What is the best course of treatment for a patient with significant cervical spondylosis at multiple levels, including C3-C4, C4-C5, and C5-C6, with moderate spinal canal stenosis and varying degrees of foraminal stenosis?

Treatment Approach for Multilevel Cervical Spondylosis with Moderate Stenosis

For multilevel cervical spondylosis at C3-C4, C4-C5, and C5-C6 with moderate spinal canal stenosis and foraminal involvement, surgical intervention is indicated if conservative management has failed or if myelopathic symptoms are present, with the specific surgical approach determined by the presence or absence of cervical kyphosis and the number of levels involved. 1, 2, 3

Initial Assessment and Conservative Management

Determine Disease Severity

• If mild myelopathy (mJOA score >12) or radiculopathy only: Trial of conservative management for 6 weeks minimum is reasonable, including activity modification, cervical immobilization, anti-inflammatory medications, and physical therapy to strengthen neck muscles. 3, 4
• If moderate to severe myelopathy (mJOA score ≤12): Surgical decompression is strongly recommended without delay, as prolonged severe stenosis can result in irreversible spinal cord damage. 3
• Conservative treatment for radiculopathy alone yields favorable results in most cases, with 70-80% improvement, making surgery unnecessary unless pain persists or progressive neurologic deficit develops. 4

Critical Imaging Assessment Required

Before proceeding with any surgical plan, you must obtain flexion-extension cervical spine radiographs to measure segmental motion at each level (C2-C3 through C6-C7). 2

• Measure anterior-posterior translation of each vertebral body relative to the one below
• Document whether motion is ≤3mm or >3mm at all levels
• This measurement is mandatory because it determines whether posterior-only approaches are contraindicated. 2

Surgical Decision Algorithm

Step 1: Assess Cervical Alignment

Check for kyphosis or loss of lordosis on lateral cervical spine radiographs:

• If kyphosis present: Posterior approach (laminectomy with fusion) is strongly preferred, as it provides superior biomechanical correction compared to anterior-only approaches. 2, 5
• If lordosis preserved: Proceed to Step 2. 6
• Critical pitfall: Laminectomy (with or without fusion) is absolutely contraindicated in the presence of kyphosis or cervical curve reversal, as it will worsen deformity and lead to late neurologic deterioration. 5, 6

Step 2: Determine Number of Levels and Compression Pattern

For your case with 3-level disease (C3-C4, C4-C5, C5-C6):

If Compression is Primarily Anterior (disc/osteophyte complex):

• Anterior corpectomy and fusion (ACCF) is recommended for 3-segment disease, as it provides direct decompression of ventral pathology and maintains better fusion rates than multilevel ACDF. 1, 3
• ACCF for 3 levels achieved neurological score improvement from 7.9 preoperatively to 13.4 at 15-year follow-up. 3
• Note: ACCF has higher graft dislodgement rates (3.8%) compared to ACDF (1.4%), though not statistically significant. 1
• Pseudarthrosis occurs in approximately 10.9% of corpectomy cases. 3

If Compression is Circumferential or Posterior Predominant:

• Laminoplasty is the preferred option IF and ONLY IF segmental motion is ≤3mm at all levels from C2-C7. 2
• Laminoplasty preserves motion, reduces axial neck pain compared to fusion, and has comparable neurological outcomes to fusion for properly selected patients. 2, 3
• Absolute contraindication: Laminoplasty is contraindicated when >3mm of motion exists at any level, as the procedure provides no stabilization and will lead to progressive kyphosis and late neurological deterioration. 2

If Segmental Motion >3mm at Any Level:

• Laminectomy with fusion is mandatory to prevent late deformity and progressive kyphosis. 2, 3
• Laminectomy with fusion prevents the 24% kyphosis rate and 29% late deterioration rate seen with laminectomy alone. 2, 3
• Laminectomy with lateral mass fusion resulted in neurological improvement in 97% of patients, with mean JOA score improvement from 12.9 to 15.6. 3
• Laminectomy with fusion showed significantly greater neurological recovery (2.0 Nurick grade improvement) compared to laminectomy alone (0.9 grade improvement). 2, 3

Step 3: Consider Patient-Specific Prognostic Factors

Factors predicting better surgical outcome:

• Age <60 years: Younger patients have significantly better recovery rates. 1
• Symptom duration <1 year: Patients with symptoms present for less than one year show better results across all treatment modalities. 1, 3, 4
• Mild to moderate preoperative myelopathy: Severe preoperative neurological deficit correlates with worse outcomes. 1
• Normal preoperative SEPs and MEPs: Abnormal neurophysiological studies predict decreased recovery. 1

Recommended Surgical Approach for Your Case

Based on the multilevel (3-level) moderate stenosis pattern described:

1. First, obtain flexion-extension radiographs to measure segmental motion. 2

2. If lordosis is preserved AND motion ≤3mm at all levels: Laminoplasty is the optimal choice, as it preserves motion, avoids fusion-related complications, and provides equivalent neurological outcomes. 2, 3

3. If lordosis is preserved BUT motion >3mm at any level: Laminectomy with fusion from C3-C6 (or C2-C7 if instability extends beyond the stenotic levels) is required. 2, 3

4. If kyphosis is present: Posterior laminectomy with fusion is strongly preferred over anterior approaches for biomechanical correction. 2

5. If anterior compression is clearly predominant on MRI and lordosis is preserved: Consider anterior corpectomy and fusion for the 3 levels, though this carries higher graft failure risk. 1, 3

Common Pitfalls to Avoid

• Never perform laminectomy alone without fusion in multilevel disease, as it leads to 29% late deterioration and 24% kyphosis development. 2, 3
• Never proceed with laminoplasty without quantitative motion measurement, as "grade 1 anterolisthesis" descriptors are insufficient and may mask >3mm motion. 2
• Never perform laminectomy (with or without fusion) in the presence of kyphosis, as it will worsen deformity. 5, 6
• Do not delay surgery in patients with moderate to severe myelopathy, as irreversible spinal cord damage can occur. 3
• Ensure adequate stabilization during anterior corpectomy to prevent cage movement and pseudarthrosis. 3

Expected Outcomes

• Neurological improvement occurs in 81-97% of patients undergoing appropriate surgical decompression with fusion. 2, 3
• Benefits are maintained for at least 5 years and up to 15 years postoperatively. 3
• Functional outcome declines with long-term follow-up in all approaches, but fusion prevents the late deterioration seen with decompression alone. 2, 3, 4