RE: Draft Key Questions for Health Technology Assessment of Cervical Spinal Fusion
for Degenerative Disc Disease
Dear Mr. Morse:
The American Association of Neurological Surgeons (AANS), and the Congress of Neurological
Surgeons (CNS), would like to thank you and the Washington State Health Care Authority for the
opportunity to provide comment on the draft key questions regarding Cervical Spinal Fusion for
Degenerative Disc Disease.
KQ1: What is the clinical effectiveness of cervical fusion for DDD with or without spondylosis and/or
radiculopathy relative to that of conservative management approaches and other alternatives?
AANS/CNS Comment: Cervical degenerative disc disease (DDD) is a progressive disorder of the
aging spine. Significant disc deterioration, known as spondylosis, is often asymptomatic in most
individuals; however, some progress to develop neck pain and/ or nerve root (radiculopathy) or spinal
cord (myelopathy) compromise. This Health Technology Assessment (HTA) is proposing to
determine the clinical effectiveness of fusion surgery for cervical DDD relative to that of conservative
management approaches and other alternatives. This question as drafted reflects a
misunderstanding of the role of surgical and non-surgical approaches, posing them as competing
modalities when in fact they are most widely utilized as complementary interventions. Currently, the
primary treatment for most with symptomatic cervical DDD (in the absence of neurologic deficit) is
conservative, non-surgical therapy. Patients that respond satisfactorily to non-surgical therapy with
lasting benefit are not indicated for surgery, and consequently cervical fusion is not considered.
Approximately 45 – 60% of patients with cervical spondylosis have good resolution of symptoms with
non-surgical treatment; yet, it is also clear that the remainder continue with moderate-to-severe pain
[1, 2]. Surgery, as such, is generally reserved for those who have persistent or worsening symptoms
despite exhaustive non-surgical management. It does not stand to reason, therefore, to assess the comparative effectiveness of non-surgical treatment (as proposed by this HTA) in a patient
population that has demonstrated failure to respond.
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