Treatment of C5-6 Cervical Disk Protrusion with Moderate Central Canal Stenosis and Mild Cord Compression
Initial conservative management is recommended for at least 3 months before considering surgical intervention, as nonoperative treatment achieves approximately 90% success rates in acute cervical radiculopathy. 1
Initial Conservative Management (First-Line)
- Begin with a structured conservative approach including physical therapy, NSAIDs, and activity modification for 3 months, as this achieves favorable outcomes in the majority of patients with cervical radiculopathy 1
- Monitor closely for development of myelopathic signs (gait instability, hand clumsiness, bowel/bladder dysfunction) which would necessitate urgent surgical evaluation 2
- Consider gabapentin (400-800 mg three times daily) for radicular pain management, as it demonstrates superior pain reduction with fewer adverse events compared to pregabalin 3, 4
Indications for Surgical Intervention
Proceed to anterior cervical decompression and fusion if any of the following are present:
- Progressive neurological deficit despite conservative management 1
- Myelopathic symptoms (even subtle lower extremity sensory changes can indicate significant cord compression) 2
- Failure of 3-month conservative trial with persistent radicular symptoms 1
- Moderate-to-severe canal stenosis with documented cord compression on MRI, particularly if symptomatic 5, 2
Surgical Approach
- Anterior cervical decompression and fusion (ACDF) is the standard surgical treatment for this pathology, providing direct decompression of the compressed neural elements 1, 6
- ACDF demonstrates superior outcomes at 3-4 months for pain relief and sensory improvement compared to conservative management, though differences may equalize at 1 year 1
- Stand-alone cervical interbody fusion cages provide effective decompression with good postoperative recovery 2
Critical Diagnostic Considerations
Do not be misled by atypical symptom patterns:
- Lower extremity sensory disturbances can be a false localizing sign of cervical cord compression, potentially leading to inappropriate lumbar-focused treatment 2
- Always obtain complete spine MRI if lower extremity symptoms are present in non-radicular patterns, as concurrent lumbar pathology may distract from the primary cervical lesion 2
- The absence of cord edema on MRI is favorable but does not eliminate the need for treatment if symptomatic compression exists 5
Monitoring and Follow-up
- Reassess within 1 month of initiating conservative management to document symptom progression or resolution 1
- Immediate surgical consultation is warranted if neurological deterioration occurs, as pretreatment ambulatory status is the strongest predictor of postoperative functional recovery 5
- Patients with rapid progression of motor deficits (<14 days) have worse functional outcomes than those with slower progression (>14 days) 5
Key Clinical Pitfalls
Avoid these common errors:
- Do not obtain unnecessary imaging studies beyond cervical spine MRI unless additional symptoms suggest alternative diagnoses 1
- Do not routinely prescribe vestibular suppressants or benzodiazepines, as these are ineffective for cervical radiculopathy 4
- Do not delay surgical intervention in patients with progressive myelopathy, as irreversible neurological deficits can develop 5
- Do not assume lumbar pathology is the primary cause when lower extremity symptoms are present—always evaluate the cervical spine thoroughly 2