Yes, you should be concerned about cervical myelopathy and need prompt neurosurgical evaluation.
Your combination of ventral cord flattening at C5-6, hyperreflexia, brisk reflexes, and urinary hesitancy (even if improved) represents clinical myelopathy that warrants urgent specialist assessment and likely surgical intervention.
Why This Matters
Your presentation fits the classic pattern of cervical spondylotic myelopathy (CSM), which is the most common form of spinal cord injury in adults 1. The key issue is that you have both structural compression (ventral cord flattening) AND clinical signs of spinal cord dysfunction (hyperreflexia, brisk reflexes, urinary symptoms) - this combination is highly significant.
The Critical Evidence
Research demonstrates that no patients without cord compression presented with myelopathy on examination 2. Conversely, when cord compression is present (as in your case with ventral flattening), 84% of patients show myelopathic signs 2. You are clearly in this group.
The absence of T2 signal changes does NOT mean you're safe. While hyperintense T2 signal in the cord correlates with more severe disease and worse prognosis 3, 2, approximately 21% of surgically-confirmed myelopathy patients have NO myelopathic signs on examination 4, and many have normal cord signal. Your normal signal is actually somewhat reassuring prognostically, but it doesn't exclude the diagnosis.
What Your Symptoms Mean
Upper Motor Neuron Signs
- Hyperreflexia and brisk reflexes are classic long-tract signs indicating spinal cord compression at the cervical level 3
- These findings localize the problem to your cervical cord, not your brain or lower spine
Urinary Hesitancy
- Bladder dysfunction is a red flag symptom in cervical myelopathy 5, 6
- Even though it improved, this indicates the cord compression has already affected autonomic pathways
- This can be an early warning sign before more severe, irreversible deficits develop
The Ventral Cord Flattening
- This represents mechanical compression of your spinal cord 3
- In the chronic/progressive setting, extrinsic compression is most commonly due to degenerative disease (spondylotic myelopathy) and is most prevalent in the cervical spine 3
- Factors include disc herniations, osteophyte complexes, and malalignment 3
Why You Need Urgent Action
Natural History is Unpredictable
CSM develops insidiously and progresses variably between patients 1. Some remain stable, but others deteriorate rapidly. The hallmark symptoms include decreased hand dexterity and gait instability 1 - watch for these carefully.
Window of Reversibility
Intramedullary cord signal changes on MRI represent prognostic factors for neurosurgical outcome 3. Your normal signal suggests you're earlier in the disease process, which means:
- Better potential for recovery with intervention
- Less irreversible cord damage (myelomalacia/gliosis) has occurred 3
- This is the optimal time to intervene, not after signal changes develop
Risk of Permanent Disability
Long-term disability may result from delay in diagnosis and management 1. Once significant cord damage occurs (visible as T2 hyperintensity), outcomes worsen substantially 2, 7.
What You Should Do Now
1. Immediate Referral to Spine Surgeon
Prompt referral to a spine surgeon is recommended for any patient suspected of having CSM 1. This means neurosurgery or orthopedic spine surgery, not just general neurology.
2. Complete MRI Evaluation
You need comprehensive cervical spine MRI if not already done 3:
- MRI is the imaging modality of choice for suspected CSM 1
- Should include T1, T2, and ideally diffusion-weighted imaging sequences 3
- Contrast is typically not required for spondylotic myelopathy but may be added 3
3. Monitor for Progressive Symptoms
Watch carefully for:
- Hand clumsiness or decreased dexterity (difficulty with buttons, writing, picking up small objects)
- Gait instability or wide-based walking
- Worsening bladder/bowel function
- Weakness in arms or legs
- Sensory changes (numbness, tingling)
Any progression of these symptoms requires immediate evaluation.
Treatment Considerations
Surgical vs. Conservative Management
According to recent AO Spine guidelines 8, 9, 7:
- Patients with mild CSM may be treated surgically or nonoperatively
- Moderate-severe disease requires operative treatment 1
- Surgery is a valid option even for mild DCM with favorable outcomes 7
Your clinical picture (hyperreflexia + urinary symptoms + cord compression) suggests you're beyond "observation only" territory. The spine surgeon will determine severity and optimal timing.
Surgical Options
If surgery is recommended, choices depend on compression pattern 8:
- Anterior approach (ACDF/ACCF) for focal anterior compression
- Posterior approach (laminoplasty/laminectomy) for multilevel or posterior compression
- Decision based on sagittal alignment, number of levels, and specific anatomy
Common Pitfalls to Avoid
- Don't wait for symptoms to worsen - CSM can progress unpredictably, and recovery potential decreases with delay
- Don't assume normal cord signal means no myelopathy - 21% of surgical myelopathy patients lack obvious signs 4
- Don't dismiss improved urinary symptoms - this was a warning sign that cord function was already compromised
- Don't delay imaging or specialist referral - MRI is essential and spine surgery consultation should be prompt 1
Bottom Line
You have objective evidence of cord compression (ventral flattening) plus clinical signs of myelopathy (hyperreflexia, urinary dysfunction). This combination requires neurosurgical evaluation regardless of normal cord signal. The absence of T2 signal changes is actually favorable for surgical outcomes if intervention is needed, but it doesn't mean you can safely observe without specialist input. Get the referral now while you're in the window for optimal recovery.