Cervical spinal fusion for degenerative disc disease
Policy context
Degenerative disc disease (DDD) of the cervical spine is a common phenomenon. Despite the increase in the frequency of fusion surgery, there are many unanswered questions regarding its place in the treatment of cervical DDD, including the optimal technical approach, identification of patient subgroups likely to benefit from fusion surgery, need for repeat surgery, long-term benefit relative to conservative management, and the likelihood of long-term complications.
Status: Decision completed
Lumbar fusion: degenerative disc disease was first reviewed by the HTA program in 2008 under the title "Discography".
- In 2012, a review of lumbar fusion medical literature was performed to determine if newly available published evidence could change the original coverage determination. The technology was not selected for rereview.
- In 2015, the HCA director selected lumbar fusion for rereview based on newly available published evidence.
Primary criteria ranking
- Safety = Medium
- Efficacy = High
- Cost = High
- Documents
Assessment timeline
- Draft key questions published: September 21, 2012
- Public comment period: September 21 to October 5, 2012
- Draft report published: January 10, 2013
- Public comment period: January 10 to February 14, 2013
- Final report published: February 18, 2013
- HTCC public meeting: March 22, 2013
Background
Degenerative disc disease (DDD) of the cervical spine is a common phenomenon; MRI studies have documented the presence of DDD in 60% of asymptomatic individuals aged greater than 40 years. Use of the term "disease" to describe this condition is something of a misnomer, however, as disc degeneration (dehydration and shrinkage) is a natural consequence of aging, and many individuals never develop overt symptoms. In others, however, DDD is accompanied by spondylosis, which is characterized by the development of osteoarthritis and bone spurs which may in turn cause general stiffness and pain. In still other patients, radiculopathy may be seen, in which specific impingement of the nerve root of the cervical spine occurs, causing pain, numbness, and tingling in the neck and extremities. Importantly, many patients experience cervical pain without imaging or other evidence of radiculopathy or spondylosis; in most of these "nonspecific" cases, no anatomic cause can be identified.
Multiple treatment options are available for symptoms associated with DDD, including so-called "conservative" measures such as physical and exercise therapy, spinal manipulation, alternative therapies, and medication; minimally-invasive procedures such as spinal injections and radiofrequency ablation; and surgical intervention. The most common surgical procedure performed is spinal fusion, which involves removal of the damaged disc(s) and creation of a permanent connection across the vertebral space by means of a graft. The use of cervical fusion procedures is increasing; national survey data indicate an 8-fold increase in cervical fusion surgeries from 1990 to 2004 and a 28-fold increase among those 65 and older.