Review criteria for cervical surgery for entrapment of a single nerve root.

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

Procedure	Conservative Care	Clinical Findings
			Subjective		Objective		Imaging
Cervical Discectomy Laminectomy Laminotomy Foraminotomy With or Without Fusion Excluding Fractures	6–8 weeks of: Physical therapy OR Medications OR Cervical traction	AND	Sensory symptoms in a dermatomal distribution that correlates with involved cervical level¹ OR Positive Spurling test	AND	Motor deficit OR Reflex changes OR Positive EMG Changes should correlate with involved cervical level	AND	Abnormal imaging that correlates nerve root involvement with subjective and objective findings, on: Myelogram with CT scan OR MRI
	A positive response to Selective Nerve Root Block² that correlates with imaging abnormality is required if there are complaints of radicular pain with no motor, sensory, reflex, or EMG changes.
Cases to be referred for physician review include: Repeat surgery at the same level Request for surgery at the C3–4 level or above Objective findings indicating myelopathy
When requesting authorization for decompression of multiple nerve roots levels, each level is subject to the criteria.

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

Brief Summary