What is the best management approach for an elderly patient with severe stenosis of the spinal canal and deformation of the spinal cord due to osteophyte formation?

Management of Severe Cervical Spinal Stenosis with Cord Deformation in Elderly Patients

Surgical decompression with fusion is the recommended treatment for elderly patients with severe cervical spinal stenosis causing spinal cord deformation, as this approach provides superior long-term outcomes for neurological recovery, pain relief, and quality of life compared to decompression alone. 1, 2

Immediate Assessment and Risk Stratification

Clinical Evaluation

• Assess for myelopathy signs including gait disturbances, balance problems, fine motor skill deterioration in hands, and bowel/bladder dysfunction 1, 2
• Quantify neurological function using the modified Japanese Orthopaedic Association (mJOA) scale, as severity correlates directly with treatment outcomes 1, 2
• Evaluate for progressive neurological deficits, which mandate immediate surgical intervention 1, 2

Imaging Confirmation

• MRI is the gold standard for evaluating both the osseous spinal column and spinal cord 3, 2
• Look for T2 hyperintensity (cord signal changes) on MRI, which indicates myelopathy and predicts worse outcomes if left untreated 1
• T1 hypointensity combined with T2 hyperintensity at the same level predicts particularly poor outcomes without intervention 1
• Spinal cord atrophy with transverse area <45 mm² may predict poor surgical prognosis but does not contraindicate surgery 1

Surgical Indications in This Population

Surgery is strongly indicated for patients presenting with:

• Progressive neurological deficits 1, 2
• Cord signal changes or syringomyelia on MRI 1, 2
• Severe and/or long-lasting symptoms 1
• Documented spinal cord deformation (as in this case) 1

The natural history without intervention is concerning: untreated severe cervicomedullary compression carries a 16% mortality rate, and prolonged severe stenosis leads to demyelination of white matter with potentially irreversible neurological deficits 1, 2

Surgical Approach Selection

For Multilevel Cervical Disease (≥4 segments)

Posterior laminectomy with fusion is recommended for extensive disease involving 4 or more segments 1

• This approach showed significantly greater neurological recovery (2.0 Nurick grade improvement) compared to anterior approaches (1.2 grade improvement) or laminectomy alone (0.9 grade improvement) 1

For Limited Disease (1-3 levels)

Anterior decompression and fusion (ACDF) is appropriate for 1-3 level disease 1

Critical Surgical Principle

Fusion must be included with decompression because:

• Fusion prevents iatrogenic instability that occurs after extensive decompression 1
• Long-term outcomes favor fusion over decompression alone 1
• Laminectomy alone is associated with higher risk of reoperation due to restenosis, adjacent-level stenosis, and postoperative spinal deformity 1
• 29% of patients experience late deterioration after laminectomy without fusion 1

Expected Outcomes

Approximately 97% of patients experience some recovery of symptoms after appropriate surgical intervention 1, 2

• Decompression with fusion provides better long-term outcomes for pain relief, functional improvement, and quality of life 1, 2
• Significant improvement in neurological function can be expected from surgical decompression with fusion 1

Critical Pitfalls to Avoid

Do Not Delay Surgery

• The disease course involves slow, stepwise decline with potential for rapid deterioration 1, 2
• Long periods of quiescence do not guarantee stability 2
• Multisegmental high signal changes on T2-weighted MRI predict poor surgical outcome but do not contraindicate surgery 1

Do Not Perform Decompression Alone

• Laminectomy without fusion should only be considered in highly selected cases with normal preoperative radiographic alignment and no evidence of instability 1
• Even in these select cases, 29% experience late deterioration 1

Special Consideration in Elderly with Comorbidities

In patients with respiratory distress requiring tracheostomy, posterior decompression and fusion should be performed before any anterior osteophyte excision to avoid implant infection 4

• Patients with cervical stenosis and spinal cord compression may experience spinal cord injury when intervertebral mobility increases even slightly after decompression 4

Preoperative Medical Optimization

Medical evaluation is mandatory in elderly patients with frequent comorbidities 5

• Despite advanced age, elective spinal decompression in elderly patients (65-80 years) is not associated with more serious or life-threatening risks than total hip replacement 6
• The operation is worthwhile for elderly patients suffering significant pain or disability 6