Is surgery or medication medically indicated for a patient with chronic neck pain, low back pain, and radiculopathy, who has disc herniation, central stenosis, and cord deformity at the C3-C4 and C4-C5 levels, and has not responded to conservative treatments including physical therapy, exercises, anti-inflammatories (Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)), and muscle relaxants?

Surgical Intervention is Medically Indicated for This Patient

Surgery is strongly recommended for this 62-year-old male patient with cervical myelopathy evidenced by cord deformity at C3-C4 and C4-C5 levels, particularly given the failure of conservative treatments and the presence of central stenosis with disc herniation causing cord compression. 1

Critical Clinical Context

This patient presents with cervical pathology requiring urgent surgical consideration, not lumbar pathology. The presence of cord deformity indicates myelopathy, which fundamentally changes the treatment paradigm from conservative management to surgical intervention.

Key Distinguishing Features

• Cord deformity and central stenosis at C3-C4 and C4-C5 represent structural spinal cord compression, which carries risk of permanent neurological injury if left untreated 2
• The cervical spine pathology described (disc herniation with cord deformity) is distinct from simple radiculopathy and requires more aggressive intervention 1
• Central stenosis with cord involvement at these levels tends to be associated with severe myelopathy and requires adequate anterior decompression 2

Evidence Supporting Surgical Intervention

Cervical Myelopathy Requires Surgery

• Anterior cervical discectomy with fusion is the established treatment for C3-C4 and C4-C5 disc herniations causing cord compression and deformity, with studies demonstrating excellent outcomes when adequate decompression is achieved 2
• Cervical disc herniations at these levels that cause cord signal changes (implied by "cord deformity") are associated with severe myelopathy and require surgical decompression 2
• Successful anterior decompression in patients with cervical disc herniation and cord involvement provides excellent outcomes, with correct fusion achieved in the majority of cases 2

Conservative Treatment Has Been Adequately Completed

• The patient has completed appropriate conservative management including physical therapy, exercises, anti-inflammatories, and muscle relaxants 3
• For cervical radiculopathy with myelopathic features (cord deformity), conservative treatment is insufficient and surgery should not be delayed 4
• There is a window of opportunity for treatment in radicular and myelopathic disorders; after this point, neural structural insults may become less reversible 4

Surgical Approach Recommendation

Anterior Cervical Discectomy and Fusion (ACDF)

• ACDF at C3-C4 and C4-C5 via anterior approach is the preferred procedure for central disc herniations with cord compression at these levels 2
• The anterior approach allows direct visualization and adequate decompression of central and large disc herniations that cause cord deformity 2
• Fusion is appropriate given the extent of decompression required and the presence of structural pathology at two contiguous levels 2

Critical Pitfalls to Avoid

• Delaying surgery in the presence of cord deformity risks permanent neurological deficit, as chronic radicular pain and myelopathy may have neural structural insults that become irreversible 4
• Do not confuse this cervical myelopathy case with lumbar stenosis cases where conservative management can be prolonged 3, 5
• The presence of cord signal changes or deformity indicates that the window for optimal surgical outcomes may be closing 4

Medication Considerations

Adjunctive Medical Management

• Neuroleptic medications such as gabapentin or pregabalin (Lyrica) should be considered as part of comprehensive perioperative management for associated radiculopathy 3
• NSAIDs and muscle relaxants have been appropriately trialed but are insufficient for structural cord compression 3
• Patient education regarding the mechanical and chemical components of radiculopathy should be provided, emphasizing that surgical decompression addresses the mechanical compression that conservative measures cannot resolve 4

Expected Outcomes

• Deltoid paralysis and radiculopathy from cervical disc herniation improve significantly with surgical decompression, with studies showing improvement from grade 2.57 to 4.14 post-operatively (p=0.001) 1
• Pain scores improve significantly from 7.64 to 3.21 points on visual analog scale following anterior cervical decompression (p=0.001) 1
• Adequate anterior decompression in cervical disc herniations with cord involvement provides excellent outcomes 2

Contraindication to Conservative Management Alone

• While conservative management is appropriate for lumbar disc herniation and simple radiculopathy 5, 6, 7, the presence of cervical cord deformity represents a surgical emergency that should not be managed conservatively 2
• The natural history of cervical myelopathy is progressive neurological deterioration without surgical intervention, unlike lumbar radiculopathy which often improves spontaneously 6, 4