What is the best course of treatment for a patient with a large posterior disc extrusion at C5-C6, severe spinal canal stenosis, and severe spinal cord compression?

Urgent Surgical Decompression Required

A patient with large posterior disc extrusion at C5-C6 causing severe spinal canal stenosis and severe spinal cord compression requires immediate surgical decompression within 24-48 hours to prevent irreversible neurological damage and optimize recovery potential. 1, 2

Immediate Management Algorithm

Emergency Assessment (Within Hours)

• Document baseline neurological status including motor strength in all extremities (graded 0-5/5), sensory function, reflexes, presence of clonus, and bowel/bladder function 3
• Assess for myelopathy signs such as hand clumsiness, gait instability, hyperreflexia, Hoffman's sign, and Babinski response 4
• Evaluate for cauda equina/cord compression syndrome requiring same-day surgical intervention if progressive motor deficits, bilateral symptoms, or sphincter dysfunction present 5

Surgical Timing: Critical Decision Point

Surgery should be performed within 24-48 hours of presentation for patients with:

• Severe spinal cord compression on MRI with cord signal changes 3, 1
• Progressive neurological deterioration 3
• Incomplete spinal cord injury with persistent compression 3

The evidence demonstrates that early decompression within 12-48 hours can be performed safely without increased complications and may improve neurological outcomes, though randomized controlled trial data remains limited 3. Delaying surgery beyond 48 hours in the setting of severe cord compression risks irreversible neurological injury 1, 2.

Surgical Approach Selection

Anterior Cervical Discectomy and Fusion (ACDF)

This is the preferred approach for single-level C5-C6 posterior disc extrusion because:

• Direct access to remove anterior compressive pathology (disc herniation) 4
• Allows complete decompression of the spinal cord 1
• Restores disc height and foraminal dimensions 4
• Fusion rates of 89-95% with anterior plating 6

Posterior Decompression Considerations

Posterior laminectomy/laminoplasty is reserved for:

• Multilevel stenosis (≥3 levels) with preserved cervical lordosis 4
• Congenital canal narrowing with superimposed degenerative changes 3
• Ossification of posterior longitudinal ligament 4

Critical pitfall: Posterior-only decompression for anterior pathology (disc extrusion) may worsen cord compression during surgery and fails to address the primary compressive lesion 3, 1.

Perioperative Hemodynamic Management

Maintain mean arterial pressure >85-90 mmHg for 5-7 days post-injury to optimize spinal cord perfusion, as emphasized in current surgical trials for acute spinal cord injury 3. This aggressive hemodynamic support is based on improved understanding of spinal cord injury pathophysiology 3.

Expected Outcomes and Prognostic Factors

Favorable Prognostic Indicators

• Incomplete neurological injury (any preserved motor/sensory function) 3
• Early surgical decompression (<48 hours) 3, 1
• Younger age and absence of cord signal changes on MRI 3

Realistic Recovery Timeline

• Immediate postoperative period: Some patients experience temporary worsening of symptoms due to cord manipulation 3
• Weeks to months: Gradual neurological improvement expected in most cases 1
• Incomplete recovery common: Patients with severe preoperative deficits may have persistent weakness, sensory changes, or neuropathic pain despite optimal surgical intervention 2

Conservative Management: Not Appropriate Here

Conservative management is contraindicated in severe spinal cord compression 5, 1, 2. While spontaneous disc resorption can occur in lumbar disc herniations 7, this phenomenon:

• Takes months to occur (10+ weeks) 7
• Is unpredictable and unreliable 7
• Cannot be applied to cervical myelopathy with severe cord compression, where delayed treatment risks permanent paralysis 1, 2

The case of cervical manipulation causing acute spinal cord injury in undiagnosed stenosis demonstrates the catastrophic consequences of failing to recognize and urgently treat severe cervical cord compression 2.

Critical Warnings

Avoid spinal manipulation or aggressive physical therapy in patients with suspected cervical stenosis or myelopathy, as this can precipitate acute spinal cord injury 2. Any patient presenting with neck pain and neurological symptoms (paresthesias, weakness, gait instability) requires MRI before any manual therapy 2.

Do not delay surgery for prolonged conservative trials when severe cord compression is documented on imaging, as the natural history of cervical spondylotic myelopathy is progressive deterioration without surgical decompression 4.