What is the treatment approach for adult cervical spinal stenosis?

Treatment of Adult Cervical Spinal Stenosis

For symptomatic adult cervical spinal stenosis, surgical decompression with fusion is the treatment of choice, providing superior long-term outcomes for pain relief, functional improvement, and quality of life compared to decompression alone. 1

Indications for Surgical Intervention

Surgery is indicated for patients meeting any of the following criteria:

• Progressive neurological deficits (weakness, gait disturbance, fine motor deterioration) 1
• Cord signal changes on T2-weighted MRI or syringomyelia 1
• Severe and/or long-standing symptoms, as prolonged compression leads to white matter demyelination and potentially irreversible deficits 1
• Symptomatic cervical myelopathy with objective findings on modified Japanese Orthopaedic Association (mJOA) scale 1

The American Academy of Neurological Surgeons emphasizes that asymptomatic radiographic stenosis does not require intervention. 1

Surgical Approach Selection

Decompression with Fusion (Preferred)

Decompression combined with instrumented fusion achieves approximately 97% symptom recovery and provides better long-term stability. 1 This approach is particularly important because:

• Laminectomy alone carries higher reoperation rates due to restenosis, adjacent-level stenosis, and postoperative spinal deformity 1
• Fusion prevents iatrogenic instability that can occur after extensive decompression 2
• Long-term outcomes favor fusion over decompression alone 2

Anterior vs. Posterior Approaches

The choice depends on the number of levels involved and anatomical considerations:

• Anterior decompression and fusion (ACDF) is appropriate for 1-3 level disease 2
• Posterior laminectomy with fusion is recommended for ≥4-segment disease 2
• Laminectomy with posterior fusion showed significantly greater neurological recovery (2.0 Nurick grade improvement) compared to anterior approaches (1.2 grade improvement) or laminectomy alone (0.9 grade improvement) 2

Decompression Alone (Limited Role)

Laminectomy without fusion may be considered only in highly selected cases with:

• Normal preoperative radiographic alignment 2
• No evidence of instability 2
• Awareness that 29% experience late deterioration 2

Conservative Management (Limited Role)

Conservative treatment may be attempted only in:

• **Younger patients (<75 years) with mild myelopathy** (mJOA score >12) and minimal gait disturbance 1
• However, clinical gains are maintained in only 70% of cases over 3 years 1
• Close neurological monitoring is mandatory, and any progression mandates surgical referral 1

Epidural steroid injections may provide temporary relief for radicular symptoms but do not address the underlying cord compression. 3

Critical Pitfalls to Avoid

• Delaying surgery in symptomatic patients: Untreated severe compression carries 16% mortality risk, and prolonged stenosis causes irreversible neurological damage 1, 4
• Inadequate decompression: Too little decompression is a more frequent mistake than too much 5
• Laminectomy without fusion in unstable spines: This leads to high reoperation rates and progressive deformity 1
• Treating lumbar stenosis first in tandem stenosis: When both cervical and lumbar stenosis are present, cervical decompression should be performed first, as treating lumbar stenosis first results in 91% requiring second-stage surgery and dramatic exacerbation of cervical symptoms 6

Expected Outcomes

Surgical decompression with fusion provides:

• 97% symptom recovery rate 1
• Significant improvement in neurological function 2
• Better long-term pain relief and quality of life compared to other approaches 1

The natural history without treatment shows stepwise decline with periods of quiescence, but long-term stability cannot be guaranteed. 1