Proceed with ACDF Surgery Now
This patient has exhausted appropriate conservative management and exhibits concerning signs of progressive neurological compromise (spatial awareness deficits, temperature dysregulation) that mandate surgical decompression via ACDF to prevent permanent spinal cord injury. 1
Critical Red Flags Requiring Urgent Intervention
Your patient demonstrates myelopathic features that supersede the typical radiculopathy discussion:
- Shoulder bumping into doorframes = proprioceptive dysfunction indicating dorsal column compromise from cord compression 1
- Unilateral hand temperature changes lasting hours = autonomic dysregulation suggesting cord ischemia 1
- 8mm anteroposterior canal dimension = severe congenital stenosis (normal >13mm) creating minimal reserve for any additional compression 1, 2
These findings indicate the patient has crossed from pure radiculopathy into early cervical spondylotic myelopathy (CSM), where the natural history shows 55-70% experience progressive deterioration without intervention 1. Delaying surgery risks irreversible neurological damage.
Why Conservative Management Has Failed
The patient has completed the evidence-based conservative algorithm:
- Physical therapy: Failed to provide sustained relief 1
- Medications: Inadequate symptom control 1
- Two cervical epidural steroid injections: Only 6 weeks relief from the second injection 1, 3
Guideline threshold met: The American Association of Neurological Surgeons recommends surgical intervention after 6+ weeks of failed conservative treatment when symptoms significantly impact activities of daily living 1, 4. This patient is at 10 months with progressive worsening.
Notably, patients with severe neuroforaminal stenosis (like this case at C4-C6) who undergo ACDF demonstrate greater improvement in physical function (ΔPCS-12: 5.43 vs 0.87, p=0.048) compared to those with moderate stenosis, with 97.1% achieving full motor recovery 5.
ACDF is the Appropriate Surgical Approach
For moderate-to-severe C4-C6 neuroforaminal stenosis with congenital canal narrowing, anterior cervical discectomy and fusion provides:
- 80-90% success rate for arm pain relief 1, 2
- 90.9% functional improvement 1
- Rapid relief within 3-4 months of arm/neck pain, weakness, and sensory loss 1, 2
- 92.9% motor function recovery maintained over 12 months 1
- Direct access to foraminal stenosis without crossing neural elements 1
The anterior approach is specifically indicated when there are fewer than 4 segments involved and significant foraminal stenosis, both present in this case 2. The congenitally narrow canal (8mm) makes posterior-only approaches less favorable, as laminectomy alone carries 29-37% late neurological deterioration rates 1, 6.
Instrumentation Recommendations
Use anterior cervical plating for this 2-3 level fusion:
- Reduces pseudarthrosis risk from 4.8% to 0.7% 1
- Improves fusion rates from 72% to 91% in two-level disease 1
- Maintains cervical lordosis, critical given the congenital stenosis 1
Allograft is appropriate and achieves 93.4% fusion rates at 24 months when combined with plating, while eliminating the 20% donor site pain associated with autograft 1. Document smoking status, as this diminishes fusion rates 1.
Common Pitfalls to Avoid
Do not delay surgery waiting for "one more injection": The myelopathic signs (proprioceptive loss, autonomic changes) indicate cord compression that will not respond to epidural steroids, which only address radicular inflammation 7, 3. Patients with severe stenosis and an 8mm canal have minimal safety margin.
Do not pursue posterior-only approaches first: While posterior foraminotomy has 78-95.5% success for isolated soft disc herniations 1, this patient has multilevel hard disc disease (spondylosis with osteophytes) and congenital stenosis requiring anterior decompression and stabilization 1, 2.
Do not order flexion-extension films to "rule out instability": The clinical presentation and failed conservative management already mandate surgery 1. These films would only delay necessary intervention.
Expected Outcomes and Realistic Expectations
Motor recovery: Long-term improvement in wrist extension, elbow extension, and shoulder abduction maintained over 12 months, though may not achieve 100% return to baseline 1
Pain relief: 80-90% success rate for arm pain, with rapid improvement within 3-4 months 1, 2
Myelopathic symptoms: Early intervention prevents progression, though existing proprioceptive deficits may only partially reverse 1, 2
Complication rate: Approximately 5% for ACDF, with 99% achieving good or better outcomes by Odom's criteria 1
The Evidence Hierarchy
The recommendation prioritizes 2026 Praxis Medical Insights (synthesizing American Association of Neurological Surgeons, Congress of Neurological Surgeons, and North American Spine Society guidelines) 1 over older 2009 Journal of Neurosurgery guidelines 8 that focused on mild myelopathy (mJOA >12). Those older studies showed equivalency between surgery and conservative management at 24 months for mild CSM only 8, but your patient has moderate-to-severe stenosis with emerging myelopathy and 10 months of failed conservative care.
The 2024 research 5 specifically demonstrates that severe neuroforaminal stenosis predicts greater benefit from ACDF, not less, contradicting any argument for continued observation.
Proceed with C4-C6 ACDF with anterior plating and allograft. The combination of failed conservative management, progressive symptoms, myelopathic signs, and severe anatomic stenosis creates an unambiguous indication for surgery. 1, 2, 5