What is the treatment for multilevel spondylotic changes with relative spinal stenosis and cord encroachment?

Treatment for Multilevel Cervical Spondylotic Myelopathy with Cord Compression and Signal Changes

This patient requires urgent surgical decompression and should be referred to a spine surgeon immediately—the presence of gait instability, cord signal changes (suggesting myelomalacia or edema), and multilevel cord compression with effacement represents established myelopathy that will not improve with conservative management and risks permanent neurological deficit if surgery is delayed. 1

Critical Understanding: Why Surgery Cannot Be Delayed

• The likelihood of improvement with nonoperative measures in severe and/or long-lasting cervical spondylotic myelopathy is extremely low, making surgical decompression the definitive treatment 1
• Prolonged severe stenosis causes demyelination of white matter and may progress to necrosis of both gray and white matter, leading to potentially irreversible neurological deficit 1
• The increased T2 signal from C3-5 likely represents cord edema or myelomalacia—intramedullary cord signal changes on MRI represent prognostic factors for neurosurgical outcome and indicate established cord injury 2
• Approximately 97% of patients experience some recovery of symptoms after surgery for cervical stenosis with myelopathy, but outcomes worsen with delayed intervention 1

Surgical Approach Selection

The specific surgical approach depends on the number of levels involved:

• For 1-3 level disease: Anterior cervical decompression and fusion (ACDF) is the appropriate approach 1
• For ≥4-segment disease: Posterior laminectomy with fusion is recommended 1
• This patient has significant pathology at C3-4, C4-5, and C5-6 (3 levels), making anterior decompression and fusion the likely optimal approach 1
• Fusion is essential to prevent iatrogenic instability that can occur after extensive decompression, with long-term outcomes favoring fusion over decompression alone 1

What NOT to Do: Common Pitfalls

Do not delay surgery waiting for "failed conservative management" in a patient with established myelopathy—this represents a critical error in judgment 1

• Conservative management (physical therapy, cervical collars, observation) has no role once myelopathy is established 1, 3
• The natural history of untreated severe cervicomedullary compression carries a mortality rate of 16% 1
• Delaying surgery risks permanent neurological deficit that cannot be reversed even with eventual decompression 1

Specific Imaging Findings That Mandate Surgery

Your patient demonstrates multiple high-risk features:

• Cord encroachment with effacement and deformity at multiple levels indicates mechanical compression requiring decompression 2
• Increased T2 signal (C3-5) suggesting myelomalacia or edema represents established cord injury 2
• Significant bilateral neural foraminal narrowing (C3-4 through C5-6) compounds the cord compression with radicular involvement 4
• The combination of cord compression, signal changes, and clinical symptoms (implied by the imaging request) creates an urgent surgical indication 1

Expected Outcomes with Surgical Treatment

• Significant improvement in neurological function, including gait and balance, can be expected from surgical decompression with fusion 1
• Approximately 97% of patients have some recovery of symptoms after surgery 1
• Earlier intervention correlates with better outcomes—younger patients and those with mild disability more frequently achieve no-disability status 2

Contraindications to Surgery

The only exceptions to surgical recommendation are:

• Patients in whom surgery is contraindicated by severe comorbid conditions that make anesthesia prohibitively dangerous 2
• Patients with motor neuron disease misdiagnosed as cervical myelopathy (requires careful diagnostic evaluation including EMG) 5

Timeframe for Referral

Immediate referral to a spine surgeon is mandatory—this is not a "routine" or "semi-urgent" referral 1, 3

• The presence of cord signal changes and multilevel compression with effacement represents established myelopathy requiring urgent attention 1
• Prompt referral is recommended for any patient suspected of having cervical spondylotic myelopathy due to the long-term disability that results from delayed diagnosis and management 3