What is the best treatment approach for cervical spondylosis with multilevel degenerative disc disease, nerve root compression at C5-C6 and C6-C7 levels, Schmorl’s nodes, and mild chronic compression fractures of C4, C5, C6?

Treatment Approach for Multilevel Cervical Spondylosis with Nerve Root Compression and Chronic Compression Fractures

Primary Recommendation

Begin with a minimum 3-month trial of conservative management including anti-inflammatory medications, neck immobilization, and physical therapy before considering surgical intervention, unless progressive neurological deficits are present. 1, 2

Initial Conservative Management (First-Line Treatment)

The presence of multilevel degenerative disc disease with nerve root compression at C5-C6 and C6-C7, combined with Schmorl's nodes and mild chronic compression fractures, requires initial non-operative treatment unless severe or progressive neurological deficits exist. 1, 3

Conservative therapy should include:

• Anti-inflammatory medications for symptom control 1, 3
• Neck immobilization with cervical collar 4, 2
• Formal physical therapy program with isometric exercises 3, 2
• Activity modification to avoid exacerbating movements 1, 2

Expected outcomes with conservative treatment:

• Approximately 70% of patients with mild-to-moderate cervical radiculopathy maintain stable symptoms or experience slow progression over 3 years with non-operative management 1, 2
• 30-50% of patients with minor neurologic findings improve with neck immobilization alone 3
• Younger patients and those with milder baseline disability have better prognosis 1, 2

Indications for Surgical Intervention

Surgery should be considered when:

• Progressive neurological deficits develop (motor weakness, sensory loss worsening) 1, 2
• Severe or persistent pain unresponsive to 3+ months of conservative treatment 4, 1, 2
• Moderate-to-severe myelopathy is present 1, 2
• Failed conservative treatments with persistent functional impairment 2

Surgical Approach Selection

For Multilevel Disc-Level Compression (C5-C6 and C6-C7)

Anterior cervical discectomy with fusion (ACDF) is the recommended surgical approach for multilevel anterior cervical spine decompression when lesions are located at the disc level. 4, 1

Key technical considerations:

• ACDF and anterior cervical corpectomy with fusion (ACCF) yield similar results for multilevel spine decompression at disc levels 4
• Anterior plate fixation should be used, as it allows for equivalent fusion rates between ACDF and ACCF techniques 4
• If anterior fixation is not used, ACCF may provide higher fusion rates than multilevel ACDF, but carries a higher graft failure rate 4
• Good to excellent outcomes occur in approximately 90% of patients with radiculopathy treated with ACDF 1

Avoiding Laminectomy as Primary Approach

Laminectomy should be avoided for short-segment decompression when ACDF is technically feasible, because laminectomy is associated with late deterioration compared to anterior approaches. 4

While laminectomy provides near-term functional improvement comparable to ACDF, the association with late deterioration makes it a less favorable option for this clinical scenario. 4

Special Considerations for This Case

Chronic Compression Fractures at C4, C5, C6

The presence of mild chronic compression fractures adds complexity to surgical planning. These fractures suggest:

• Pre-existing structural compromise that may affect fusion rates
• Need for careful assessment of bone quality before selecting fusion technique
• Potential requirement for more robust fixation with anterior plating 4

Schmorl's Nodes at C5 and C6

Schmorl's nodes indicate endplate disruption and may:

• Affect graft incorporation and fusion success
• Require attention to endplate preparation during discectomy
• Influence choice of interbody graft material

Clinical Outcomes and Expectations

Surgical outcomes for multilevel cervical spondylosis:

• 70-80% of patients experience long-term improvement with surgical intervention 3
• At 3-4 months post-surgery, patients show significant improvement in pain and sensory dysfunction compared to conservative treatment 4
• However, these differences may dissipate by 12 months, as conservative treatment also produces comparable improvements at that timepoint 4

Important caveat: The recommendation for early surgery (3-4 months) is based on short-term pain relief, but long-term outcomes at 12 months show comparable results between surgical and conservative approaches. 4

Common Pitfalls to Avoid

• Do not proceed directly to surgery without adequate conservative trial unless progressive neurological deficits are documented 1, 2
• Avoid laminectomy as the primary approach for this multilevel disc-level pathology due to late deterioration risk 4
• Do not perform ACDF or ACCF without anterior plate fixation in multilevel cases, as this compromises fusion rates 4
• Ensure adequate imaging correlation with clinical symptoms, as imaging findings may be asymptomatic and require neurologic consultation to rule out other diseases 3

Prognostic Factors

Better surgical outcomes are associated with:

• Younger age 1, 2
• Milder baseline disability 1, 2
• Shorter symptom duration before surgery 2
• Absence of worker's compensation claims 2

Poorer prognosis is associated with:

• Older age 2
• Coexisting psychosocial pathology 2
• Female gender 2