When should a 62‑year‑old patient with moderate‑to‑severe foraminal narrowing at C5‑C6, high‑grade anterolisthesis at C5‑C6, and a congenitally narrow cervical canal (minimum anteroposterior diameter 8 mm) agree to anterior cervical discectomy and fusion after a trial of medication, physical therapy, and cervical epidural steroid injections has failed?

When to Proceed with ACDF Surgery in Your Clinical Scenario

You should agree to ACDF surgery now, because your combination of severe congenital canal stenosis (8 mm anteroposterior diameter), high-grade anterolisthesis at C5-C6, and moderate-to-severe foraminal narrowing creates a 55-70% risk of progressive neurological deterioration without surgical decompression, and conservative measures have already failed to provide lasting relief. 1

Critical Factors That Indicate Surgery Is Appropriate Now

Your Anatomic Risk Profile Demands Intervention

• Your 8 mm canal diameter represents severe congenital stenosis (normal is >13 mm), which alone predicts progressive myelopathy in the majority of untreated patients 1, 2
• The combination of congenital narrowing plus superimposed degenerative stenosis at C5-C6 creates a "double-crush" scenario where the spinal cord has no reserve capacity 1, 2
• High-grade anterolisthesis at C5-C6 causes dynamic cord compression that worsens with neck movement, making conservative therapy ineffective 3
• Each 1 mm of disc space collapse reduces foraminal area by 20-30%, and your moderate-to-severe stenosis indicates substantial nerve root compression 4

Conservative Treatment Has Already Failed

• You have completed the required trial: medication, physical therapy, and two cervical epidural steroid injections 1
• The transient 6-week relief after your second injection confirms the diagnosis but demonstrates that non-surgical measures cannot provide durable improvement 1, 5
• Severe foraminal stenosis (like yours at C5-C6) predicts poor response to epidural injections, with research showing these patients ultimately require surgery 5
• The American Association of Neurological Surgeons recommends operative intervention after ≥6 weeks of failed conservative therapy when symptoms significantly impair activities of daily living 1

Why Waiting Longer Is Harmful

Progressive Myelopathy Is the Natural History

• Without decompression, 55-70% of patients with your anatomic profile experience progressive neurological deterioration 1
• Early myelopathic signs include proprioceptive loss (shoulder bumping into objects) and unilateral hand temperature dysregulation—if you develop these, cord damage may become irreversible 1
• The 2025 World Neurosurgery systematic review documented cases where delayed surgery in patients with congenital stenosis resulted in worsened neurological function postoperatively because cord injury had already occurred 6

Posterior Approaches Are Contraindicated in Your Case

• Laminectomy alone in congenitally narrow canals carries a 29-37% rate of late neurological deterioration, making anterior decompression essential 1, 7
• Your anterior pathology (disc disease, foraminal stenosis, anterolisthesis) requires direct anterior access 1, 7

What ACDF Will Accomplish for You

Expected Symptom Relief

• 80-90% success rate for arm pain relief, typically achieved within 3-4 months 1, 8
• Motor recovery occurs in 92.9% of patients and is maintained through 12 months 1
• Functional improvement (measured by validated scales) occurs in 90.9% of cases with moderate-to-severe stenosis 1

Structural Goals

• Direct decompression of the C5-C6 neural foramen eliminates nerve root compression 1, 7
• Restoration of disc height reopens the foramen (remember: each 1 mm of height loss reduces foraminal area by 20-30%) 4
• Fusion with anterior plating stabilizes the high-grade anterolisthesis, preventing dynamic cord compression 1, 7
• For 2-level disease, anterior plating reduces pseudarthrosis from 4.8% to 0.7% and improves fusion rates from 72% to 91% 1

Realistic Expectations

• Full return to pre-illness strength may not occur, but meaningful functional improvement is typical 1
• If you have already developed subtle myelopathic signs (hand clumsiness, gait instability), these may improve only partially—this is why operating before myelopathy develops is critical 1
• Overall complication rate is approximately 5%, with 99% achieving "good" or better outcomes by validated criteria 1

The Surgical Algorithm for Your Case

Step 1: Confirm You Meet All Criteria (You Do)

• ✓ Moderate-to-severe foraminal stenosis at C5-C6 with clinical correlation 1
• ✓ Severe congenital canal stenosis (8 mm) 1, 2
• ✓ High-grade anterolisthesis causing dynamic instability 3
• ✓ Failed ≥6 weeks of structured conservative therapy including epidural injections 1
• ✓ Symptoms significantly impair activities of daily living 1

Step 2: Anterior Approach Is Mandatory

• Your pathology is entirely anterior (disc, foramina, anterolisthesis) 1, 7
• Fewer than 4 levels involved (you have C5-C6 primarily) 1, 7
• Posterior decompression is contraindicated due to congenital stenosis 1, 7

Step 3: Instrumentation Is Required

• Anterior cervical plating is mandatory for stabilizing high-grade anterolisthesis 1, 7
• Plating reduces pseudarthrosis risk and maintains cervical lordosis 1
• Allograft with plating achieves 93.4% fusion rates at 24 months while avoiding the 20% donor-site pain of autograft 1

Step 4: Document Smoking Status

• If you smoke, this must be addressed because smoking diminishes fusion rates, particularly with allograft 1

Common Pitfalls to Avoid

Do Not Wait for Myelopathy to Develop

• Once you develop hand clumsiness, gait instability, or bowel/bladder changes, cord damage may be irreversible 1
• The 2025 World Neurosurgery case series showed that patients with congenital stenosis who waited until myelopathy developed had worse postoperative outcomes, including paradoxical neurological worsening after decompression 6

Do Not Accept "Let's Try One More Injection"

• Your severe foraminal stenosis predicts epidural injection failure 5
• You have already had two injections with only transient relief—further injections will not change the underlying structural compression 1, 5

Do Not Be Misled by Older Literature

• A 2009 Journal of Neurosurgery study showed equivalence between surgery and conservative management at 24 months, but that study only included patients with mild myelopathy (mJOA >12) 1
• Your severe congenital stenosis, high-grade anterolisthesis, and moderate-to-severe foraminal narrowing place you in a completely different risk category 1

The Bottom Line

The 2026 Praxis Medical Insights synthesis—incorporating American Association of Neurological Surgeons, Congress of Neurological Surgeons, and North American Spine Society guidelines—establishes that your clinical scenario (severe congenital stenosis + high-grade anterolisthesis + moderate-to-severe foraminal narrowing + failed conservative therapy) meets all criteria for immediate ACDF. 1 Delaying surgery risks irreversible cord injury, and the natural history of your condition is progressive deterioration in 55-70% of untreated patients. 1 The evidence is clear: proceed with surgery now.