What are the treatment options for a patient with cervical spinal stenosis (CSS) and difficulty with balance and gait?

Treatment of Cervical Spinal Stenosis with Balance and Gait Difficulty

For a patient with cervical spinal stenosis presenting with balance and gait difficulties—indicating moderate to severe cervical spondylotic myelopathy (CSM)—surgical decompression is strongly recommended, as these symptoms represent significant spinal cord compression that will likely progress to irreversible neurological damage without intervention. 1, 2

Understanding the Clinical Significance

Your patient's balance and gait difficulties are hallmark features of cervical myelopathy, not simple radiculopathy 3. This distinction is critical because:

• Gait disturbances and balance problems indicate spinal cord compression (myelopathy), which represents moderate to severe disease 3
• Long periods of severe stenosis lead to demyelination of white matter and potentially irreversible necrosis of both gray and white matter 1, 3
• The natural history shows that with severe and/or long-lasting CSM symptoms, the likelihood of improvement with nonoperative measures is extremely low 1
• Patients with severe myelopathy (modified Japanese Orthopaedic Association [mJOA] score ≤12) show significant improvement after surgical intervention 1

Treatment Algorithm Based on Disease Severity

For Moderate to Severe CSM (Your Patient)

Surgical decompression is the definitive treatment:

• Benefits are maintained for at least 5 years and up to 15 years postoperatively 1, 2
• Approximately 97% of patients experience some recovery of symptoms after surgery 3
• The primary goal is to halt disease progression and prevent irreversible spinal cord damage 4
• Neurological improvement occurs in 97% of patients, with mean JOA scores improving from 12.9 to 15.6 2

For Mild CSM Only (mJOA score >12, age <75 years)

If your patient had only mild symptoms without gait/balance issues, either surgical or nonoperative management could be offered for the short term (3 years) 1:

• Nonoperative options include prolonged immobilization in a stiff cervical collar, "low-risk" activity modification or bed rest, and anti-inflammatory medications 1, 2
• Clinical gains after nonoperative treatment are maintained over 3 years in 70% of mild cases 1

However, this does not apply to your patient with gait and balance difficulties.

Surgical Approach Selection

The specific surgical technique depends on the anatomical pattern of compression:

Anterior Approaches

• Anterior cervical discectomy and fusion (ACDF) is effective for 1-2 level disease 2, 5
• Anterior corpectomy is recommended for 3-segment disease 2
• Subtotal corpectomy with reconstruction can improve neurological scores from an average of 7.9 preoperatively to 13.4 at 15-year follow-up 2
• Ideal for patients with kyphosis or anterior compression from disc-osteophyte complexes 5

Posterior Approaches

• Laminectomy with fusion prevents post-laminectomy kyphosis and is recommended for ≥4-segment disease 2
• Laminectomy with lateral mass fusion resulted in neurological improvement in 97% of patients 2
• Laminoplasty preserves motion and reduces axial neck pain, comparing favorably with anterior corpectomy for neurologic recovery 2, 5
• Laminoplasty has a lower complication rate than corpectomy but higher incidence of postoperative axial symptoms 5

Evidence on Approach Superiority

• Laminectomy with posterior fusion showed significantly greater rates of neurological recovery (average 2.0 Nurick grade improvement) compared to anterior approach (1.2 grade improvement) or laminectomy alone (0.9 grade improvement) 2

Critical Pitfalls to Avoid

Timing-Related Errors

• Delaying surgical intervention in patients with moderate to severe myelopathy leads to irreversible spinal cord damage 2, 3
• Patients with symptoms present for less than one year before surgery show better results across all treatment modalities 2
• Long periods of severe stenosis over many years are associated with demyelination and necrosis leading to potentially irreversible deficit 1

Technical Surgical Errors

• Never perform laminectomy alone (without fusion)—it has a concerning 29% rate of long-term late deterioration and should be avoided 2
• Laminectomy alone is associated with higher risk of reoperation due to restenosis, adjacent-level stenosis, and postoperative spinal deformity 3
• Inadequate stabilization during surgery can lead to cage movement and pseudarthrosis 2
• C5 nerve palsy can develop after surgery, especially when laminae are elevated to an angle >60° 2

Misdiagnosis Pitfalls

• Do not mistake myelopathy for simple radiculopathy—gait and balance problems indicate cord compression, not just nerve root compression 3
• Post-surgical kyphosis occurs in approximately 10% of patients after laminoplasty 2
• Pseudarthrosis can occur in approximately 10.9% of cases after corpectomy 2

Outcome Assessment

Use validated functional outcome measures to track surgical results:

• Modified Japanese Orthopaedic Association (mJOA) scale 1
• Myelopathy Disability Index (MDI) 1
• SF-36 scale 1
• Gait analysis 1

These measures have proven validity and reliability in assessing patients undergoing surgery for CSM 1.