Treatment of Mild C6-7 Cervical Spinal Stenosis
For patients younger than 75 years with mild cervical spondylotic myelopathy at C6-7 (mJOA score >12), both operative and nonoperative management options should be offered, as objectively measurable deterioration in function is rarely seen acutely over a 36-month period. 1
Initial Conservative Management Approach
Conservative treatment is appropriate as the first-line approach for mild cervical stenosis without progressive neurological deficits. 1 The evidence demonstrates:
Class I evidence shows that in patients under 75 years with mild CSM, nonoperative management associates with stable clinical course over 36 months, with mJOA scores, 10-meter walk times, and activities of daily living assessments typically not worsening. 1
Clinical gains from conservative treatment are maintained over 3 years in 70% of patients with mild disease. 1
Physical therapy for up to 3 months is recommended for patients without significant neurological symptoms. 2
When to Proceed with Surgical Intervention
Operative therapy should be offered when patients have severe and/or long-lasting symptoms, as the likelihood of improvement with nonoperative measures becomes low. 1
Specific surgical indications include:
- Progressive neurological deficits despite conservative management 3
- Cord signal changes on T2-weighted MRI or syringomyelia development 3
- Development of myelopathy symptoms: gait disturbances, balance problems, fine motor skill deterioration, or bowel/bladder dysfunction 3
- Failure of 3-month conservative trial in symptomatic patients 2
Critical Monitoring Parameters
Patients managed conservatively require close neurological monitoring, as the natural history of cervical spondylotic myelopathy is variable with potential for stepwise decline. 1, 3
- Any progression of symptoms, development of cord signal changes, or worsening gait disturbance mandates surgical referral. 3
- Long periods of severe stenosis associate with demyelination of white matter and may result in necrosis of both gray and white matter, leading to potentially irreversible deficits. 1
Important Clinical Pitfalls
Approximately 20% of patients initially managed conservatively ultimately require surgery, highlighting the importance of ongoing assessment rather than assuming stability. 1
Delaying surgery in patients with progressive neurological symptoms risks irreversible neurological damage, as prolonged severe stenosis causes demyelination and potential necrosis. 1, 3
Asymptomatic radiographic stenosis does not require intervention, but symptomatic patients with cord compression and progressive deficits should not be denied timely surgical treatment. 3
Expected Outcomes
- Approximately 97% of patients experience some recovery of symptoms after appropriate surgical intervention for symptomatic stenosis. 3
- Surgical decompression with fusion provides better long-term outcomes for pain relief, functional improvement, and quality of life compared to decompression alone. 3
- For anterior cervical decompression and fusion (ACDF) in 1-3 level disease, significant improvement in neurological function can be expected. 3