Management of Multilevel Cervical Spinal Stenosis with Compressive Myelopathy
This patient requires urgent surgical decompression with fusion given the presence of T2 hyperintensity cord signal changes indicating compressive myelopathy at multiple levels. 1
Immediate Surgical Referral is Mandatory
Surgical intervention is indicated for any patient with cord signal changes on T2-weighted MRI or syringomyelia, regardless of symptom severity. 1 The presence of T2 hyperintensity in the right hemicord at C3-C4 represents demyelination and spinal cord injury that will become irreversible if left untreated. 1, 2
Why Surgery Cannot Be Delayed
- Untreated severe cervicomedullary compression carries a 16% mortality rate. 1, 2
- Long periods of severe stenosis lead to demyelination of white matter and potentially irreversible neurological deficits. 1, 2
- The natural history shows stepwise decline with periods of quiescence that do not guarantee stability—meaning current mild symptoms can rapidly deteriorate. 1, 3
- Surgical decompression reliably arrests myelopathy progression and often improves neurological deficits, with approximately 97% of patients experiencing some symptom recovery. 1, 4
Recommended Surgical Approach
Decompression with instrumented fusion provides superior long-term outcomes compared to laminectomy alone. 1
Specific Technical Considerations
- Multilevel involvement (C3-C4, C4-C5, C5-C6, C6-C7) requires comprehensive decompression addressing all stenotic levels to prevent progression. 1
- Laminectomy alone carries higher reoperation risk due to restenosis, adjacent-level stenosis, and postoperative spinal deformity (18% reoperation rate). 5, 1
- Instrumented fusion after decompression prevents kyphotic progression and provides better pain relief, functional improvement, and quality of life. 5, 1
- The straightened cervical lordotic curvature increases the indication for fusion to restore proper alignment and prevent postoperative kyphosis. 3
Preoperative Assessment
Quantify Neurological Function
- Use the modified Japanese Orthopaedic Association (mJOA) scale to objectively measure myelopathy severity, as this correlates with treatment outcomes. 1
- Document specific deficits: gait disturbances, fine motor deterioration in hands, bowel/bladder dysfunction, upper/lower extremity weakness. 1, 2
Confirm Imaging Findings
- The T2 hyperintensity at C3-C4 with cord contour deformity confirms active myelopathy requiring intervention. 6
- Gadolinium enhancement localized to the level of maximum compression (rather than extensive enhancement) distinguishes compressive myelopathy from inflammatory myelitis. 6
- Multiple levels of moderate-to-severe neural foraminal stenosis may contribute to radicular symptoms but the myelopathy takes priority. 7
Critical Pitfalls to Avoid
Do not attempt conservative management or epidural steroid injections in patients with cord signal changes. 1 While epidural injections may be appropriate for radicular symptoms from foraminal stenosis, they do not address spinal cord compression and will delay definitive treatment. 7
Do not wait for symptom progression. The presence of T2 cord signal changes is an absolute indication for surgery even if symptoms are currently mild, as irreversible cord damage is already occurring. 1, 2
Do not misinterpret the T2 hyperintensity as transverse myelitis. The localized gadolinium enhancement at the compression site (rather than extensive enhancement) and the gradual progressive course distinguish compressive myelopathy from inflammatory conditions. 6