Cervical Spinal Stenosis and Cervical Myelopathy

Why this page covers two terms

Cervical stenosis is the narrowing. Cervical myelopathy is what happens when the narrowing starts to affect the spinal cord running through it.

They are treated together here because they sit on one continuum with one treatment set, and splitting them into two pages would produce two thin ones. What matters clinically is not which word appears on the report but whether the cord is being affected, and that is a question answered by examination rather than by imaging alone.

The signs are functional, not painful

This is the part worth reading carefully, because it is why this diagnosis gets missed.

A compressed nerve root hurts. A compressed spinal cord often does not. Instead it degrades fine control, and the early signs look like ageing:

Buttons, zips, coins and jewellery clasps become fiddly. Handwriting gets worse. Objects get dropped. Typing becomes less accurate. Walking feels less certain, particularly in the dark or on uneven ground, and some patients notice they have started watching their feet.

Numbness or pins and needles in both hands is common, and the bilateral pattern is a clue: a single compressed nerve root affects one arm, whereas the cord supplies both.

Patients frequently present having attributed all of this to getting older. It is worth taking seriously in anyone over fifty whose hand function and balance have changed together.

How it is assessed

The examination looks for signs of cord involvement rather than root involvement: brisk reflexes, changes in tone, specific signs elicited at the hand and the foot, and the way the patient walks. Gait is often the most informative thing in the room.

MRI shows the canal, the degree of narrowing, and whether there is any change in the cord itself. Standing X-rays show alignment, which influences what operation would suit.

The critical judgement is whether the imaging findings match the clinical signs. Cervical narrowing is common on films. Narrowing plus clumsy hands plus an altered gait is a different situation and is treated as one.

Why waiting is weighed differently here

For most spine conditions, non-operative care first is the correct default, and this practice applies that default routinely.

Cervical myelopathy is the significant exception, and the reason is the recovery profile. Nerve roots recover reasonably well after being decompressed, even late. The spinal cord does not. Deficits that have been present for a long time frequently persist after the pressure is relieved.

So the realistic aim of surgery for established myelopathy is usually to stop the decline rather than to reverse it. That makes the timing of the decision part of the treatment, which is not true of a disc herniation that will probably resorb.

Stenosis on a film with no clinical signs of myelopathy is a different matter and can reasonably be watched.

What the operation would be

The choice depends on where the compression is, how many levels are involved, and the alignment of the neck.

Compression at one or two levels from the front may be addressed anteriorly, and in selected patients that can be done in a motion-preserving way with cervical disc replacement.

Multilevel cord compression usually needs a more extensive decompression, either from the front across several levels or from the back by enlarging the canal. Preserving motion matters less here than giving the cord room, and this is one of the situations where the larger operation is frequently the correct one.

Whichever approach, the principle is the same as everywhere else on this site: the operation has to be complete first and small second. A tissue-sparing approach that leaves the cord compressed has not helped anyone.

If you have been told you have this

Two things are worth doing. Get the examination findings, not just the MRI report, because the diagnosis rests on them. And do not sit on it for months to see whether it settles, which is reasonable advice for many spine problems and poor advice for this one.

A second opinion is welcome here as anywhere, and it is worth getting promptly rather than eventually.