What is the recommended treatment for a patient with multilevel cervical spondylosis at the C5-C6 level, should they need to see an Orthopedic (Ortho) specialist?

Management of Multilevel Cervical Spondylosis at C5-C6

Yes, referral to an orthopedic spine surgeon or neurosurgeon is necessary for multilevel cervical spondylosis at C5-C6, particularly if there are any signs of myelopathy, progressive neurological deficits, or symptoms persisting beyond 4-6 weeks despite conservative management. 1

Critical Decision Points for Specialist Referral

Immediate Surgical Referral Required If:

• Gait and balance difficulties are present - this indicates established cervical myelopathy (spinal cord compression) requiring urgent surgical evaluation, not simple radiculopathy 2
• Progressive neurological deficits including weakness, hand clumsiness, or deteriorating motor function 1
• Evidence of spinal cord compression on MRI with corresponding clinical symptoms 1
• Persistent severe pain despite 6 weeks of adequate conservative management 1

Conservative Management May Be Attempted First If:

• Mild symptoms without myelopathy (modified Japanese Orthopaedic Association scale score >12) 1
• No neurological deficits - only mechanical neck pain without radicular symptoms 1
• Symptoms present for less than 4-6 weeks 1

Initial Conservative Management (Before Specialist Referral)

For patients without red flag symptoms, attempt conservative treatment for 4-6 weeks: 1

• NSAIDs as first-line pharmacologic treatment for pain and stiffness 1
• Physical therapy focusing on neck stabilization, range of motion exercises, and postural correction 1
• Activity modification and ergonomic adjustments 1
• Home exercise programs which show Level Ib evidence for improving function 1

When to Obtain MRI

MRI should be ordered if: 1

• Symptoms persist beyond 4-6 weeks
• Any neurological symptoms develop (weakness, numbness, gait disturbance)
• Radicular symptoms are present
• Clinical suspicion for myelopathy exists

Critical caveat: MRI has high rates of abnormalities in asymptomatic individuals, so imaging findings must correlate with clinical presentation 1, 3

Prognostic Factors Indicating Need for Surgery

Poor prognostic factors that favor early surgical referral: 1

• Female gender 1
• Older age 1
• Radicular symptoms 1
• Duration of symptoms >1 year 4
• Presence of clinical radiculopathy with cervical stenosis - associated with development of symptomatic cervical spondylotic myelopathy 1

Surgical Approach Selection (For Specialist)

For multilevel disease at C5-C6 specifically: 1, 2

• Anterior approach (ACDF or corpectomy) is preferred for 1-3 level disease 1, 2
• Posterior approach (laminectomy with fusion or laminoplasty) is preferred for ≥4 segments of involvement 1, 2
• Laminectomy with posterior fusion demonstrates significantly greater neurological recovery (average 2.0 Nurick grade improvement) compared to anterior approach (1.2 grade improvement) or laminectomy alone (0.9 grade improvement) 1

Critical Pitfalls to Avoid

Do not delay surgical referral waiting for "failed conservative management" if: 2

• Established myelopathy with gait disturbance is present
• Progressive neurological deficits are occurring
• Long periods of severe stenosis risk demyelination and potentially irreversible spinal cord damage 2

Do not rely solely on imaging findings - spondylotic changes are common in patients >30 years and correlate poorly with neck pain 1, 3

Do not assume all neck pain requires surgery - nearly 50% of acute cervical neck pain cases have residual symptoms at 1 year, but most resolve with conservative measures 1

Expected Outcomes

With appropriate surgical intervention: 2

• Approximately 97% of patients have some recovery of symptoms after surgery for cervical stenosis with myelopathy 2
• Anterior surgical approaches show improvement rates of approximately 73-74% 1
• Younger patients and those with shorter symptom duration typically have better outcomes 4, 1

Natural history without surgery in severe cases: 2

• Untreated severe cervicomedullary compression carries a mortality rate of 16% 2
• Late deterioration occurs in approximately 29% of patients who undergo laminectomy alone without fusion 1