What is the best course of treatment for a patient with marked spinal canal stenosis and flattening of the cervical cord?

Surgical Decompression with Fusion is Indicated for Marked Cervical Spinal Stenosis with Cord Flattening

For a patient with marked spinal canal stenosis and flattening of the cervical cord, surgical decompression with fusion should be performed, as this represents symptomatic cervical myelopathy requiring intervention to prevent irreversible neurological deterioration. 1

Rationale for Surgical Intervention

• Cord flattening on imaging indicates significant compression that warrants surgical treatment, as long periods of severe stenosis lead to demyelination of white matter and potentially irreversible neurological deficits 1
• Surgical intervention is specifically indicated for patients with cord signal changes or evidence of structural cord compromise (such as flattening), even if symptoms are currently mild 1, 2
• Untreated severe cervicomedullary compression carries a mortality rate of 16%, making observation inappropriate for marked stenosis with cord deformity 1
• The natural history of cervical spondylotic myelopathy shows stepwise decline with periods of quiescence that do not guarantee stability, meaning early intervention is preferable to waiting for frank neurological deterioration 1

Surgical Approach Selection

The choice between anterior and posterior approaches depends on the number of levels involved:

• For 1-3 level disease: Anterior cervical decompression and fusion (ACDF) is the appropriate approach 1, 3
• For ≥4 segment disease: Posterior laminectomy with fusion is recommended 1, 3
• Fusion is mandatory rather than decompression alone, as fusion prevents iatrogenic instability and provides superior long-term outcomes for pain relief, functional improvement, and quality of life 1, 2
• Laminectomy without fusion should be avoided, as it carries a 29% rate of late deterioration and higher reoperation risk due to restenosis, adjacent-level stenosis, and postoperative spinal deformity 1, 2

Expected Outcomes and Prognostic Factors

• Approximately 97% of patients experience some symptom recovery after surgical decompression with fusion 1, 2
• Posterior laminectomy with fusion demonstrates superior neurological recovery (2.0 Nurick grade improvement) compared to anterior approaches (1.2 grade improvement) or laminectomy alone (0.9 grade improvement) 1

Prognostic indicators to assess preoperatively:

• Multisegmental high signal changes on T2-weighted MRI predict poorer surgical outcomes but do not contraindicate surgery 4, 1
• T1 hypointensity combined with T2 hyperintensity at the same level predicts worse outcomes 1
• Spinal cord atrophy with transverse area <45 mm² may predict poor surgical prognosis 1
• Patients with >1 segment of spinal cord hyperintensity on T2-weighted images have the worst recovery rates, though surgery remains indicated 4

Critical Timing Considerations

• Surgery should be performed urgently rather than delayed, as the presence of cord flattening represents established structural compromise 4, 1
• The goal of surgery in cervical stenosis is to halt disease progression and prevent irreversible cord damage 5
• Conservative management is inappropriate when cord compression with structural changes (flattening) is present, as this indicates the disease has progressed beyond the stage where non-operative treatment is viable 1, 2

Common Pitfalls to Avoid

• Do not pursue conservative management when cord flattening is present—this represents structural compromise requiring decompression 1, 2
• Do not perform laminectomy without fusion, as this leads to unacceptably high rates of late deterioration and reoperation 1, 2
• Do not delay surgery waiting for symptom progression, as irreversible cord damage may occur during observation 1
• Asymptomatic radiographic stenosis does not require intervention, but cord flattening indicates the stenosis is no longer asymptomatic at the tissue level 1, 2