Cervical Radiculopathy with a Disc-Osteophyte Complex and Myelopathy Signs
A 58-year-old man presents with 8 weeks of right C6 radicular pain and numbness in the thumb and index finger, plus new subjective hand clumsiness and two falls. Exam shows right biceps and brachioradialis weakness (4/5), a diminished right biceps reflex, and positive Hoffmann sign bilaterally with mild gait unsteadiness. Cervical MRI shows a right paracentral disc-osteophyte complex at C5-C6 causing moderate right foraminal and lateral recess stenosis, with mild cord indentation but no overt T2 cord signal change. There is also mild congenital canal narrowing (AP diameter 11 mm). The surgeon proposes an anterior cervical discectomy and fusion at C5-C6 and asks you to comment on the imaging before consent.
1. How do the radicular and myelopathic findings localize, and what does the imaging add or fail to add?
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The radicular findings localize to right C6: pain/numbness in the thumb/index finger, biceps and brachioradialis weakness, and a diminished biceps reflex. The C5-C6 level is the correct target for the radicular component.
The myelopathic findings (bilateral Hoffmann, hand clumsiness, unsteady gait, falls) are a separate and more serious problem. They indicate cord dysfunction, and with a canal AP diameter of 11 mm he has developmental stenosis that makes the cord vulnerable. Crucially, the MRI shows only mild cord indentation and no T2 hyperintensity - absence of T2 signal change does not exclude myelopathy and should not reassure the surgeon that the cord is fine. Clinical myelopathy can precede visible signal change. The imaging supports multifactorial cord compromise (stenosis plus disc-osteophyte) but understates the clinical severity.
2. Does the proposed single-level C5-C6 ACDF address the problem, and what would you flag before consent?
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It addresses the radicular component well if the right C5-C6 foramen is the sole pain generator. But it may not address the myelopathic component if the cord is being compressed at other levels or by the congenitally narrow canal - a single-level ACDF at C5-C6 may leave residual cord compression above or below.
Flag before consent:
- Confirm the cord compression is maximal at C5-C6 and not multilevel; review sagittal cord contour and consider whether a posterior decompression or laminoplasty is needed for the stenotic canal.
- The absence of T2 signal change means you cannot use it to justify or rule out surgery - rely on the clinical myelopathy.
- Document baseline myelopathy severity (e.g., mJOA) so postoperative change is measurable.
- Confirm the radicular level with selective nerve root block or EMG if there is any ambiguity before committing to fusion.
3. The patient asks whether surgery will fix his clumsiness. What is the honest prognostic answer, and what alternative should be discussed?
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Be honest: decompression for myelopathy aims to halt progression, and many patients improve, but recovery of fine motor function is variable and often incomplete, especially with a long-standing stenotic canal. Do not promise resolution of clumsiness.
Discuss the alternative of nonoperative management for the radicular pain (physical therapy, gabapentinoids, selective nerve root injection) while recognizing that myelopathy is a relative surgical urgency - progressive myelopathy is generally an indication for decompression because conservative management risks irreversible cord injury, particularly with an 11 mm canal and falls already occurring. The falls themselves are a safety issue (risk of fall-related cord injury). Frame it as: surgery is recommended primarily to protect the cord and prevent worsening, with realistic expectations about hand function, and the radicular pain has a better chance of resolving than the myelopathy.