long-Term Outcomes Following Cervical Total Disc Replacement Versus Anterior Cervical Discectomy and Fusion. Cureus. Dec 2022; 14: e32399. 10.7759/cureus.32399.

17. Nunley P, Frank K, Stone M. Patient Selection in Cervical Disc Arthroplasty. International Journal of Spine Surgery. 2020; 14: S29-S35. 10.14444/7088.

18. Donk R D, Verbeek A L M, Verhagen W I M, Groenewoud H, Hosman A J F. Whats the best surgical treatment for patients with cervical radiculopathy due to single-level degenerative disease? A randomized controlled trial. PLoS One. 2017; 12: e0183603. 10.1371/journal.pone.0183603.

19. Badiee R, Mayer R, Pennicooke B, Chou D, Mummaneni P. Complications following posterior cervical decompression and fusion: a review of incidence, risk factors, and prevention strategies. J Spine Surg. Mar 2020; 6: 323-333. 10.21037/jss.2019.11.01.

20. Jackson K 2, Devine J. The Effects of Smoking and Smoking Cessation on Spine Surgery: A Systematic Review of the Literature. Global Spine J. Nov 2016; 6: 695-701. 10.1055/s-0036-1571285.

21. Rajaee S, Kanim L, Bae H. National trends in revision spinal fusion in the USA: patient characteristics and complications. Bone Joint J. Jun 2014; 96-b: 807-16. 10.1302/0301-620x.96b6.31149.

22. Washington State Health Care Authority. Artificial disc replacement - Re-review [Adopted March 17, 2017]. Washington State Health Care Authority. 2008; Accessed: September 23, 2024. www.hca.wa.gov/assets/program/adr-rr-final-findings-decision-20170317.pdf.

23. Washington State Health Care Authority. Cervical Spinal Fusion for Degenerative Disc Disease [Adopted May 17, 2013]. Washington State Health Care Authority. 2013; Accessed: September 23, 2024. www.hca.wa.gov/assets/program/csf_final_findings_decision_052013%5B1%5D.pdf.

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.