When is it appropriate to proceed with anterior cervical discectomy and fusion for a patient with multilevel cervical spondylosis, severe C5‑C6 neuroforaminal narrowing, congenital canal stenosis (anteroposterior diameter ≈8 mm), and persistent symptoms despite physical therapy and two epidural steroid injections?

When to Proceed with ACDF Surgery for Your Cervical Spondylosis

Based on your clinical presentation—severe C5-C6 neuroforaminal narrowing, congenital stenosis (8 mm AP diameter), failed physical therapy, and only temporary relief from epidural steroid injections—you meet established criteria for proceeding with the recommended 2-level ACDF surgery. 1, 2

Your Clinical Picture Meets Surgical Indications

You have documented the key requirements that justify surgical intervention:

• Failed conservative management: You completed physical therapy and received two epidural steroid injections with minimal benefit (only 6 weeks relief from the second injection), meeting the standard threshold of attempting conservative therapy before surgery 1, 2

• Anatomic severity: Your MRI demonstrates severe neuroforaminal narrowing at C5-C6 combined with congenital stenosis (8 mm AP diameter is significantly narrowed—normal is >13 mm), which represents moderate-to-severe pathology requiring surgical correction 1, 2

• Multilevel disease: Your multilevel neuroforaminal narrowing with severe involvement at C5-C6 indicates that a 2-level fusion is appropriate when clinical symptoms correlate with these imaging findings 1, 2

Evidence Supporting Surgical Intervention Now

ACDF provides 80-90% success rates for arm pain relief and 90.9% functional improvement when performed for cervical radiculopathy with documented neural compression after conservative management has failed 2, 3. The procedure offers:

• Rapid symptom relief: ACDF provides relief within 3-4 months compared to continued conservative treatment, which at 12 months shows comparable outcomes but requires significantly longer suffering 2

• Motor function recovery: 92.9% of patients experience motor function recovery that is maintained over 12 months following anterior decompression 2

• Long-term stability: For 2-level disease, anterior cervical plating reduces pseudarthrosis risk from 4.8% to 0.7% and improves fusion rates from 72% to 91% 2

Critical Factors That Indicate Surgery Is Appropriate

Your congenital stenosis (8 mm AP diameter) is a particularly important factor:

• Congenital stenosis increases vulnerability: The narrow baseline canal diameter means less reserve capacity for tolerating disc degeneration and foraminal narrowing 4

• Progressive risk: With congenital stenosis, continued conservative management may allow progressive neurological deterioration, as the spinal cord has minimal room for accommodation 3, 4

• Temporary injection relief indicates mechanical compression: The fact that your second epidural injection provided 6 weeks of relief confirms that inflammation is present, but the return of symptoms indicates ongoing mechanical compression that requires surgical decompression 1, 2

What You Should Verify Before Proceeding

Before scheduling surgery, confirm these details with your neurosurgeon:

• Clinical-radiographic correlation: Ensure your specific symptoms (arm pain distribution, sensory changes, weakness patterns) match the C5-C6 and adjacent level pathology seen on MRI 1, 2

• Instrumentation plan: For 2-level fusion, anterior cervical plating is strongly recommended to reduce pseudarthrosis risk and maintain cervical lordosis 2, 3

• Graft selection: Allograft with anterior plating achieves 93.4% fusion rates at 24 months and eliminates the 20% rate of donor site pain associated with iliac crest autograft harvest 2

Red Flags That Would Make Surgery More Urgent

Watch for these warning signs that would make surgery more urgent:

• Progressive motor weakness: New or worsening weakness in specific muscle groups (shoulder, elbow, wrist, hand) indicates advancing nerve compression 2, 3

• Myelopathic symptoms: Gait difficulties, balance problems, hand clumsiness, or bowel/bladder changes suggest spinal cord compression and require urgent surgical decompression 3

• Intractable pain: Pain that prevents sleep, work, or basic activities despite medications represents significant functional deficit warranting surgery 1, 3

Why Delaying Further May Not Be Advisable

The natural history of your condition argues against prolonged delay:

• Congenital stenosis with acquired disease: Your combination of congenital narrowing plus multilevel spondylosis creates a "double-hit" scenario where the spinal cord and nerve roots have minimal reserve capacity 4

• Diminishing returns from injections: The fact that your first injection provided no relief and the second only 6 weeks suggests you are exhausting non-surgical options 1

• Risk of permanent changes: Prolonged nerve compression can lead to irreversible changes, and timely decompression optimizes recovery potential 2, 3

Common Pitfalls to Avoid

• Do not wait for complete motor weakness: Significant motor deficits may not fully recover even after successful surgery, so proceeding before severe weakness develops is preferable 2, 3

• Do not assume more injections will help: Your pattern of minimal/temporary relief from epidural injections indicates mechanical compression that requires surgical decompression rather than repeated injections 1, 2

• Do not delay if myelopathic symptoms appear: Progressive neurological deficits, particularly myelopathy with gait instability, warrant urgent surgical decompression as the natural history shows 55-70% of patients experience progressive deterioration without intervention 2, 3

The Bottom Line

You have met the established criteria for ACDF: documented conservative treatment failure, radiographic evidence of moderate-to-severe pathology (severe C5-C6 neuroforaminal narrowing plus congenital stenosis), and the clinical presentation that correlates with your imaging findings. 1, 2 The 2-level fusion recommended by your neurosurgeon is appropriate for multilevel disease with severe involvement at C5-C6, and the addition of anterior cervical plating will optimize fusion rates and maintain cervical alignment 2, 3. Proceeding with surgery now, rather than continuing to delay with additional conservative measures that have already failed, offers you the best opportunity for symptom relief and functional recovery while minimizing the risk of permanent neurological injury from prolonged compression 2, 3, 4.