Adult with C5‑C6 moderate‑to‑severe central canal stenosis, large uncinate spurs, facet arthropathy, presenting with neck pain, occipital headache, left facial paresthesia, left arm numbness, and urinary urgency—what is the diagnosis and optimal management?

Cervical Myelopathy with Moderate-to-Severe C5-C6 Stenosis Requiring Urgent Neurosurgical Evaluation

You have cervical myelopathy—spinal cord compression at C5-C6—and require urgent neurosurgical consultation within 1-2 weeks for surgical decompression, as your constellation of symptoms (occipital headaches, facial paresthesias, arm numbness, and urinary urgency) indicates spinal cord dysfunction that will not resolve with conservative treatment and risks permanent neurological injury. 1

Understanding Your Diagnosis

Your MRI shows moderate-to-severe central canal stenosis at C5-C6 with an AP diameter of only 6-7mm (normal is >13mm), complete obliteration of CSF around the cord, and mild cord flattening. 2 This degree of narrowing—with no protective CSF cushion—places your spinal cord at high risk for catastrophic injury from even minor trauma like a fall or sudden neck movement. 3

Why Your Symptoms Indicate Myelopathy (Not Just Radiculopathy)

• Urinary urgency is a classic myelopathic sign indicating spinal cord involvement, not simply nerve root compression. 1
• Facial paresthesias suggest upper cervical cord dysfunction or referred symptoms from severe cord compression. 2
• Bilateral symptoms (your left arm numbness combined with other diffuse symptoms) point to central cord pathology rather than isolated nerve root compression. 1
• Occipital headaches radiating from the neck combined with these neurological findings suggest cervicogenic pain from structural instability and cord irritation. 3

The large uncinate spurs causing moderate-to-severe foraminal narrowing explain your left arm numbness (C6 nerve root compression), but the urinary and facial symptoms indicate the more serious problem: your spinal cord itself is being compressed. 3, 1

Why Surgery Cannot Be Delayed

The Natural History Without Decompression

Cervical myelopathy does not improve with conservative treatment—physical therapy, NSAIDs, and collars are appropriate only for isolated radiculopathy without myelopathic signs. 1 Once myelopathy develops:

• Progressive neurological deterioration is the expected course without surgical decompression. 1
• The degree of canal narrowing you have (6-7mm with cord flattening and no CSF) represents severe anatomic compromise that predisposes to sudden, irreversible spinal cord injury from minor trauma. 3, 2
• Delayed surgery after myelopathy onset results in incomplete recovery—early decompression (ideally within weeks to months of symptom onset) provides the best chance for neurological improvement. 3

The Evidence on Surgical Timing

A 2025 meta-analysis in World Neurosurgery documented that patients with spinal cord compression and signal changes (like the cord flattening on your MRI) who undergo decompression within 48 hours to several weeks have better outcomes than those who delay. 3 One illustrative case showed a patient with similar congenital canal narrowing and superimposed degenerative stenosis who underwent urgent posterior decompression within 48 hours—despite some initial postoperative worsening, early intervention prevented permanent disability. 3

The key principle: once cord compression with myelopathic symptoms develops, the window for optimal recovery narrows rapidly. 3, 1

What Surgery Involves and Expected Outcomes

Surgical Options

For your pathology—anterior compression from disc/ligament/bone at C5-C6 with foraminal stenosis—the standard approach is:

• Anterior cervical discectomy and fusion (ACDF) at C5-C6, which directly removes the compressive disc, osteophytes, and ligament, then stabilizes the segment. 1
• Some surgeons may consider C3-C7 posterior decompression if multilevel ligamentous thickening (noted at C3-C4 and C4-C5) contributes significantly, though your primary pathology is at C5-C6. 3

Realistic Outcome Expectations

• Pain relief and sensory improvement occur in 52-99% of patients, with significant improvement typically seen at 3-4 months post-surgery. 1
• Motor recovery (arm strength, hand function) is superior with surgery compared to conservative treatment at 12 months. 1
• Myelopathic symptoms (urinary urgency, gait instability if present) may improve but often incompletely if surgery is delayed—this is why urgency matters. 1
• Recurrent symptoms occur in up to 30% of patients, usually from adjacent-level degeneration years later. 1

Risks of Delaying

The 2025 case series showed that even with urgent surgery, patients with pre-existing cord signal changes can experience postoperative neurological worsening (one patient developed worse hand weakness immediately after decompression). 3 However, without surgery, progressive myelopathy is inevitable, and the risk of catastrophic spinal cord injury from minor trauma remains unacceptably high. 3, 2

Why Conservative Treatment Is Inappropriate in Your Case

When Conservative Management Works

The ACR Appropriateness Criteria and clinical guidelines support a 6-12 week trial of physical therapy, NSAIDs, and activity modification for:

• Isolated radiculopathy (arm pain/numbness) without myelopathic signs. 3, 1
• Mild-to-moderate foraminal stenosis without central canal compromise. 1

Why You Don't Qualify

• Urinary urgency is an absolute red flag indicating spinal cord dysfunction—this mandates immediate surgical referral, not a trial of conservative care. 3, 1
• Moderate-to-severe central stenosis with cord flattening and no CSF represents structural pathology that cannot be reversed by physical therapy. 1, 2
• Epidural steroid injections are insufficient for moderate-to-severe structural stenosis and should not delay definitive surgical decompression. 1

Immediate Next Steps

1. Request urgent neurosurgical consultation (within 1-2 weeks, not months)—provide your MRI report and emphasize urinary urgency. 1
2. Avoid high-risk activities: no contact sports, heavy lifting, or activities that risk falls or sudden neck movements until evaluated by a surgeon. 3, 2
3. Monitor for worsening myelopathy: increasing hand clumsiness, difficulty with fine motor tasks (buttoning shirts, writing), gait instability, or worsening bladder/bowel function require emergency evaluation. 1
4. Do not accept reassurance that "degenerative changes are normal for your age"—your specific combination of severe stenosis, cord compression, and myelopathic symptoms is not a normal aging finding and requires intervention. 3

Common Pitfalls to Avoid

• Mistaking myelopathy for radiculopathy: many patients with cord compression are initially treated for "pinched nerves" with injections or physical therapy, delaying definitive care. 1
• Waiting for "complete paralysis": myelopathy progresses insidiously, and waiting for dramatic weakness means missing the window for optimal recovery. 3, 1
• Assuming surgery can be delayed indefinitely: unlike radiculopathy, myelopathy is a surgical urgency, not an elective decision. 1

Your imaging and symptoms together constitute cervical myelopathy requiring surgical decompression—this is not a "wait and see" situation. 3, 1