What is the best management option for an elderly patient with severe cervical stenosis, worsening neck pain, and difficulty with gait and balance?

Surgical Decompression is the Best Management

This elderly patient with severe cervical stenosis, worsening symptoms, and gait/balance difficulties should undergo surgical decompression, as the likelihood of improvement with nonoperative measures is extremely low in severe and/or long-lasting cervical spondylotic myelopathy (CSM). 1

Why Surgery is Indicated

The presence of gait and balance difficulties indicates cervical myelopathy, which represents spinal cord compression requiring urgent attention. 2 The combination of:

• Several years of symptoms (chronic, long-lasting disease)
• Progressive worsening over recent months
• Severe stenosis on MRI
• Myelopathic signs (gait/balance impairment)

...creates a clinical scenario where long periods of severe stenosis are associated with demyelination of white matter and may result in necrosis of both gray and white matter leading to potentially irreversible deficit. 1, 2

Why Conservative Options Are Inappropriate

Cervical collar, traction, and physical therapy evaluation are contraindicated in this clinical scenario for several critical reasons:

• Operative therapy should be offered to patients with severe and/or long lasting symptoms, because the likelihood of improvement with nonoperative measures is low. 1
• Gait disturbance represents established myelopathy, not simple radiculopathy, making conservative management futile 2
• The natural history shows that untreated severe cervicomedullary compression carries a mortality rate of 16% 2

Epidural steroid injections are designed for radicular pain management, not for treating myelopathy with cord compression. 3 This patient's primary problem is mechanical spinal cord compression causing myelopathy, which requires surgical decompression—injections cannot decompress the spinal cord. 3

Surgical Approach Selection

The specific surgical technique depends on the number of levels involved and alignment:

• Anterior decompression and fusion (ACDF) is appropriate for 1-3 level disease 2
• Posterior laminectomy with fusion is recommended for ≥4-segment disease 2
• Fusion prevents iatrogenic instability that can occur after extensive decompression, with long-term outcomes favoring fusion over decompression alone 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

Expected Outcomes

Approximately 97% of patients have some recovery of symptoms after surgery for cervical stenosis with myelopathy. 2 Significant improvement in neurological function, including gait and balance, can be expected from surgical decompression with fusion. 2

Critical Pitfall to Avoid

Do not delay surgery waiting for "failed conservative management" in a patient with established myelopathy and gait disturbance. The presence of myelopathic signs (gait/balance problems) with severe stenosis on MRI is itself an indication for surgery. 1, 2 Even minor trauma to the neck can cause irreversible spinal cord changes when marked stenosis is present. 4

The mean time until improvement in balance after surgery is approximately 60 days, with strength recovering around 50 days and numbness around 84 days. 5 However, delaying surgery risks permanent neurological deficit that cannot be reversed even with eventual decompression. 1, 2