Does a patient with cervical spine degeneration, left paracentral disc bulge at C3/C4, and mild neuroforaminal canal narrowing at C3/C4, C4/C5, and C5/C6 require referral to a neurosurgeon or can they undergo physiotherapy and review in six to eight weeks?

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Last updated: April 29, 2025 • View editorial policy

From the Guidelines

The patient can initially undergo physiotherapy with a review in six to eight weeks rather than immediate neurosurgical referral. The MRI findings indicate degenerative changes at multiple cervical disc levels with mild bilateral neuroforaminal narrowing and facet joint arthropathy, most notably at C3/C4, C4/C5, and C5/C6. While there is a left paracentral disc bulge at C3/C4 that slightly flattens the left aspect of the spinal cord, there is no significant spinal canal stenosis, no cord signal abnormality, and the nerve root compression appears mild. These findings are consistent with cervical spondylosis that can often be managed conservatively, as suggested by the American College of Radiology Appropriateness Criteria for cervical neck pain or cervical radiculopathy 1.

The patient's symptoms of neck pain and paresthesia in the right C7 and C8 distribution can be addressed through a structured physiotherapy program focusing on cervical spine mobilization, postural correction, and strengthening exercises. The absence of "red flags" such as trauma, malignancy, or systemic diseases, as outlined in the ACR Appropriateness Criteria 1, further supports the initial approach of conservative management.

During the six to eight week review, the patient's symptoms should be reassessed, and if there is persistence or worsening of symptoms, particularly neurological symptoms like increased paresthesia or new weakness, then neurosurgical referral would be appropriate at that time. This approach aligns with the principle of starting with conservative management for mild to moderate degenerative spine conditions before considering surgical intervention, as most cases of acute cervical neck pain with radicular symptoms resolve spontaneously or with conservative treatment measures 1.

Key points to consider in the patient's management plan include:

  • Monitoring for any signs of neurological deterioration
  • Adherence to the physiotherapy program
  • Regular follow-up to assess the response to conservative management
  • Consideration of neurosurgical referral if symptoms persist or worsen despite conservative management.

From the Research

MRI Findings and Clinical Implications

  • The MRI findings indicate straightening of the normal alignment of the cervical spine, with no spinal canal mass or cord signal abnormality 2.
  • There are degenerative changes at multiple levels, including C2/C3, C3/C4, C4/C5, C5/C6, and C6/C7, with varying degrees of disc bulge, facet joint arthropathy, and neuroforaminal canal narrowing 3, 4, 5.
  • The most significant finding is a left paracentral disc bulge at C3/C4, which slightly flattens the left aspect of the spinal cord, with mild bilateral neuroforaminal canal narrowing and facet joint arthropathy 3, 4.

Predictive Value of MRI Findings

  • Studies have shown that MRI findings can predict the severity of disc degeneration and disc protrusion in the cervical spine 3, 4.
  • The Cervical Phenotype Index (CPI) has been developed to predict patient-reported outcomes and adjacent segment degeneration/disease after anterior cervical discectomy and fusion (ACDF) 4.
  • However, the predictive value of MRI findings for clinical outcomes is not always clear, and asymptomatic individuals may also have abnormal MRI findings 5, 6.

Management Options

  • Given the presence of degenerative changes and neuroforaminal canal narrowing, referral to a neurosurgeon may be considered for further evaluation and management 4, 2.
  • Alternatively, physiotherapy and review in six to eight weeks may be a reasonable approach, depending on the patient's symptoms and clinical progression 2.
  • A systematic approach to interpreting the spinal MRI and correlating the findings with clinical symptoms is essential for guiding therapeutic decision-making and treatment monitoring 2.

References

Guideline

acr appropriateness criteria<sup>®</sup> cervical neck pain or cervical radiculopathy.

Journal of the American College of Radiology, 2019

Research

Cervical spine MRI phenotypes and prediction of pain, disability and adjacent segment degeneration/disease after ACDF.

Journal of orthopaedic research : official publication of the Orthopaedic Research Society, 2021

Research

Disc degeneration of cervical spine on MRI in patients with lumbar disc herniation: comparison study with asymptomatic volunteers.

European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 2011

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.