What is the first‑line treatment for an adult with degenerative cervical spinal stenosis presenting with neck pain, radiculopathy, or mild myelopathic symptoms?

Treatment Options for Cervical Spinal Stenosis

First-Line Conservative Management

Conservative treatment is the recommended initial approach for adults with degenerative cervical spinal stenosis presenting with neck pain, radiculopathy, or mild myelopathy, with 73-90% of patients improving without surgery. 1, 2

Initial Conservative Therapy (Minimum 6 Weeks)

• Activity modification, cervical immobilization with soft collar, and NSAIDs form the foundation of initial management 2
• Physical therapy with isometric neck exercises should be initiated early 2
• Conservative treatment produces improvement in 30-50% of patients with mild myelopathy and even higher rates in those with radiculopathy alone 2
• A trial of at least 6 weeks of conservative management is required before considering interventional procedures or surgery 3, 1

Expected Outcomes with Conservative Care

• In patients with mild cervical spondylotic myelopathy, 73.1% remain stable or improve with conservative treatment alone over 3+ years of follow-up 1
• Radicular symptoms typically respond favorably to conservative measures, with most patients avoiding surgical intervention 3, 2
• Neck immobilization alone can produce improvement in 30-50% of patients presenting with minor neurologic findings 2

Indications for Surgical Intervention

Surgery should be offered when conservative treatment fails after 6+ weeks, when there is progressive neurologic deterioration, or when patients present with moderate-to-severe myelopathy. 3, 2, 4

Specific Surgical Indications

• Progressive neurologic deficits despite conservative management 3, 2
• Severe or worsening myelopathy with gait disturbance or hand dysfunction 3, 4
• Persistent intractable pain limiting activities of daily living after 6+ weeks of conservative therapy 3, 2
• Clear correlation between clinical symptoms and imaging findings showing spinal cord or nerve root compression 3, 4

Surgical Approach Selection Algorithm

Anterior cervical discectomy and fusion (ACDF) is the standard surgical procedure for 1-2 level cervical stenosis, with 70-80% of patients achieving long-term improvement. 3, 2

Anterior Approaches

• ACDF is preferred for 1-2 level central pathology, particularly in patients with disc-level compression and predominant radiculopathy 3
• Anterior cervical corpectomy is indicated for non-disc level encroachment, 3 contiguous levels of pathology, or when kyphosis and instability are present 3
• Anterior approaches generally produce good initial results in approximately 70% of patients with myelopathy 2

Posterior Approaches

• Laminoforaminotomy is preferred in younger patients with posterolateral or lateral soft disc herniations, focal foraminal osteophyte impingement, and predominant upper extremity symptoms 3
• Laminoplasty is indicated for 4 or more levels of stenosis, particularly in patients with continuous OPLL or congenital stenosis without severe kyphosis 3
• Full endoscopic laminotomy decompression demonstrates 90.48% excellent/good outcomes with less trauma, faster recovery, and reduced adjacent segment degeneration compared to ACDF for single-level disease 5

Critical Clinical Pitfalls to Avoid

• Do not operate based on imaging alone: Degenerative changes on MRI are present in 65% of asymptomatic patients aged 50-59, and imaging findings correlate poorly with symptoms 6, 3
• Do not recommend prophylactic surgery: Surgery is not indicated for asymptomatic patients or those with isolated neck pain without extremity symptoms 3
• Do not delay surgery inappropriately: Patients with moderate-to-severe myelopathy or progressive neurologic deficits should undergo timely surgical intervention, as functional outcomes decline with prolonged cord compression 2, 4
• Recognize adverse prognostic factors: Segmental instability and severe cervical spinal stenosis on imaging predict higher rates of conservative treatment failure (26.9% deterioration rate) 1

Monitoring and Follow-Up

• Patients managed conservatively require periodic clinical assessment to detect neurologic deterioration 1
• If myelopathy worsens during conservative treatment, timely surgical intervention remains effective and produces outcomes equivalent to those who never deteriorated 1
• Surgical results for myelopathy are modest, with functional outcomes declining over long-term follow-up, though surgery reliably arrests progression 2, 4