3rd Qtr Physician 2016 Spine Surg Case Study #5

Health Plan: BSCA
Cervical Artificial Disc Replacement- CPT 22856

This 37 y/o F has complaints of neck and left arm pain with numbness, weakness and tingling which began 2 years ago and was treated successfully with a C5-6 discectomy one year ago.
She has been seen by a neurologist with EMG studies which have ruled out peripheral neurologic disease including carpal tunnel syndrome.

She has been treated with physical therapy and medications for the last 3 months and has seen her specialist on 4 occasions, however her left upper extremity radicular symptoms have exacerbated.

Physical examination revealed full ROM of the cervical spine with 4-/5 weakness of the left wrist extensors and shoulder external rotators with numbness in the C6 distribution. Reflexes are normal.

Recent MRI shows recurrent HNP Left C5-6 with neural foraminal compromise. The levels above and below are unremarkable.

Surgeon is requesting a single level ADR @ C5-6.

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