Interpret the cervical spine X‑ray of a 66‑year‑old woman showing multilevel spondylotic changes with advanced disc degeneration at C5‑6, moderate changes at C6‑7, mild changes at C4‑5, facet arthropathy and C2‑3 facet fusion, severe left‑side bony foraminal narrowing at C3‑4, C4‑5, C5‑6 and moderate right‑side narrowing at C5‑6, and recommend appropriate management.

Cervical Spine X-ray Interpretation and Management

Radiographic Findings Summary

This X-ray demonstrates multilevel cervical spondylosis with severe left-sided foraminal stenosis requiring MRI evaluation to determine if surgical intervention is warranted 1.

The key pathologic findings include:

• Advanced degenerative disc disease at C5-6 with diffuse disc space narrowing and endplate osteophyte formation 1
• Moderate degenerative changes at C6-7 and mild disease at C4-5 1
• Multilevel facet arthropathy with spontaneous C2-3 facet fusion 1
• Severe left-sided bony foraminal narrowing at C3-4, C4-5, and C5-6 from combined degenerative changes 1
• Moderate right-sided foraminal narrowing at C5-6 1
• Maintained vertebral body heights and satisfactory alignment (no instability) 1

Clinical Significance and Next Steps

MRI of the cervical spine is the mandatory next imaging study to evaluate for neural compression, cord signal changes, and soft tissue pathology that cannot be assessed on plain radiographs 1. The ACR Appropriateness Criteria emphasize that MRI is more sensitive than CT in identifying degenerative cervical disorders and is essential for surgical planning 1.

Critical Clinical Correlation Required

The radiographic findings must be correlated with clinical symptoms to determine management 1:

• If radicular symptoms are present (arm pain, numbness, weakness following a dermatomal pattern), the severe left-sided foraminal stenosis at multiple levels likely represents the pain generator and warrants consideration for surgical decompression after failed conservative management 2, 3
• If myelopathic symptoms exist (gait instability, hand clumsiness, hyperreflexia), the multilevel stenosis may be causing spinal cord compression requiring urgent surgical evaluation 1, 4
• If only axial neck pain without neurologic symptoms, degenerative changes alone do not mandate cross-sectional imaging or surgery, as spondylotic changes are common in patients over 30 and correlate poorly with neck pain 1

Management Algorithm

Conservative Management (First-Line for Radiculopathy)

At least 6 weeks of comprehensive conservative treatment is required before considering surgery 2:

• Active, in-person physical therapy (not just home exercises) 2
• Pharmacologic management with NSAIDs, acetaminophen, or tricyclic antidepressants 2
• Identification and management of psychological factors 2

Surgical Indications

Surgery should be considered only after documented failure of conservative management with the following criteria 2, 3:

• Neural compression symptoms causing radiculopathy with arm numbness/weakness 2
• Activities of daily living limitations from neural compression 2
• MRI-confirmed multilevel cervical spondylosis with nerve root or cord compression correlating with clinical symptoms 2, 3

Surgical Approach Selection

For this patient with multilevel disease at C4-5, C5-6, and C6-7:

• Anterior cervical discectomy and fusion (ACDF) with anterior plating is the preferred approach for disc-level pathology at 2-3 contiguous levels, with 74-88% symptom improvement rates and 95% fusion rates 2, 3
• Multilevel ACDF demonstrates superior outcomes to laminectomy alone, which is associated with late deterioration (29% at >30 months) 1, 2
• Anterior plating improves fusion rates and reduces pseudarthrosis risk in multilevel constructs 2, 3

Critical Pitfalls to Avoid

• Do not assume degenerative changes equal surgical indication – spondylotic changes on imaging are common in asymptomatic patients over 30 and correlate poorly with symptoms 1
• Verify adequate conservative treatment – documentation must include actual physical therapy claims/notes, not just statements of "tried PT" 2
• Assess imaging severity accurately – "mild" or "mild-to-moderate" stenosis does not meet surgical criteria even with symptoms 2
• The C2-3 facet fusion is likely degenerative (not traumatic or congenital) given the multilevel facet arthropathy, but clinical history should confirm absence of prior trauma 5
• Left-sided predominance of foraminal stenosis should correlate with left-sided radicular symptoms if surgery is considered 3

Expected Natural History

Without intervention, cervical disc degeneration progresses in 85% of patients, but symptoms develop in only 34% 1. Patients developing symptoms show more frequent progression including anterior dural compression, posterior disc protrusion, disc space narrowing, and foraminal stenosis 1. The C5-6 level is the most commonly degenerated, with progression typically occurring to contiguous levels (C4-5 and C6-7), which matches this patient's pattern 6.