What is the appropriate treatment for an elderly patient with spondylosis at cervical levels, severe canal stenosis at C3-4 and C5-6, moderate canal stenosis at C4-5 and C6-7, cord contouring, and suspected mild cord compression?

Surgical Decompression is Urgently Indicated for This Patient

This elderly patient requires surgical decompression and fusion without delay—the presence of cord contouring and suspected cord compression with multilevel severe stenosis represents established cervical spondylotic myelopathy (CSM), which will not improve with conservative management and risks permanent neurological deficit if surgery is postponed. 1

Why This is NOT "Normal Aging"

While cervical spondylosis is common in elderly patients, severe canal stenosis with cord compression and cord contouring represents pathological compression requiring urgent surgical intervention, not benign age-related changes. 1 The critical distinction is:

• Asymptomatic degenerative changes on imaging are common and may not require treatment 2
• However, cord contouring and suspected cord compression indicate established spinal cord injury that will progress without decompression 1
• Long periods of severe stenosis cause demyelination and potentially irreversible necrosis of both gray and white matter 1

The Critical Pitfall: Do NOT Delay Surgery

The single most dangerous error is delaying surgery while attempting "conservative management" in a patient with established cord compression. 1 This is because:

• The likelihood of improvement with nonoperative measures in severe CSM is extremely low 1
• Untreated severe cervicomedullary compression carries a 16% mortality rate 1
• Delaying surgery risks permanent neurological deficit that cannot be reversed even with eventual decompression 1
• Once demyelination and necrosis occur, the damage is irreversible 1

Recommended Surgical Approach

For this patient with multilevel disease (4 levels: C3-4, C4-5, C5-6, C6-7):

Posterior laminectomy with fusion is the recommended approach for ≥4-segment disease. 1 Specifically:

• Laminectomy with posterior fusion demonstrates significantly greater neurological recovery (average 2.0 Nurick grade improvement) compared to anterior approaches (1.2 grade improvement) or laminectomy alone (0.9 grade improvement) 3
• Fusion is essential to prevent iatrogenic instability and late deterioration, which occurs in approximately 29% of patients who undergo laminectomy alone 3
• Laminoplasty is an alternative equivalent strategy for multilevel CSM 3

Alternative for Limited Disease

If disease were limited to 1-3 levels, anterior cervical decompression and fusion (ACDF) would be appropriate 1, but this patient has 4-level involvement requiring posterior approach.

Expected Outcomes with Surgery

Approximately 97% of patients have some recovery of symptoms after surgery for cervical stenosis with myelopathy. 1 More specifically:

• Significant improvement in neurological function can be expected 1
• Posterior laminectomy with fusion shows improvement rates of 73-74% 3
• Earlier intervention correlates with better outcomes 2

Prognostic Factors in Elderly Patients

Age alone is NOT a contraindication to surgery in elderly patients. 2 The evidence shows:

• Increased age was not a risk factor for poor outcomes in patients undergoing laminoplasty 2
• Recovery rates were similar between patients >70 years (62%) and younger patients (59%) 2
• However, symptom duration >12 months and more severe stenosis do negatively affect outcomes in elderly patients 2
• Lower preoperative functional scores (JOA scale <12) predict worse outcomes 2

What Determines Urgency

The presence of any of these features mandates urgent surgical evaluation:

• Cord contouring on MRI (present in this patient) 1
• Suspected cord compression (present in this patient) 1
• Gait and balance difficulties (indicates established myelopathy) 1
• Progressive neurological deficits 3
• Multisegmental T2 hyperintensity on MRI (strongly correlates with poor outcome if untreated) 2

Conservative Management is NOT Appropriate Here

Conservative management may only be considered in:

• Mild CSM with modified Japanese Orthopaedic Association (mJOA) score >12 in patients <75 years 3
• Absence of cord compression on imaging 3

This patient has severe stenosis with cord compression at multiple levels—conservative management is futile and dangerous. 1