Can a 62‑year‑old woman with moderate‑to‑severe cervical spondylosis and radiculopathy develop cervical myelopathy without a gait disturbance?

Can Cervical Spondylosis with Radiculopathy Progress to Myelopathy Without Gait Disturbance?

Yes, it is absolutely possible for a 62-year-old woman with moderate-to-severe cervical spondylosis and radiculopathy to develop cervical myelopathy without initially manifesting gait disturbance, though gait dysfunction is one of the hallmark features of established myelopathy. 1, 2

Understanding the Clinical Progression

Cervical myelopathy develops insidiously over time as degenerative changes compress the spinal cord, and the natural history follows variable patterns 3, 2, 4:

• Episodic deterioration occurs in 75% of patients, characterized by new symptoms appearing in discrete episodes with quiescent intervals between, though 2/3 of patients show gradual deterioration even during "stable" periods 2
• Slow steady progression occurs in 20% of patients, marked by gradual worsening without stepwise decline 2
• Rapid onset followed by plateau occurs in 5% of patients 2

Early Myelopathy Can Present Without Gait Disturbance

The hallmark symptoms of cervical myelopathy include decreased hand dexterity, gait instability, and sensory/motor dysfunction, but these do not all appear simultaneously 4:

• Hand symptoms often precede gait problems: Weakness in specific muscle groups of the arms, particularly affecting grip strength and hand intrinsic muscles, is characteristic of early myelopathy 2
• Fine motor skill deterioration in the hands can be the presenting feature 1
• Pain radiating down the arms when radiculopathy coexists with myelopathy is common 2
• Generalized weakness or stiffness in the legs may develop later as a cardinal feature 2

Critical Warning Signs That Myelopathy Is Developing

Even without overt gait disturbance, several findings indicate progression from radiculopathy to myelopathy 1, 5, 6:

• Long tract signs: Presence of clonus, Hoffman sign, Babinski sign, or inverted radial reflexes 6
• Cord signal changes on T2-weighted MRI: These represent established cord injury and indicate myelopathy even before clinical symptoms are severe 1, 5
• Bowel or bladder dysfunction in advanced cases 1
• Deterioration of fine motor skills such as difficulty with buttons, writing, or manipulating small objects 1

The Danger of Waiting for Gait Disturbance

This is a critical pitfall to avoid: Do not delay evaluation or treatment waiting for gait disturbance to develop, as this represents more advanced disease 5:

• Long periods of severe stenosis lead to demyelination of white matter and may result in necrosis of both gray and white matter, causing potentially irreversible neurological deficits 1, 5
• Untreated severe cervicomedullary compression carries a mortality rate of 16% 5
• Prolonged symptom duration before diagnosis correlates with poorer surgical outcomes 2
• Delaying surgery risks permanent neurological deficit that cannot be reversed even with eventual decompression 5

When to Suspect Progression to Myelopathy

In your 62-year-old patient with moderate-to-severe spondylosis and radiculopathy, suspect myelopathy development if any of the following occur 1, 2, 6:

• New or worsening hand clumsiness or loss of dexterity
• Development of hyperreflexia or pathologic reflexes (Hoffman, Babinski)
• Cord signal changes on MRI (T2 hyperintensity)
• Progressive weakness beyond the radicular distribution
• Any balance problems, even subtle ones

Management Implications

For moderate to severe myelopathy (mJOA score ≤12), surgical decompression is strongly recommended and should not be delayed, as it provides sustained neurological improvement for 5-15 years and prevents irreversible spinal cord damage 5:

• Approximately 97% of patients have some recovery of symptoms after surgery 5
• Earlier intervention correlates with better outcomes 5
• Factors predicting better surgical outcomes include younger age, shorter symptom duration (<12 months), and higher preoperative mJOA scores 5

The modified Japanese Orthopaedic Association (mJOA) scale should be used to objectively quantify neurological function, as severity of myelopathy correlates with treatment outcomes 1, 5:

• mJOA score >12 indicates mild myelopathy
• mJOA score ≤12 indicates moderate to severe myelopathy requiring surgical intervention 5

Bottom Line for This Patient

Given that this patient already has moderate-to-severe spondylosis with radiculopathy, she is at high risk for developing myelopathy. Close neurological monitoring is essential, and any progression of symptoms, development of long tract signs, or cord signal changes on MRI mandates urgent surgical referral 1. Do not wait for gait disturbance to appear before acting, as this represents more advanced, potentially irreversible disease 5.