What is the appropriate treatment for a patient with degenerative disc disease and moderate to severe canal and foraminal stenosis at C5-6 and C6-7 levels?

Treatment Approach for Multilevel Cervical Degenerative Disease with Moderate to Severe Stenosis

For a patient with moderate to severe canal and foraminal stenosis at C5-6 and C6-7 from degenerative disc disease, surgical decompression with fusion is the definitive treatment when conservative management fails or neurological deficits are present.

Initial Conservative Management

• Conservative treatment should be attempted for at least 6 weeks before considering surgical intervention, including formal physical therapy, anti-inflammatory medications, and potentially epidural steroid injections 1
• Trial of neuroleptic medications (gabapentin or pregabalin) is appropriate for radicular symptoms 2
• Surgery becomes indicated when symptoms persist or progress after optimal conservative management, typically 6 weeks, or when significant neurological deficits develop 1

Critical Red Flags Requiring Urgent Surgical Evaluation

• Myelopathy signs (hand clumsiness, gait disturbance, hyperreflexia, Hoffman's sign, clonus) warrant prompt surgical intervention regardless of conservative treatment duration 3
• Progressive motor weakness or bowel/bladder dysfunction indicates urgent decompression 3
• Spinal cord signal changes on MRI (T2 hyperintensity) represent myelomalacia and predict worse outcomes if surgery is delayed 3

Surgical Approach Selection

For multilevel cervical stenosis at C5-6 and C6-7 with both canal and foraminal involvement:

• Anterior cervical discectomy and fusion (ACDF) at both levels is the standard approach for addressing disc-osteophyte complexes and uncovertebral hypertrophy causing anterior compression 3
• Posterior decompression (laminectomy/laminoplasty) with or without fusion may be considered when stenosis is primarily posterior or involves more than 3 levels 3
• Combined anterior-posterior approaches provide superior decompression for severe multilevel disease with both anterior and posterior compression 2

Specific Technical Considerations

• MRI is the preferred imaging modality to evaluate soft tissue compression, disc pathology, and spinal cord signal changes 3
• CT or CT myelography is useful when MRI is contraindicated or to better assess bony foraminal stenosis from uncovertebral and facet hypertrophy 3
• Flexion-extension radiographs should be obtained to assess for instability, which would favor fusion over decompression alone 1

Expected Outcomes and Complications

• Approximately 88% of surgical lesions are correctly identified preoperatively with MRI in cervical radiculopathy cases 3
• Surgical decompression improves quality of life in approximately 97% of patients with symptomatic stenosis 2
• Common pitfall: Early surgery (within 48 hours) in spinal cord injury without fracture may paradoxically worsen neurological function due to cord edema and reperfusion injury, as demonstrated in illustrative cases where patients developed increased signal changes and worse motor function postoperatively 3

Algorithm for Decision-Making

Step 1: Assess for myelopathy or progressive neurological deficits

• If present → Proceed to surgical planning (do not delay for conservative treatment)
• If absent → Initiate 6-week conservative trial

Step 2: After 6 weeks of conservative management

• Symptoms resolved/improved → Continue conservative care
• Symptoms persistent/worsening → Proceed to surgical evaluation

Step 3: Determine surgical approach based on imaging

• Anterior compression (disc-osteophyte complex) at 1-2 levels → ACDF
• Posterior compression or >3 levels → Posterior decompression ± fusion
• Combined anterior/posterior compression → Consider 360-degree approach

Step 4: Assess for instability

• Instability present on dynamic imaging → Add fusion to decompression
• No instability → Decompression alone may suffice for posterior approaches

Key Caveats

• Degenerative findings on MRI are present in >65% of asymptomatic patients over age 50, so imaging must correlate with clinical symptoms 3
• False-positive and false-negative MRI findings are common in cervical radiculopathy, with poor correlation between imaging and physical examination in some studies 3
• Avoid urgent surgery in acute traumatic spinal cord injury without fracture, as the illustrative case demonstrates potential for neurological deterioration from surgical manipulation of an edematous cord 3
• Patients with congenital canal narrowing are at higher risk for myelopathy from minor trauma and may benefit from prophylactic decompression 3