3rd Qtr Physician 2016 Spine Surg Case Study #3
Health Plan: BSCA
ACDF-CPT 22551, 22845, 20931
36 y/o F has a long history of neck issues dating back to a MVA at age 18 with neck pain and radicular symptoms ever since. Recent exacerbation over the last 2 years without injury.
She has developed clumsiness in her hands with weakness of her left upper extremity and occasional tingling in her hands.
She has tried physical therapy as prescribed by her primary care doctor for 2 months without relief. Multiple medications and activity modifications have not helped.
Physical examination revealed diffuse 4/5 weakness of the left upper extremity with decreased sensation in the C5 distribution and hyperreflexic DTRs. Gait is antalgic, however no obvious clonus or Babinski is present.
Recent MRI shows a large HNP at C4-5 with myelomalacia/cord compression and signal change.
Impression is cervical myelopathy with HNP @ C4-5 with a plan for cervical decompression and fusion.
The request is for a C4-5 ACDF.
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