Management of Moderate C5-C6 Space Loss
For moderate C5-C6 disc space loss with symptomatic cervical radiculopathy, begin with conservative multimodal therapy for 4-6 weeks, reserving surgical anterior cervical decompression for patients with persistent severe pain, progressive neurological deficits, or failed conservative management. 1, 2
Initial Conservative Management (First-Line Approach)
Conservative treatment achieves 75-90% success rates in cervical radiculopathy and should be the initial approach for moderate C5-C6 space loss 2. The multimodal protocol includes:
- Cervical collar immobilization for short-term use (avoid prolonged immobilization) 1, 3
- Physical therapy with strengthening and stretching exercises 2, 3
- Nonsteroidal anti-inflammatory drugs for pain control 2, 3
- Head traction may provide temporary decompression, particularly as cervical flexion significantly increases foraminal volume at C5-C6 4, 3
- Multimodal analgesia including gabapentinoids for neuropathic symptoms if present 1
Critical timeframe: Continue conservative management for 4-6 weeks before considering surgical intervention 2.
Diagnostic Imaging Requirements
MRI of the cervical spine without contrast is the appropriate imaging modality for evaluating C5-C6 space loss with radicular symptoms 1, 2. MRI provides superior visualization of:
- Disc herniations and nerve root compression 2
- Spinal cord signal changes that may indicate myelopathy 1
- Foraminal stenosis and degenerative changes 1
Important caveat: Degenerative changes on MRI are common in patients over 30 years and correlate poorly with symptoms alone 1. Clinical correlation is essential—85% of patients show progressive disc degeneration on MRI over 10 years, but only 34% develop symptoms 1.
Red Flags Requiring Urgent Surgical Evaluation
Proceed directly to surgical consultation if any of the following are present:
- Progressive neurological deficits (worsening weakness or sensory loss) 2, 5
- Bilateral symptoms suggesting cervical myelopathy rather than simple radiculopathy 2
- Spinal cord signal changes on MRI indicating cord compression 1
- Severe or intractable pain despite adequate conservative management 5, 3
- Bladder/bowel dysfunction or loss of perineal sensation 2
Surgical Intervention
Anterior cervical decompression with or without fusion is recommended when conservative management fails after 4-6 weeks or red flags are present 1, 2. The evidence shows:
- Rapid relief (within 3-4 months) of arm and neck pain, weakness, and sensory loss compared to physical therapy 1
- Surgical outcomes for arm pain relief range from 80-90% 2
- Long-term improvement at 12 months in wrist extension, elbow extension, and shoulder function 1
Surgical timing consideration: For traumatic spinal cord injury with C5-C6 involvement, decompression within 48 hours may be considered, though outcomes are variable and postoperative neurological worsening can occur 1.
Common Pitfalls to Avoid
Do not over-interpret MRI findings: Degenerative changes at C5-C6 are extremely common in asymptomatic individuals over 30 years old 1. Base surgical decisions on clinical symptoms correlated with imaging, not imaging alone.
Recognize atypical presentations: If symptoms affect both arm and leg unilaterally, consider cervical myelopathy (cord compression) rather than simple radiculopathy, which requires more urgent evaluation 2.
Avoid prolonged conservative management in progressive deficits: While most cases respond to conservative care, delaying surgery in patients with progressive weakness or myelopathic signs can lead to irreversible neurological damage 2, 5.
Consider non-spinal causes: When presentation is atypical with both upper and lower extremity symptoms, evaluate for multiple sclerosis or other neurological disorders 2.