In a patient with a 12‑month history of moderate‑to‑severe cervical foraminal stenosis at C4‑C6 with radiculopathy, failed conservative treatment, new myelopathic signs (clonus, weak Hoffmann’s sign, and abnormal tandem gait), mild cord flattening without frank compression on MRI, and a recent six‑minute walk test showing desaturation to 84 % (autonomic dysfunction), would a typical neurosurgeon proceed with decompression surgery?

Surgical Decompression is Strongly Indicated

Yes, a typical neurosurgeon would proceed with decompression surgery in this patient, and this is the appropriate course of action given the presence of new myelopathic signs despite failed conservative management. The combination of objective myelopathy (clonus, positive Hoffmann's sign, failed tandem gait) with 12 months of failed conservative treatment represents a clear surgical indication, regardless of the degree of cord compression visible on imaging 1.

Key Clinical Decision Points

Myelopathy Trumps Imaging Findings

The presence of clinical myelopathy with objective upper motor neuron signs is the critical factor, not the degree of cord compression on MRI. Your patient demonstrates:

• Clonus (definitive upper motor neuron sign)
• Positive Hoffmann's sign (pathologic reflex)
• Failed tandem gait test (gait disturbance indicating myelopathy)
• Mild cord flattening (structural correlate, even without frank compression)

Guidelines clearly establish that surgery is indicated for patients with myelopathic symptoms when conservative treatment has failed 1. The evidence shows surgical patients with myelopathy perform better in functional status compared to nonoperative management, and patients with severe myelopathy (mJOA <12) demonstrate statistically significant improvement beginning at 6 months and continuing through 24 months after surgical decompression 1.

The 12-Month Conservative Trial is Complete

Your patient has undergone an appropriate trial of conservative management for one year without improvement—in fact, they have progressed from isolated radiculopathy to myelopathy. This progression of neurologic symptoms during conservative treatment is itself an indication for surgery 2. The guidelines note that while acute phase nonoperative management is the mainstay for radiculopathy, surgical decompression is recommended when nonoperative measures have failed 2.

Autonomic Dysfunction as an Additional Surgical Indication

The desaturation to 84% during the 6-minute walk test attributed to autonomic dysfunction is particularly compelling. A 2017 case report documented autonomic dysreflexia caused by cervical stenosis that resolved after anterior cervical decompression and fusion 3. The authors hypothesized that cervical compression disrupts regulatory control of sympathetic preganglionic neurons. While this is a single case report, it suggests that autonomic symptoms may represent another manifestation of cord compromise requiring surgical intervention.

Surgical Approach Considerations

For your patient with C4-C6 foraminal stenosis and radiculopathy plus myelopathy, the surgical approach should address both:

• Anterior cervical decompression and fusion (ACDF) is appropriate for 2-3 contiguous levels with both central and foraminal pathology 4, 5
• The anterior approach effectively addresses both the foraminal stenosis causing radiculopathy and any central stenosis contributing to myelopathy
• Recent practice pattern surveys show consensus for operative management in patients with myelopathy and myelomalacia, and in patients with severe radiculopathy 6

Critical Pitfalls to Avoid

Do not delay surgery based on "mild" imaging findings when clinical myelopathy is present. The disconnect between imaging severity and clinical symptoms is well-recognized in cervical myelopathy. Cord flattening without frank compression can still produce significant myelopathic symptoms, and the primary aim of surgical treatment is to prevent deterioration of neurological deficits 7.

Do not wait for further neurologic deterioration. The evidence shows that patients with established myelopathy benefit from surgery, and delaying intervention risks irreversible spinal cord injury. While mild myelopathy may show equivalency between surgical and nonoperative management at 3 years in some studies 1, your patient has already failed conservative treatment and is showing progression.

The Evidence Hierarchy

The 2009 Journal of Neurosurgery guidelines 1, 2 provide Class I and II evidence supporting surgical intervention for:

• Cervical radiculopathy with failed conservative treatment (rapid relief within 3-4 months) 2
• Myelopathy, particularly when symptoms are progressive or moderate-to-severe 1

More recent survey data from the Cervical Spine Research Society (2025) confirms contemporary practice patterns favor operative management for patients with myelopathy and for those with severe radiculopathy 6, aligning with your clinical scenario.

The combination of objective myelopathy, failed 12-month conservative trial, progressive symptoms, and possible autonomic involvement creates a compelling indication for surgical decompression that most neurosurgeons would act upon.