Lauren Matteini, MD, now approaches many cervical spine cases by trying to disqualify the operation she would prefer to perform. The operation is cervical disc replacement.
“In my practice now, I’m trying to find a reason not to do it,” Dr. Matteini, a spine surgeon at Geneva, Ill.-based Fox Valley Orthopedics, told Becker’s. “I’m an arthroplasty until you prove to me otherwise that you need a fusion.”
That reversal captures how dramatically cervical spine surgery is changing.
For decades, fusion was the familiar answer to a damaged cervical disc: remove the diseased tissue, stabilize the segment and eliminate motion. Cervical disc replacement was the narrower alternative, reserved for carefully selected patients who fit a relatively limited profile.
Dr. Matteini still performs fusions, and some patients unquestionably need them. But she believes the burden of proof has shifted. The question is no longer whether a patient is an unusually good candidate for motion preservation. It is whether the anatomy gives her a compelling reason to sacrifice motion at all.
The patients moved first
Dr. Matteini does not believe surgeons alone drove cervical disc replacement into the mainstream. Patients did. They now arrive in her office having researched arthroplasty, read about motion preservation and compared it with fusion. Many are seeking a second opinion after another surgeon has already recommended fusion.
“They’re oftentimes coming in asking whether or not they’re a candidate for an arthroplasty or replacement,” she said. “Then when I say yes, they’ll say, ‘Well, why didn’t that surgeon offer it to me?'” That question is becoming more common as patients gain access to information that was once largely confined to medical meetings and journal articles.
The dynamic has changed the clinical encounter. Patients are no longer only asking whether surgery will relieve their symptoms. They are asking which operation preserves more of the spine they have, what the long-term trade-offs may be and whether a permanent fusion is truly necessary.
For Dr. Matteini, that pressure has been constructive. Patients, she said, are “driving the forces behind us doing better for them.”
Selection is becoming less about the patient’s profile
As confidence in cervical arthroplasty has grown, patient selection has become less about fitting someone into a narrow demographic category and more about reading the anatomy correctly. Dr. Matteini begins with imaging.
One clear contraindication is spondylolisthesis, or abnormal translation at the disc space. Restoring motion to a segment that is already moving abnormally could worsen instability rather than solve it. Another concern is substantial posterior compression from a thickened ligamentum flavum. In some patients, reducing motion through fusion may allow that tissue to remodel. Preserving motion could leave the spinal cord compressed from behind.
That distinction is particularly important in patients with myelopathy. Many patients with spinal cord compression can still qualify for cervical disc replacement, Dr. Matteini said, provided the imaging does not show significant compression from both the front and back.
The evolution is subtle but important. Cervical arthroplasty is no longer being framed as an option only for a small group of ideal patients. In Dr. Matteini’s practice, it is the starting point until instability, posterior compression or another anatomic finding makes fusion more appropriate.
The bridge she does not want to burn
Motion preservation does not guarantee permanent motion. Some cervical artificial discs eventually develop bone growth around the segment and auto-fuse. Dr. Matteini has seen that happen, including in patients who underwent two-level arthroplasty and later maintained motion at one level while the other fused naturally.
Critics can point to those cases and ask why the surgeon did not simply perform a fusion from the beginning. Dr. Matteini asks the opposite question.
“Why would you burn that bridge up front?” she said. Even when a segment eventually auto-fuses, the patient may have preserved motion for years before that occurs.
Those years still matter. The patients she has followed after auto-fusion are not necessarily returning because the original operation failed. They may have muscular neck pain or unrelated symptoms, while the radiculopathy that brought them to surgery remains resolved.
“They had several years of continued asymptomatic function,” she said. That experience has reinforced her belief that a possible fusion later does not erase the value of motion today. Her goal is not motion preservation at any cost. It is avoiding an irreversible decision before the patient’s anatomy requires it.
The system still pays more for fusion
The clinical shift toward cervical disc replacement is colliding with a reimbursement system built around a different era of spine surgery. Dr. Matteini said fusion is generally reimbursed more favorably than arthroplasty.
“It takes me less time to do an arthroplasty than it would to do a fusion because there are fewer steps,” she said. “But I am not rewarded for being efficient, and I am not rewarded for doing the right thing.”
The tension is not merely theoretical. A young patient with a disc extrusion and severe radiculopathy may be an excellent candidate for disc replacement. Dr. Matteini can preserve motion, perform the operation efficiently and potentially reduce long-term concerns associated with fusing the segment.
The payment, however, may still favor fusion. She does not believe most surgeons select operations solely for financial reasons. But she does believe the incentives are strong enough to influence the system.
“There are doctors out there who will look at that and say, ‘I have to do more disc arthroplasties to get reimbursed for one fusion,'” she said. Patients are becoming more alert to those conflicts, she said. Payers have been slower to respond.
The patients insurers still exclude
Dr. Matteini sees some of the greatest untapped potential in patients who already have fused levels. A patient may have undergone cervical fusion years before disc replacement became widely available. If adjacent segment disease later develops, preserving motion at the new diseased level may be especially valuable.
Yet obtaining approval for arthroplasty next to a prior fusion can be difficult. The same is true for patients with congenital fusion. Even when the level requiring treatment is several segments away, the presence of a congenital fusion can trigger a denial.
“There are a lot of insurance company red flags and red tape and hoops to jump through,” Dr. Matteini said. She hopes payers will become more receptive to arthroplasty in previously fused or auto-fused patients, as well as to hybrid constructs that combine fusion and disc replacement in the same operation.
A patient with two diseased levels may not need the same solution at both. One segment may be unstable and require fusion. The adjacent level may remain stable enough for arthroplasty. A hybrid operation allows the surgeon to treat each level according to its pathology instead of forcing the entire cervical spine into one category.
The next expansion
Dr. Matteini believes the next five years will be defined less by a new artificial disc than by broader permission to use the existing concept. Hybrid constructs. Arthroplasty adjacent to a previous fusion. Three-level replacements. Possibly even four-level procedures in carefully selected patients.
She is cautious about the last category.
“I’m not a huge fan of doing four levels,” she said. “I think that’s a lot of surgery for that patient.” But she also questions whether a four-level fusion is the better alternative. Achieving reliable fusion across four disc spaces places substantial demands on the patient’s biology and carries its own risks.
“Doing four-level arthroplasty is probably better than doing a four-level fusion for a patient,” she said. “Asking four discs to fuse in the same setting is a big setup for disaster, given the literature we have.”
The future she envisions is not arthroplasty for everyone. It is greater freedom to build the operation around each level rather than around insurance rules or historical precedent.
A second opinion before an irreversible decision
Dr. Matteini gives patients one piece of advice regardless of which operation she recommends. Get another opinion when the plan does not make sense to you. She applies that principle to her own recommendations as well.
“If they’re not sure about the plan that they’ve been provided, even in my hands, it’s always great to get a second opinion,” she said. That advice carries additional weight when the choice is between preserving motion and permanently eliminating it.
Fusion remains one of the most successful and necessary operations in cervical spine surgery. For patients with instability, deformity or certain patterns of compression, it may be the safest and most durable option.
But it is no longer the automatic answer. Patients know more. Long-term arthroplasty data has matured. Surgeons have grown more confident. Selection has become more anatomically precise. What has not evolved as quickly is the system surrounding the operation.
Dr. Matteini believes cervical disc replacement’s next chapter will depend on whether reimbursement and coverage rules catch up with the clinical shift already underway. Until then, the most important question may be the one more patients are beginning to ask after being told they need a fusion: Was motion preservation considered first?
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
