• Washington State Department of Labor and Industries. Review criteria for cervical surgery for entrapment of a single nerve root. Olympia (WA): Washington State Department of Labor and Industries; 2004 Jun. 1 p.

This is the current release of the guideline.

This guideline updates a previous version: Washington State Department of Labor and Industries. Criteria for cervical surgery related to entrapment of a single cervical nerve root. Olympia (WA): Washington State Department of Labor and Industries; 2002 Aug. 1 p.

Entrapment of a single cervical nerve root

Evaluation
Treatment

Neurological Surgery
Neurology
Orthopedic Surgery

Advanced Practice Nurses
Health Care Providers
Health Plans
Hospitals
Physical Therapists
Physician Assistants
Physicians
Utilization Management

To present guidelines for cervical surgery related to entrapment of a single cervical nerve root in the injured worker

The injured worker with entrapment of a single cervical nerve root

Evaluation (Criteria for Surgery)

1. Documentation of failure of patient to improve with conservative care (e.g., physical therapy, medications, cervical traction)
2. Evaluation of subjective clinical findings (sensory symptoms in a dermatomal distribution that correlated with involved cervical level or positive Spurling test)
3. Evaluation of objective clinical findings (motor deficit, reflex changes, positive electromyogram findings)
4. Imaging studies (myelogram with computed tomography [CT] scan, magnetic resonance imaging [MRI])

Surgical Treatment

1. Cervical laminectomy, discectomy, or laminotomy
2. Cervical foraminotomy with or without fusion, excluding fractures

• Benefits of cervical surgery, such as relief of pain, weakness, or sensory loss; return to work; relief of preoperative neurological deficit
• Risks of cervical surgery, such as postoperative complications
• Patient satisfaction

Searches of Electronic Databases

A review of the current medical literature was conducted for prospective randomized trials of cervical discectomy with, or without, fusion; cervical discectomy with fusion and instrumentation; and the effect of smoking on spinal fusion.

Not stated

Not stated

Not applicable

Review

Not stated

Expert Consensus

Consensus development has generally taken place between the permanent members of the subcommittee (orthopedic surgeon, physiatrist, occupational medicine physician, neurologist, neurosurgeon) and ad hoc invited physicians who are clinical experts in the topic to be addressed.

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

External Peer Review
Internal Peer Review

Following input from community-based practicing physicians, the guideline was further refined.

Review Criteria for Cervical Surgery Related to Entrapment of a Single Cervical Nerve Root

¹ Sensory deficit, motor weakness, and reflex changes may vary depending on innervation.

• C4–5 disc herniation with compression of C5 nerve root may produce sensory deficit in the lateral upper arm and elbow; motor weakness in the deltoid and variably in the biceps (elbow flexion); and reflex changes variably in the biceps.
• C5–6 disc herniation with compression of the C6 nerve root may produce sensory deficit in the radial forearm, thumb, and index finger; motor weakness in the biceps, forearm supination, and wrist extension; and reflex changes in the biceps and brachioradialis.
• C6–7 disc herniation with compression of the C7 nerve root may produce sensory deficit in the index and middle fingers; motor weakness in the triceps (elbow extension), wrist flexion, and variably in the finger flexors; and reflex changes in the triceps.

² A selective nerve root block may be considered "positive" if it:

• Initially produces pain in the distribution of the nerve root being blocked, and
• Produces at least 75% reduction in pain for a duration consistent with the type of local anesthetic used for the block.

Abbreviations: CT, computed tomography; EMG, electromyogram; MRI, magnetic resonance imaging

None provided

The type of supporting evidence is not specifically stated for each recommendation.

The recommendations were developed by combining pertinent evidence from the medical literature with the opinions of clinical expert consultants and community-based practicing physicians. Because of a paucity of specific evidence related to the injured worker population, the guideline is more heavily based on expert opinion.

The (surgical) guidelines are meant to increase the proportion of surgical requests authorized for workers who truly require surgery and to decrease the proportion of such authorizations among workers who do not fall within the guideline.

None stated

Current cigarette smoking is a relative contraindication.

• This medical treatment guideline was developed through collaboration with the Washington State Department of Labor and Industries and the Washington State Medical Association (WSMA) Industrial Insurance Advisory Section of the Interspeciality Council. Labor and Industries is solely responsible for coverage decisions that may result from use of this guideline.
• The Office of the Medical Director works closely with the provider community to develop medical treatment guidelines on a wide range of topics relevant to injured workers. Guidelines cover areas such as lumbar fusion, indications for lumbar magnetic resonance imaging (MRI), and the prescribing of controlled substances. Although doctors are expected to be familiar with the guidelines and follow the recommendations, the department also understands that guidelines are not hard-and-fast rules. Good medical judgment is important in deciding how to use and interpret this information.
• The guideline is meant to be a gold standard for the majority of requests, but for the minority of workers who appear to fall outside of the guideline and whose complexity of clinical findings exceeds the specificity of the guideline, a further review by a specialty-matched physician is conducted.
• The guideline-setting process will be iterative; that is, although initial guidelines may be quite liberally constructed, subsequent tightening of the guideline would occur as other national guidelines are set, or other scientific evidence (e.g., from outcomes research) becomes available. This iterative process stands in contrast to the method in some states of placing guidelines in regulation. Although such regulation could aid in the dissemination and quality oversight of guidelines, flexibility in creating updated guidelines might be limited.

Getting Better

Effectiveness

• Washington State Department of Labor and Industries. Review criteria for cervical surgery for entrapment of a single nerve root. Olympia (WA): Washington State Department of Labor and Industries; 2004 Jun. 1 p.

Not applicable: The guideline was not adapted from another source.

1991 May (revised 2004 Jun)

Washington State Department of Labor and Industries - State/Local Government Agency [U.S.]

Washington State Department of Labor and Industries

Washington State Department of Labor and Industries (L&I), Washington State Medical Association (WSMA) Industrial Insurance Advisory Section of the Interspecialty Council

Medical Director, Washington State Department of Labor and Industries (L&I): Gary Franklin, MD

The individual names of the Washington State Medical Association (WSMA) Industrial Insurance Advisory Committee are not provided in the original guideline document.

Not stated

This is the current release of the guideline.

This guideline updates a previous version: Washington State Department of Labor and Industries. Criteria for cervical surgery related to entrapment of a single cervical nerve root. Olympia (WA): Washington State Department of Labor and Industries; 2002 Aug. 1 p.

None available

This summary was completed by ECRI on February 14, 2000. It was sent to the guideline developer for review on February 15, 2000; however, to date, no comments have been received. The guideline developer has given NGC permission to publish the NGC summary. This summary was updated by ECRI on May 27, 2004. The information was verified by the guideline developer on June 14, 2004. This summary was updated again by ECRI on October 20, 2004. The information was verified by the guideline developer on November 5, 2004.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.