How to explain and treat X-ray results showing mild to moderate degenerative changes and anterior fusion of C5-C6 without evidence of acute fracture?

Explaining X-ray Results to Patient

Your X-ray shows degenerative changes in your cervical spine (neck arthritis) with a previous fusion at C5-C6 that appears intact, and importantly, there is no fracture or acute injury requiring immediate intervention. 1

Patient-Friendly Explanation

• Previous Surgery Status: The fusion hardware at C5-C6 from your prior surgery is intact and well-positioned, with no evidence of loosening or failure 1

• Degenerative Changes: You have mild to moderate "wear and tear" arthritis affecting multiple levels of your neck, which includes:

  • Disc space narrowing (the cushions between vertebrae are thinner)
  • Facet joint enlargement (the small joints in the back of your spine show arthritis)
  • These changes are common and do not necessarily correlate with symptom severity 1

• No Acute Injury: There is no fracture or bone break, and your spine alignment is normal without any slippage of vertebrae 1

• Limitations of X-rays: X-rays cannot fully evaluate soft tissues, ligaments, or disc problems—if your symptoms persist or worsen, advanced imaging (CT or MRI) may be needed 1

Treatment Algorithm

Initial Conservative Management (First-Line for All Patients)

Conservative treatment should be attempted first unless severe or progressive neurological deficits are present. 2

• Activity Modification: Maintain normal activity rather than bed rest, which is more effective for neck pain 2

• Pharmacologic Management:

  • Neuropathic pain medications (gabapentin, pregabalin) for radicular symptoms, as simple analgesics respond poorly 2
  • NSAIDs for axial neck pain
  • Opioids only with strict restrictions: lowest dose, shortest duration, close monitoring due to lack of long-term benefit and significant harm potential 2

• Physical Therapy: Structured exercise program focusing on cervical stabilization and range of motion 2

• Duration: Trial conservative management for 6-12 weeks before escalating 2

Escalation for Persistent Symptoms

• Image-Guided Epidural Steroid Injections: For persistent radicular symptoms despite initial conservative therapy (fluoroscopy or CT guidance essential—never blind injections) 2

• Advanced Imaging Indications:

  • Persistent symptoms after 6-12 weeks of conservative management
  • Progressive neurological deficits
  • Severe radicular pain unresponsive to conservative care
  • CT is the most sensitive and specific modality for assessing fusion status and hardware complications 1, 3
  • MRI for evaluating soft tissue pathology, disc herniation, or neural compression 1

Surgical Consideration Criteria

Surgery is indicated ONLY when there is radiographic confirmation of specific pathology correlating with clinical symptoms. 3

Indications for Surgical Intervention:

1. Adjacent Segment Disease: New symptomatic compression above or below the fusion with:

   • Radiographic stenosis on MRI/CT
   • Correlating radiculopathy or myelopathy
   • Failed conservative management (minimum 6-12 weeks) 1, 2

2. Hardware Failure: Documented on CT showing loosening, fracture, or migration 1, 3

3. Pseudarthrosis: Radiographic nonunion with persistent symptoms, though this requires CT confirmation showing motion >4° on flexion-extension or lack of bridging trabeculation 1, 3

4. Progressive Neurological Deficits: Myelopathy or severe radiculopathy with objective findings 2

Critical Pitfall to Avoid:

Do NOT proceed with surgery based on symptoms alone without radiographic confirmation of pathology—imaging findings must correlate with clinical presentation. 3, 2

Surgical Approach Selection (If Surgery Indicated)

For adjacent segment disease or recurrent compression after prior ACDF, posterior revision (laminoforaminotomy) is superior to anterior revision. 2

• Posterior Approach Outcomes:

  • Fusion rates: 94-100% 1, 2
  • Clinical improvement: 77-88% 1, 2
  • Hardware failure: 12% 1, 2
  • Reoperation rate: 2% 1, 2

• Anterior Revision Outcomes (inferior):

  • Fusion rates: 45-76% 1, 2
  • Clinical improvement: 40-59% 1, 2
  • Hardware failure: 45% 1, 2
  • Reoperation rate: 44% 1, 2

Specialist Referral Timeline

• Within 2 weeks: Severe radicular pain or any neurological deficits 2
• Within 3 months: Less severe but persistent symptoms despite conservative management 2

Monitoring and Follow-Up

• Clinical reassessment at 6 weeks, 3 months, and 6 months during conservative management 2
• Repeat imaging only if symptoms progress or new neurological findings develop 1, 3
• Long-term surveillance: Adjacent segment disease can develop years after fusion, with reported reoperation rates of 22.2% at 10 years 1