Physician 1st Quarter 2016 Spine Surgery IRR - Case Study #2
55-year-old female with prior authorization request for anterior cervical decompression and fusion of
C4–5 (CPT 22551, 22845).
The patient has had progressive neck pain radiating into both upper extremity's for the last year. It exacerbated after a recent car accident.
She has had extensive conservative care including trigger point injections and physical therapy, however recently developed dexterity issues in her upper extremities.
Physical examination shows unsteady gait with restricted range of motion in flexion and rotation of the cervical spine and tenderness throughout the mid cervical spine. There is 4/5 weakness in the triceps and decreased grip strength of both upper extremities. Deep tendon reflexes were hyper-reflexic and symmetric with positive Hoffman and Spurling maneuvers.
Cervical spine MRI was consistent with a large C4–5 osteophytic ridge/disc complex resulting in severe spinal stenosis with spinal cord myelomalacia and 3mm retrolisthesis.
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