What is the initial management for a patient with cervical stenosis and gait disturbance?

Initial Management of Cervical Stenosis with Gait Disturbance

For patients with cervical stenosis presenting with gait disturbance, surgical decompression should be strongly considered as the primary treatment, as gait disturbance represents a manifestation of cervical myelopathy indicating significant cord compression that warrants intervention. 1

Why Gait Disturbance Demands Urgent Attention

Gait disturbance in the context of cervical stenosis is a red flag symptom indicating cervical myelopathy—compression of the spinal cord itself. This is distinct from simple radiculopathy and carries serious implications:

• Gait disturbance represents cord compression and myelopathy, which is a progressive neurological condition that can lead to irreversible deficits if left untreated 1, 2
• Long periods of severe stenosis cause demyelination of white matter and potentially irreversible necrosis of both gray and white matter, making early intervention critical 3, 1
• Untreated severe cervicomedullary compression carries a 16% mortality rate 1
• Gait analysis shows progressive deterioration: as myelopathy worsens, patients develop decreased stride length, reduced swing phase, slower gait speed, increased step width, and prolonged double support duration 2

Clinical Assessment Priorities

Before determining the treatment approach, specific clinical features must be documented:

• Severity of myelopathy: Use the modified Japanese Orthopaedic Association (mJOA) scale to objectively quantify neurological function 3
• Upper extremity involvement: Look for fine motor skill deterioration in hands, weakness, and hyperreflexia 1, 4
• Lower extremity motor function: Document ability to ascend/descend stairs without support, as this correlates with severe myelopathy 2
• Bowel or bladder dysfunction: This indicates advanced disease requiring urgent intervention 1
• Duration and progression of symptoms: Severe and/or long-lasting symptoms have low likelihood of improvement with nonoperative measures 3

Imaging Confirmation

• MRI is essential to confirm cord compression and assess for cord signal changes on T2-weighted images, which indicate myelopathy and predict worse outcomes 1
• Cord signal changes or syringomyelia on MRI are absolute indications for surgical intervention 1

Treatment Algorithm

For Patients with Gait Disturbance (Indicating Myelopathy):

Surgical decompression is the recommended treatment because:

• Gait disturbance indicates symptomatic myelopathy with progressive neurological deficits, which is an indication for surgery 1
• Approximately 97% of patients have some recovery of symptoms after surgery 1
• Decompression with fusion provides better long-term outcomes for pain relief, functional improvement, and quality of life compared to laminectomy alone 1
• Laminectomy alone carries higher risk of reoperation due to restenosis, adjacent-level stenosis, and postoperative spinal deformity 1

Limited Role for Conservative Management:

Conservative management may only be considered in highly selected cases:

• Younger patients (< 75 years) with mild CSM (mJOA score > 12) and minimal gait disturbance may be offered both operative and nonoperative options, as objectively measurable deterioration is rarely seen acutely in this specific subgroup 3
• However, clinical gains after nonoperative treatment are maintained over 3 years in only 70% of cases, meaning 30% will deteriorate 3
• The natural history is variable with stepwise decline, and long periods of quiescence do not guarantee stability 3, 1

When Conservative Management is Attempted:

If the patient has truly mild disease (mJOA > 12, age < 75, minimal gait disturbance):

• Close neurological monitoring is mandatory with serial examinations
• Cervical interlaminar epidural steroid injections may provide temporary symptom relief for radicular pain components, but do not address the underlying cord compression 5
• Any progression of gait disturbance or development of cord signal changes mandates surgical referral 1

Critical Pitfalls to Avoid

• Do not mistake gait disturbance from cervical myelopathy for lumbar stenosis or Parkinson-like disorders—cervical stenosis can present with lower extremity symptoms and gait problems that mimic lumbar disease 6, 7
• Do not delay surgery in patients with cord signal changes, as this indicates established myelopathy with risk of permanent deficit 1
• Do not assume asymptomatic radiographic stenosis requires intervention—only symptomatic patients with progressive deficits need surgery 1
• Consider tandem cervical and lumbar stenosis (occurs in 3.4% of spinal stenosis cases), as both may contribute to gait disturbance and require coordinated surgical planning 6

Surgical Approach Selection

Decompression with fusion is preferred over laminectomy alone to minimize long-term complications and reoperation rates 1